Based on observation, interview, and record review conducted during the Abbreviated survey (Complaint #NY00379718) completed on 6/10/2025, the facility did not ensure the resident's right to be free from abuse, neglect or mistreatment for one (1) (Resident #2) of three (3) residents reviewed for abuse, neglect and mistreatment. Specifically, a Certified Nurse Aide #3 did not follow Resident #2's care plan for dietary meal consistency when they provided Resident #2 with a regular chicken consistency that caused Resident #2 to choke and required back thrusts and mouth sweeps to clear their throat and mouth. This is evidenced by: The facility policy and procedure titled, Abuse/Neglect, revised 4/2025, documented the following: it is the policy of the facility that all residents have the right to be free from neglect, verbal, sexual, physical or mental abuse, corporal punishment, exploitation and involuntary seclusion. The facility education titled, Reportable Incidents / Examples, undated, provided by Director of Nursing #1, documented the following: Neglect may include, but is not limited to: failure to carry out physician orders, failure to follow the care plan, or failure to provide adequate hydration and nutrition. The facility policy and procedure titled, Dining Room Duties: Serving Meal Trays, revised 11/2016, documented the following: it is the policy of the facility that each resident will be provided with a dignified, pleasant dining experience at each meal to enhance socialization, increase mental awareness, stimulate appetite, provide optimal nutritional intake (based on individual preferences and needs); and foster the highest level of independence - safely and efficiently. Serving meal trays included check meal ticket (resident specific information identifying resident name, diet, and food items on tray) to assure the correct resident, item and consistency. Residents unhappy with the meal should be offered a substitute. Call kitchen to order substitutes as necessary, state you name, the unit you are calling from, the resident's name who needs a substitute and item requested. The facility policy and procedure titled, Therapeutic Dining, revised 3/2025, documented the following: it is the policy of the facility that each resident will be evaluated for a diet consistency and need for feeding strategies to allow safe nutritional intake, to provide staff with concise instructions for resident diet restrictions and feeding strategies. Resident #2 had diagnoses including dementia with agitation (a behavior change characterized by restlessness, excessive movement, and sometimes aggression, often triggered by changes in routine, environment, or cognitive decline), chronic obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lung, causing breathing problems), and malignant neoplasm of the bladder (bladder cancer). The Minimum Data Set (a resident assessment tool) dated 2/23/2025 documented Resident #2 was cognitively severely impaired, sometimes understood and sometimes understands, did not exhibit behaviors of rejection of care, required supervision or touching assistance for eating (helper provides verbal cues and / or touching / steadying and / or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.) and required a mechanically altered diet (a change in texture of food or liquids). Review of the comprehensive care plan dated 8/22/2023 documented the following: Nutrition / Hydration Comfort Care as evidenced by dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). Documented interventions included provide the least restrictive diet necessary to allow optimal intake, mechanically altered diet. Review of the Dietary - Quarterly Nutritional Assessment for Resident #2 dated 2/24/2025 documented the following: regular diet, mechanical soft consistency with ground meats, thin liquids, had impaired swallowing, and required partial / moderate assist with supervision or touching assistance. Review of Resident #2's meal ticket, undated identified by Director of Nursing #1 as the meal ticket that was on Resident #2's meal tray on 5/04/2025 supper meal documented regular mechanical soft with ground meats, extra sauce / gravy, included three (3) each chicken tenders - must be minced. Review of, Nursing Home Investigative Report, completed by Director of Nursing #1 on 5/04/2025 at 9:06 PM, revealed the following: • The alleged abuse, neglect or mistreatment occurred as a result of a care plan violation on 5/04/2025 resulting in Resident #2 having a choking episode and required back thrusts and mouth sweeps to clear their throat and mouth of chicken. This was related to Resident #2 being given the wrong food consistency; served regular consistency chicken tenders and resident's diet is mechanical soft with ground meats. • Facility initiated an investigation and suspended Certified Nurse Aide #3 pending the investigation. • The facility investigation statements revealed Certified Nurse Aide #4 reported they witnessed Certified Nurse Aide #3 swap out a tray that belonged to Resident #2 and before they could report what they witnessed to the nurse, Resident #2 started to choke, and they immediately reported what they witnessed. A statement by Licensed Practical Nurse #2 documented, Certified Nurse Aide #4 notified them Certified Nurse Aide #3 swapped out Resident #2's meal tray with someone else's whose food was not of mechanical sot / minced consistency, and they asked Certified Nurse Aide #3 if they had swapped out Resident #2's tray and Certified Nurse Aide #3 informed them they may have but they do not remember because they get confused. • The facility's investigation conclusion documented statements were obtained from all staff involved, the findings of the investigation documented, Certified Nurse Aide #3 was feeding Resident #2 the wrong meal consistency food (served regular and diet is mechanical soft, minced meat). The facility concluded that Resident #2 choked from Certified Nurse Aide #3 feeding them the wrong food consistency. During a telephone interview on 6/05/2025 at 12:42 PM, Certified Nurse Aide #3 stated during the supper meal on 5/04/2025, Resident #3 was served a fish sandwich, and requested chicken, they noticed Resident #2 had minced chicken on their plate, so they took the food plate from Resident #2's tray and gave it to Resident #3. They stated Resident #4 had regular chicken tenders on a plate and didn't want them because they were eating pancakes, so they took Resident #4's food plate of chicken tenders and gave it to Resident #2. They stated they did intentionally swap the meal plates but mistakenly did not read Resident #2's meal ticket consistency and provided them with the wrong consistency and they choked and needed attention from the nurse to clear their mouth and throat. They stated they should not have swapped residents' meal plates and should have called the kitchen for an alternative plate for Resident #3 when they asked for a different meal. During a telephone interview on 6/05/2025 at 1:38 PM, Certified Nurse Aide #4 stated they heard Certified Nurse Aide #3 state they were going to switch Resident #2's plate and they observed the plate that was in Certified Nurse Aide #3's hand and informed Certified Nurse Aide #3 not to give Resident #2 the food (regular chicken) that was on that plate because it wasn't the correct consistency for Resident #2. Certified Nurse Aide #4 stated they did not know where Certified Nurse Aide #3 got the plate of food from and didn't realize they were going to feed Resident #2 after they informed them it was the wrong consistency. They stated Resident #2 started coughing and choking and the nurses had to respond to assist Resident #2 to clear their throat. During a telephone interview on 6/05/2025 at 2:16 PM, Licensed Practical Nurse #2 stated on 5/04/2025 Resident #2 was choking on regular chicken at supper and stated they were unable to continue the interview at this time. During a telephone interview on 6/05/2025 at 2:50 PM, Registered Nurse #3 stated they interviewed staff on 5/04/2025 related to Resident #2's choking incident. They stated upon investigating the staff interviews, they learned Certified Nurse Aide #3 swapped out three (3) resident's meal plates and mistakenly didn't identify Resident #2 was to have minced meat and was not to receive regular chicken fingers, which caused Resident #2 to choke, and Director of Nursing #1 was aware. During another telephone interview on 6/09/2025 at 12:35 PM, Licensed Practical Nurse #2 stated they were in the dining room, heard Certified Nurse Aide #3 shout 'spit it out' and observed them pulling Resident #2 away from the dining room table. Upon assessing Resident #2, they observed the resident flushed and unable to communicate. They were unable to provide the Heimlich maneuver because of the high back wheelchair, so they instead completed a finger sweep and pulled two (2) pieces of chicken out of the resident's mouth. They stated Certified Nurse Aide #4 informed them Certified Nurse Aide #3 took another resident's plate of food that was a regular consistency, told Certified Nurse Aide #3 they were not to feed Resident #2 that consistency, and yet Certified Nurse Aide #3 started feeding Resident #2 the regular consistency anyway. This resulted in Resident #2 choking on the food. Licensed Practical Nurse #2 stated they immediately informed Registered Nurse #3. During an interview on 6/09/2025 at 11:53 AM, Nurse Practitioner #1 stated they assessed Resident #2 after the choking episode and was aware they received the wrong meal consistency. They further stated that they would have expected Certified Nurse Aide #3 to have read the meal ticket and provided the meal consistency that was indicated on their meal ticket. They stated they were not aware Certified Nurse Aide #3 swapped three (3) resident meal plates and stated Certified Nurse Aide #3 was negligent with their actions. During a telephone interview on 6/10/2025 at 10:37 AM, Medical Director #1 stated Certified Nurse Aide #3 should have ensured they provided the correct consistency meal according to their plan of care and meal ticket. They stated they were not aware Certified Nurse Aide #3 swapped three (3) resident meal plates and stated Certified Nurse Aide #3 was negligent with their actions. During an interview on 6/10/2025 at 11:36 AM, Director of Nursing #1 stated they would have expected Certified Nurse Aide #3 to have called to the kitchen when Resident #3 wanted an alternative meal. They stated staff should not swap resident meals plates because of specific diet plans, food consistencies and potential food allergies. They stated Certified Nurse Aide #3 was negligent with their actions. During an interview on 6/10/2025 at 12:08 PM, Administrator #1 stated they would have expected Certified Nurse Aide #3 to have called to the kitchen when Resident #3 wanted an alternative meal. They stated staff should not swap resident meals plates because of specific diet plans, food consistencies and potential food allergies. They stated Certified Nurse Aide #3 was negligent with their actions. 10 New York Codes, Rules and Regulations 415.4 (b)(1)(i)

Based on observation, interview and record review conducted during an Abbreviated survey (Complaint #NY00378218) completed on 6/10/2025, the facility did not ensure that all alleged violations involving abuse, neglect, mistreatment including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made to the facility's Administrator and the State Survey Agency for one (1) (Resident #5) of three (3) residents reviewed. Specifically Resident #5 was found to have an injury of unknown source to their right eye, and it was not reported within the required timeframe. This is evidenced by: The facility policy and procedure title, Resident Incident / Accident Reporting, date revised 9/2023 documented the following: all resident incident / accidents are reported, investigated and documented at the time of the incident / accident or upon discovery, in an effort to prevent or decrease recurrence. Accident - any happening that results in bodily injury, including but not limited to falls, fractures, lacerations, burns, skin tears and bruises. At the time of an incident / accident or upon discovery, staff are to notify the Nursing Supervisor. The Registered Nurse is responsible to assess and assure appropriate medical attention follow-up. The facility policy and procedure titled, Abuse/Neglect, revised 4/2025, documented the following: it is the policy of the facility that all residents have the right to be free from neglect, verbal, sexual, physical or mental abuse, corporal punishment, exploitation and involuntary seclusion. Investigate all reported incidents and accidents and resident complaints for potential abuse, neglect and possible crime. Once an incident has been reported, notify the Director of Nursing or Administrator and begin the investigation. As soon as the investigation begins and there is reasonable cause to believe it is reportable to the Department of Health using the current annual, a determination must be made if it meets the two (2) hour or twenty-four (24) hour reporting mandate. If physical injuries, provider to be notified to determine level of follow-up needed. Review of facility form undated titled, Reportable Incidents/Examples, documented the following: Notify the Supervisor and Administrator immediately - Reportable incidents must be reported to the Department of Health by Administration Immediately, examples included injury of unknown origin; resident has a new bruise, fracture, skin tear without explanation. Resident #5 had diagnoses including dementia (a generalized term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hypertension (a condition in which the force of the blood against the artery walls is too high), and Peripheral Vascular Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). The Minimum Data Set (a resident assessment tool) dated 4/25/2025 documented Resident #5 was cognitively severely impaired, usually understands and usually understood. The undated comprehensive care plan for Resident #5 identified as current by Director of Nursing #1 documented that Resident #5 required substantial / maximal assistance with dressing and may be resistant to care; cognition deficit as evidenced by short term memory loss with difficulty with decision making and difficulty memory recall and behavior symptoms dated physical / verbal abuse with resistance to care as evidenced by refusal of hands on care, verbally and physically aggressive to staff and others. Review of Resident #5 ' s Progress Notes dated 3/01/2025 through 6/09/2025 documented the following: - Dated 4/08/2025 at 5:26 PM: Registered Nurse #4 documented the following: purpura (is a medical term describing purple - colored spots or patches on the skin caused by bleeding under the skin due to broken blood vessels) noted below the resident ' s right eye, no pain noted when assessed. - Dated 4/14/2025 at 4:33 PM: Nurse Practitioner #2 documented the following: ecchymosis (the medical term for bruises) to right lower eye, per nursing they rub vigorously. - Dated 4/16/2025 at 8:22 PM: Registered Nurse #3 documented the following: bruise right eye Nurse Practitioner assessed resident ' s right eye and determined a bruise. The bruise is purple with yellow area surrounding and fading in color, measures six (6) centimeters by three (3) centimeters under right eye. The area above the right eye lid measures two (2) centimeters by (0.5) centimeters. Resident denies pain or discomfort and resident denies any harm or wrongdoing. Family was aware last week while visiting resident and states the purple has been there for over a week and resident did not know how it happened as they had already asked him. - Dated 4/16/2025 at 9:22 PM: Nurse Practitioner #2 documented the following: ecchymosis below left eye is resolving turning purple/green/yellow, on better view can now observe ecchymosis to upper medial lid. Resident has no pain on palpation, no asymmetry of the periorbital ring. Resident does not recall how this developed. - Dated 4/18/2025 at 9:59 AM: Medical Director #1 documented the following: Visit date 4/17/2025, resident was seen as requested by Director of Nursing regarding the new skin lesion around Resident #5 ' s eye. Per Director of Nursing, no report of a fall, Nurse Practitioner #2 ' s progress notes reviewed from 4/14/2025 and 4/16/2025. Assessment documented, a small and dissipating ecchymosis (a discoloration of the skin resulting from bleeding underneath) below the right lower eyelid is present and Resident #5 was unable to recall what had happened. Etiology questionable (the cause or origin of the condition was not clearly understood or identified). Review of the facility ' s Accident form dated 4/16/2025 Registered Nurse #3 documented, estimated date 4/11/2025 at 12:00 PM bruise right eye, possible cause resident rubbed their eye too hard and the multiple eye scrubs made the area further purple. Registered Nurse #3 was on unit doing rounds and Nurse Practitioner #2 and administration were looking at Resident #5 ' s right eye and requested them to complete an incident report for area noticed last week. Statements documented on the Accident report included the following: - Dated 4/17/2025 Licensed Practical Nurse #3: On 4/08/2025, Resident #5 had a linear dark red/purple area, intact skin under right eye. The area was slightly crescent in shape and followed the large droopy bag under their right eye. Registered Nurse #4 was made aware, daughter was present the next day and inquired with staff, explained the area was referred to as a purpura area. - Dated 4/17/2025 Certified Nurse Aide #5: They saw Resident #5 ' s eye and asked Registered Nurse #4 what happened to their eye and Registered Nurse #4 informed them they had a purpura area. - Dated 4/17/2025 Nurse Practitioner #1: Was told by staff on 4/16/2025 they suspected a bruise to Resident #5 ' s eye that staff were calling a purpura and informed Administration as soon as possible. - Dated 4/18/2025 Nurse Practitioner #3: They observed Resident #5 walking past them and observed their eye and asked Nurse Practitioner #2 what happened to Resident #5 ' s eye. Nurse Practitioner #2 replied that it was being documented as purpura by nursing but the way it was shaped it looked like they may have had an injury to their right eye, and it appeared to be bruised. Nurse Practitioner #2 agreed it was a bruise but does not know where it came from. During an interview on 6/10/2025 at 9:05 AM, Nurse Practitioner #1 stated Registered Nurse #4 should have reported the discoloration around Resident #5 ' s eye to the provider for an assessment and the Director of Nursing or Administrator because it was an injury of unknown origin on 4/08/2025, and the facility should have reported it to the New York State Department of Health within the regulatory guidelines. During an interview on 6/10/2025 at 9:46 AM, Registered Nurse #3 stated Registered Nurse #4 should have reported the discoloration around Resident #5 ' s eye to the provider for an assessment and the Director of Nursing or Administrator because it was an injury of unknown origin on 4/08/2025, and the facility should have reported it to the New York State Department of Health within the regulatory guidelines. During an interview on 6/10/2025 at 10:16 AM, Medical Director #1 stated they were not aware Registered Nurse #4 identified Resident #5 had a discolored area on their right eye on 4/08/2025 and would have expected Registered Nurse #4 to have reported the discoloration around Resident #5 ' s eye to the provider for an assessment and the Director of Nursing or Administrator because it was an injury of unknown origin on 4/08/2025, and the facility should have reported it to the New York State Department of Health within the regulatory guidelines. During an interview on 6/10/2025 at 11:35 AM, Director of Nursing #1 stated Registered Nurse #4 should have reported the discoloration around Resident #5 ' s eye to the provider for an assessment and the Director of Nursing or Administrator because it was an injury of unknown origin on 4/08/2025, and the facility should have reported it to the New York State Department of Health within the regulatory guidelines of 24 hours. During an interview on 6/10/2025 at 11:56 AM, Administrator #1 stated they were not aware Registered Nurse #4 identified Resident #5 had a discolored area on their right eye on 4/08/2025 and would have expected Registered Nurse #4 to have reported the discoloration around Resident #5 ' s eye to the provider for an assessment and the Director of Nursing or them because it was an injury of unknown origin on 4/08/2025, and the facility should have reported it to the New York State Department of Health within the regulatory guidelines of 24 hours. 10 New York Codes, Rules and Regulations 415.4(b)(2)

Based on observation, interview and record review conducted during an Abbreviated survey (Complaint #NY00379718 and #NY00378218) completed on 6/10/2025, it was determined the facility did not ensure that all violations of abuse, neglect, mistreatment were thoroughly investigated for two (2) (Resident #2 and #5) of three (3) residents reviewed. Specifically, (1.) An incident involving Resident #2, who was fed regular chicken consistency by Certified Nurse Aide #3, was not thoroughly investigated to determine where the Certified Nurse Aide retrieved the regular consistency meal; and (2.) Resident #5's injury of unknown origin was not investigated thoroughly. Reference F 600 D and F 609 D This is evidenced by: The facility policy and procedure titled, Abuse/Neglect, revised 4/2025, documented the following: it is the policy of the facility that all residents have the right to be free from neglect, verbal, sexual, physical or mental abuse, corporal punishment, exploitation and involuntary seclusion. Investigate all reported incidents and accidents and resident complaints for potential abuse, neglect and possible crime. Statements from staff must be done immediately, and the person conducting the investigation will use the employee statement to determine the need for an interview. The facility policy and procedure titled, Resident Incident / Accident Reporting, revised 9/2023, documented the following: Accident - any happening that results in bodily injury, including but not limited to falls, fractures, lacerations, burns, skin tears and bruises. The purpose is to document occurrence of incident / accidents, identify unsafe practices, reduce preventable incident / accidents through root cause analysis, and provide education and follow-up to prevent further occurrences. Obtain resident and staff statements regarding the event, an investigation regarding the circumstance of the incident or accident must be conducted by the nursing supervisor by obtaining and reviewing statements from all staff who have the potential to be knowledgeable of the incident or accident. Follow up interviews will be conducted as necessary. (1.) Resident #2 had diagnoses including dementia with agitation (a behavior change characterized by restlessness, excessive movement, and sometimes aggression, often triggered by changes in routine, environment, or cognitive decline), chronic obstructive pulmonary disease (a condition caused by damage to the airways or other parts of the lung, causing breathing problems), and malignant neoplasm of the bladder (bladder cancer). The Minimum Data Set (a resident assessment tool) dated 2/23/2025 documented Resident #2 was cognitively severely impaired, sometimes understood and sometimes understands, did not exhibit behaviors of rejection of care, required supervision or touching assistance for eating (helper provides verbal cues and / or touching / steadying and / or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.) and required a mechanically altered diet (a change in texture of food or liquids). Review of the comprehensive care plan dated 8/22/2023 documented the following: Nutrition / Hydration Comfort Care as evidenced by dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage). Documented interventions included provide the least restrictive diet necessary to allow optimal intake, mechanically altered diet. Review of the Dietary Quarterly Nutritional Assessment for Resident #2 dated 2/24/2025 documented the following: regular diet, mechanical soft consistency with ground meats, thin liquids, had impaired swallowing, and required partial / moderate assist with supervision or touching assistance. Review of Resident #2's meal ticket, undated identified by Director of Nursing #1 as the meal ticket that was on Resident #2's meal tray on 5/04/2025 supper meal documented regular mechanical soft with ground meats, extra sauce / gravy, included three (3) each chicken tenders - must be minced. Review of, Nursing Home Investigative Report, completed by Director of Nursing #1 on 5/04/2025 at 9:06 PM, revealed the following: • The alleged abuse, neglect or mistreatment occurred as a result of a care plan violation on 5/04/2025 resulting in Resident #2 having a choking episode and required back thrusts and mouth sweeps to clear their throat and mouth of chicken. This was related to Resident #2 being given the wrong food consistency; served regular consistency chicken tenders and resident's diet is mechanical soft with ground meats. • The facility's investigation conclusion documented statements were obtained from all staff involved, the findings of the investigation documented, Certified Nurse Aide #3 was feeding Resident #2 the wrong meal consistency food (served regular and diet is mechanical soft, minced meat). The facility concluded that Resident #2 choked from Certified Nurse Aide #3 feeding them the wrong food consistency. Review of Resident #3's meal ticket, undated identified by Dietary Typist #1 as the meal ticket that was provided on 5/04/2025 supper meal documented, their diet: regular diet mechanical soft / hamburger ground on roll, extra sauce / gravy and food items included 1 fish sandwich, sweet potato tots and soup. Review of Resident #4's meal ticket, undated identified by Dietary Typist #1 as the meal ticket that was provided on 5/04/2025 supper meal documented, their diet: regular no added salt / mechanical soft / regular chicken and bacon and regular bagel with cream cheese / extra sauce / gravy and food items included (3) chicken tenders, mango sauce, dipping, sweet potato tots. During a telephone interview on 6/05/2025 at 12:42 PM, Certified Nurse Aide #3 stated during the supper meal on 5/04/2025, Resident #3 was served a fish sandwich, and they requested to have chicken. Certified Nurse Aide #3 stated they noticed Resident #2 had minced chicken on their plate, so they took the food plate from Resident #2's tray and gave it to Resident #3. They stated Resident #4 had regular chicken tenders on a plate and didn not want them because they were eating pancakes, so they took Resident #4's food plate of chicken tenders and gave it to Resident #2. They stated they did intentionally swap the meal plates but mistakenly did not read Resident #2's meal ticket consistency and provided them with the wrong consistency and they choked and needed attention from the nurse to clear their mouth and throat. They stated they should not have swapped residents' meal plates and should have called the kitchen for an alternative plate for Resident #3 when they asked for a different meal. During a telephone interview on 6/05/2025 at 2:50 PM, Registered Nurse #3 stated they interviewed staff on 5/04/2025 related to Resident #2's choking incident. They stated upon investigating the staff interviews, they learned Certified Nurse Aide #3 swapped out three (3) resident's meal plates and mistakenly did not identify Resident #2 was to have minced chicken tenders and was not to receive regular chicken tenders, which caused Resident #2 to choke. They stated Director of Nursing #1 was aware that Certified Nurse Aide #3 swapped out three (3) resident meal plates. They stated they did not request Certified Nurse Aide #3 to update their written statement to clarify they swapped out three (3) resident meal plates and they did not review Resident #3's and Resident #4's dietary plan to ensure they received the appropriate diet meal plan and correct consistency. Additionally, they stated they did not add Resident #3 and Resident #4 to the investigation. During an interview on 6/09/2025 at 10:06 AM, Therapy Department Director #1 stated they were not aware Certified Nurse Aide #3 swapped three (3) resident meal plates and was not aware how Resident #2 received regular consistency chicken which caused them to choke. They stated they would have expected Director of Nursing #1 to have informed them Resident #3 and Resident #4's supper plates were also swapped, and they would have assessed the meals they received to ensure the food was appropriate according to their meal plans. They stated all staff were expected if they want an alternative meal, they were to call the kitchen for a tray and should never swap resident meal plates between the residents to ensure consistency and diet restrictions are followed. They stated the facility did not complete a thorough investigation. During an interview on 6/09/2025 at 11:53 AM, Nurse Practitioner #1 stated they were not aware Certified Nurse Aide #3 swapped three (3) resident meal plates and would have expected a thorough investigation to include a review of Resident #3 and Resident #4's dietary plan to ensure they received the correct diet and consistency. During a telephone interview on 6/10/2025 at 10:37 AM, Medical Director #1 stated they were not aware Certified Nurse Aide #3 swapped three (3) resident meal plates and would have expected a thorough investigation to include where Certified Nurse Aide #3 obtained the regular chicken from that Resident #2 was fed. They stated they would have expected Director of Nursing #1 to have thoroughly investigated Resident #3 and Resident #4's meal tickets and dietary plan to ensure they also received the correct consistency and dietary plan and would have expected Director of Nursing #1 to have had the information documented in the investigation. During an interview on 6/10/2025 at 11:36 AM, Director of Nursing #1 stated they were not aware where Certified Nurse Aide #3 got the regular chicken tenders from that they fed Resident #2. They stated they did not complete a thorough investigation to determine where they retrieved the regular consistency chicken tenders from. They stated they were informed Certified Nurse Aide #3 swapped out meal plates that also involved Resident #3 and #4 and identified they were all mechanical soft, and did not identify Resident #4 had regular chicken tenders on their meal plan, that was provided to Resident #2. They stated they had not completed a thorough investigation and should have thoroughly reviewed and included Resident #3's and Resident #4's information in the investigation based on the interviews. During an interview on 6/10/2025 at 12:08 PM, Administrator #1 stated the facility did not complete a thorough investigation and would have expected Director of Nursing #1 to have identified where Certified Nurse Aide #3 obtained the regular chicken tenders from that Resident #2 was fed and have thoroughly reviewed and included Resident #3's and #4's information in the investigation. They stated they were not aware Certified Nursing Aide #3 swapped out 3 resident meal plates and they should have been informed. (2.) Resident #5 had diagnoses including dementia (a generalized term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hypertension (a condition in which the force of the blood against the artery walls is too high), and Peripheral Vascular Disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). The Minimum Data Set (a resident assessment tool) dated 4/25/2025 documented Resident #5 was cognitively severely impaired, usually understands and usually understood. The undated comprehensive care plan for Resident #5 identified as current by Director of Nursing #1 documented the following, Resident #5 required substantial / maximal assistance with dressing and may be resistant to care; cognition deficit as evidenced by short term memory loss with difficulty with decision making and difficulty memory recall and behavior symptoms dated of physical / verbal abuse with resistance to care as evidenced by refusal of hands on care, verbally and physically aggressive to staff and others. Review of Resident #5's Progress Notes dated 3/01/2025 through 6/09/2025 documented the following: • Dated 4/08/2025 at 5:26 PM Registered Nurse #4 documented the following: purpura a medical term describing purple - colored spots or patches on the skin caused by bleeding under the skin due to broken blood vessels) noted below the resident's right eye, no pain noted when assessed. • Dated 4/14/2025 at 4:33 PM Nurse Practitioner #2 documented the following: ecchymosis (the medical term for bruises) to right lower eye, per nursing they rub vigorously. • Dated 4/16/2025 at 8:22 PM Registered Nurse #3 documented the following: bruise right eye Nurse Practitioner assessed resident's right eye and determined a bruise. The bruise is purple with yellow area surrounding and fading in color, measures six (6) centimeters by three (3) centimeters under right eye. The area above the right eye lid measures two (2) centimeters by (0.5) centimeters. Resident denies pain or discomfort and resident denies any harm or wrongdoing. Family was aware last week while visiting resident and states the purple has been there for over a week and resident did not know how it happened as they had already asked him. • Dated 4/16/2025 at 9:22 PM Nurse Practitioner #2 documented the following: ecchymosis below left eye is resolving turning purple/green/yellow, on better view can now observe ecchymosis to upper medial lid. Resident has no pain on palpation, no asymmetry of the periorbital ring. Resident does not recall how this developed. • Dated 4/18/2025 at 9:59 AM Medical Director #1 documented the following: Visit date 4/17/2025, resident was seen as requested by Director of Nursing regarding the new skin lesion around Resident #5's eye. Per Director of Nursing, no report of a fall, Nurse Practitioner #2's progress notes reviewed from 4/14/2025 and 4/16/2025. Assessment documented, a small and dissipating ecchymosis (a discoloration of the skin resulting from bleeding underneath) below the right lower eyelid is present and Resident #5 was unable to recall what had happened. Etiology questionable (the cause or origin of the condition was not clearly understood or identified). Review of the facility's Accident form dated 4/16/2025 Registered Nurse #3 documented, estimated date 4/11/2025 at 12:00 PM bruise right eye, possible cause resident rubbed their eye too hard and the multiple eye scrubs made the area further purple. Registered Nurse #3 was on unit doing rounds and Nurse Practitioner #2 and administration were looking at Resident #5's right eye and requested them to complete an incident report for area noticed last week. Statements documented on the Accident report included the following: • Dated 4/17/2025 Licensed Practical Nurse #3: On 4/08/2025 Resident #5 had a linear dark red/purple area, intact skin under right eye. The area was slightly crescent in shape and followed the large droopy bag under their right eye. Registered Nurse #4 was made aware, daughter was present the next day and inquired with staff, explained the area was referred to as a purpura area. • Dated 4/17/2025 Certified Nurse Aide #5: They saw Resident #5's eye and asked Registered Nurse #4 what happened to their eye and Registered Nurse #4 informed them they had a purpura area. • Dated 4/17/2025 Nurse Practitioner #1: Was told by staff on 4/16/2025 they suspected a bruise to Resident #5's eye that staff were calling a purpura and informed Administration as soon as possible. • Dated 4/18/2025 Nurse Practitioner #3: They observed Resident #5 walking past them and observed their eye and asked Nurse Practitioner #2 what happened to Resident #5's eye. Nurse Practitioner #2 replied that it was being noted as purpura but the way it was shaped it looked like they may have had an injury to their right eye, and it appeared to be bruised. Nurse Practitioner #2 agreed it was a bruise but does not know where it came from. During an interview on 6/10/2025 at 9:05 AM Nurse Practitioner #1 stated they recalled staff were referring Resident #5's eye discoloration as a purpura area and it looked like a bruise, therefore they reported it to either the Deputy Administrator or the Director of Nursing, unable to recall who they reported it to. They stated Registered Nurse #4 should not have diagnosed it as a purpura area and reported it to the provider for an assessment and initiated an investigation on 4/08/2025. During an interview on 6/10/2025 at 9:05 AM Certified Nurse Aide #6 stated they worked the night shift providing care to Resident #5 on 4/07/2025 into the morning of 4/08/2025 and they were not interviewed or asked any questions from the facility concerning the bruise on Resident #5's right eye. They stated they do not know how the resident's eye was bruised. During an interview on 6/10/2025 at 9:33 AM Certified Nurse Aide #8 stated they were assigned to Resident #5 on 4/08/2025 day shift and they were not asked any questions for the investigation of Resident #5's bruised right eye. They stated they had not observed Resident #5 rubbing their eyes and did not know how the bruise was obtained. During an interview on 6/10/2025 at 9:46 AM Registered Nurse #3 stated they were notified by the Deputy Administrator #1 and Assistant Director of Nursing #1, Resident #5 had a bruise on their right eye and the nursing staff were identifying it as a purpura area and was directed to complete the Accident / Incident form and investigation. They stated the facility's process for investigating an injury of unknown origin is to interview all staff members assigned to the Resident's unit for the date the unknown injury is identified and the previous 24 hours to rule out abuse. They stated they believed the staff were aware of the area approximately one (1) week prior to Nurse Practitioner #2 determined it was a bruise / injury of unknown origin. They stated they picked the date 4/11/2025 and did not review the progress notes prior to 4/11/2025 and did not identify Registered Nurse #4 had documented on 4/08/2025 Resident #5 had a purpura area beneath their right eye. They stated they had not interviewed Registered Nurse #4 because they were no longer employed at the facility, and did not interview Certified Nurse Aide #6, #7, and #8 the assigned staff members for Resident #5 for the 24 hours prior to the documented purpura and they should have. They stated they did not complete a thorough investigation to rule out abuse. Additional interview attempts contact Registered Nurse #4, Nurse Practitioner #2, and Certified Nurse Aide #6 were not successful. During an interview on 6/10/2025 at 10:16 AM, Medical Director #1 stated they were not aware Registered Nurse #4 identified Resident #5 had a discolored area on their right eye on 4/08/2025 and would have expected Registered Nurse #4 to have notified a provider to assess the area and should not have diagnosed it as a purpura area. They stated they would have expected Director of Nursing #1 to have ensured a thorough investigation was completed by interviewing staff on 4/08/2025 and 4/07/2025 on the unit to rule out abuse and potentially determine how the injury of unknown origin occurred. During an interview on 6/10/2025 at 11:35 AM, Director of Nursing #1 stated they would have expected Registered Nurse #4 to have notified the provider on 4/08/2025 to assess Resident #5's discolored right eye and to have initiated an investigation. They stated Registered Nurse #3 should have reviewed the progress notes and completed a thorough investigation starting with staff scheduled on 4/08/2025. Upon review of the staff assignment sheets dated 4/08/2025 and 4/07/2025 they stated Certified Nurse Aide #6, #7, and #8 were assigned to Resident #5 and should have been interviewed and were not. They stated the facility did not complete a thorough investigation to rule out abuse. During an interview on 6/10/2025 at 11:56 AM, Administrator #1 stated they were not aware Registered Nurse #4 had documented Resident #5 had a purpura area beneath their right eye on 4/08/2025 and would have expected them to have notified a provider to complete an assessment and determine if the discoloration was a purpura area or bruise. They stated since Registered Nurse #4 had identified the discoloration of Resident #5's eye on 4/08/2025 they would have expected the facility investigation to have obtained statements or interviews from staff assigned to Resident #5 on 4/08/2025 and 4/07/2025. Upon review of the assignment sheets and the Accident Report of staff interviewed, they stated Certified Nurse Aide #6, #7, and #8 were assigned to Resident #5 and should have been interviewed and were not. They stated the facility did not complete a thorough investigation to rule out abuse. 1010 New York Codes, Rules and Regulations 415.4(b)(3)

Based on observation, interview and record review conducted during an Abbreviated survey (Compliant #NY00379178) completed on 6/10/2025, the facility did not ensure that all residents comprehensive person-centered care plans were implemented as planned, consistent with resident's rights and meet their preferences, goals and medical, physical, and psychosocial needs that are identified in the comprehensive assessment for one (1) (Resident #1) of three (3) residents reviewed. Specifically, the resident was not provided with two (2) staff members for incontinent care and bed mobility as care planned. This is evidenced by: The facility policy and procedure titled Care Planning revised date 5/2023 documented that residents will have a comprehensive person-centered care plan identifying resident ' s strengths, goals, life history and preferences in place to guide their care and Certified Nurse Assistant instructions provide detailed information and instructions to meet each resident ' s individual needs. Resident #1 had diagnoses including dementia with agitation, generalized anxiety disorder and major depressive disorder. The Minimum Data Set (a resident assessment tool) dated 4/11/2025 documented Resident #1 was cognitively severely impaired, rarely / never understood and rarely / never understands, does not exhibit behaviors of rejection of care, and is dependent and requires assistance of two (2) or more helpers for toileting hygiene (maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement) and requires assistance of two (2) or more helpers for bed mobility (roll from lying on back to left and right side and return to lying on back on the bed). The comprehensive care plan identified as current by the Director of Nursing documented at risk for skin breakdown as evidenced by decreased mobility and incontinence, interventions dated 7/01/2023 included toilet use required support of two (2) plus person physical assist, incontinent bowel and bladder and bed mobility support of two (2) plus person physical assist. The Certified Nurse Assistant Assignments Summary (a guide used by staff to provide care) identified as current by the Director of Nursing documented Resident #1 was incontinent and required two (2) plus person physical assist incontinent care and bed mobility. During an incontinence care observation on 6/04/2025 at 10:11 AM, Certified Nurse Aide #1 was observed to remove Resident #1 ' s soiled brief and provide incontinent care of feces and urine cleaning Resident ' s buttocks and peri area turning and positioning Resident #1 from back to right side, to back to left side while providing incontinent care and applied a clean brief turning and positioning Resident #1 without a second person assist. While being turned and positioned Resident #1 observed to intermittently state. ' hey, hey, hey. ' During an interview on 6/04/2025 at 1:50 PM, Certified Nurse Aide #1 reviewed Resident #1 ' s care plan and stated the care plan documented the resident required two (2) persons assist for incontinent care and bed mobility. They stated they did not ask for any assistance to provide the observed incontinent care and should have. They stated Resident #1 required two (2) persons assist for incontinent care and bed mobility because the resident was totally dependent and often has behaviors, therefore a second assist is for the resident ' s safety. During an interview on 6/04/2025 at 2:01 PM, Certified Nurse Aide #2 stated Resident #1 required two (2) persons assist for incontinent care and bed mobility because the resident was totally dependent and would have expected Certified Nurse Aide #1 to have asked for assistance and followed the plan of care. During an interview on 6/04/2025 at 2:10 PM, Licensed Practical Nurse #1 stated Resident #1 requires two (2) persons assist for incontinent care and bed mobility because the resident is totally dependent on staff and doesn ' t assist with turning and positioning. They stated it is for the resident ' s safety that two (2) persons provide the care and would have expected Certified Nurse Aide #1 to have asked staff for assistance and followed the plan of care. During an interview on 6/04/2025 at 2:24 PM, Registered Nurse #1 stated Resident #1 required two (2) persons assist for incontinent care and bed mobility because the resident was totally dependent on staff and did not assist with turning and positioning. They stated it was for the resident ' s safety that two (2) persons provided the care and would have expected Certified Nurse Aide #1 to have asked staff for assistance and followed the plan of care. During an interview on 6/04/2025 at 3:16 PM, Director of Nursing #1 stated care plans were developed based on resident needs. Upon review of Resident #1 ' s plan of care, they stated the resident required two (2) persons assist for incontinent care and bed mobility and would have expected Certified Nurse Aide #1 to follow the plan of care and have a second person assisting with the care provided. During an interview on 6/10/2025 at 12:13 PM, Administrator #1 stated they expected all staff to follow a resident ' s plan of care. 10 New York Code, Rules and Regulations 415.11 (c)(1)

Based on observation, interview and record review conducted during an Abbreviated survey (Compliant #NY00379178) completed on 6/10/2025, the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (1) (Resident #1) of one (1) resident reviewed for infection control practices. Specifically, Resident #1 was on Enhanced Barrier Precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including mask, gown and glove use during high contact resident care activities) and staff did not wear proper personal protective equipment while providing incontinent care of urine and feces. Additionally, the facility did not have transmission-based precaution policies to prevent the spread of infections, when and how isolation should be used for a resident; including but not limited to the type and duration of the isolation, depending upon the infectious agent or organism involved. This is evidenced by: The facility policy and procedure titled, Infection Control, revised 10/2024, documented the following: it is the policy of the facility to follow the Federal regulations, and the purpose is to adhere to principles and rules of infection control, to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The Medical Director, Infection Control Nurse and Nursing Supervisors determine what procedures (such as isolation) should be applied to an individual resident. Control Specific Isolation is used by facility - see Specific Card(s) which explain what is to be used and for what purpose per Centers for Disease Control and Prevention (the national public health agency of the United States) recommendations. Preventing the spread of infection included, initiate appropriate isolation and/or control in a timely manner and *Enhanced Barrier Precautions per Centers for Disease Control and Prevention. *Note to reader: Enhanced Barrier Precautions is an infection control strategy that uses targeted gown and glove use during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms; it is a supplement to standard precautions and existing isolation guidelines, aiming to reduce the spread of microorganisms that can cause infections. The facility specific card (signage) for Enhanced Barrier Precautions, documented everyone must clean their hands, including before entering and when leaving the room, providers and staff must also: Wear gloves and gown for the following high-contact resident care activities included dressing, providing hygiene, changing briefs or assisting with toileting. Resident #1 had diagnoses including dementia with agitation (a behavior change characterized by restlessness, excessive movement, and sometimes aggression, often triggered by changes in routine, environment, or cognitive decline), generalized anxiety disorder (a mental health condition characterized by excessive worry and anxiety about a wide range of everyday situations) and major depressive disorder (a mood disorder characterized by persistent low mood, loss of interest or pleasure in activities, and other symptoms that interfere with daily functioning). The Minimum Data Set (a resident assessment tool) dated 4/11/2025 documented Resident #1 was cognitively severely impaired, rarely / never understood and rarely / never understands, did not exhibit behaviors of rejection of care, and was frequently incontinent of bowel and bladder (having no or insufficient voluntary control over urination or defecation). Review of the comprehensive care plan identified as current by the Director of Nursing documented the following: Infection Control Precautions dated 9/04/2024 as evidenced by Multidrug-Resistant Organisms, extended-spectrum beta-lactamase-producing bacteria (these are bacteria that produce an enzyme that makes them resistant to certain common antibiotics) in urine. Documented interventions included staff to wear personal protective equipment per precaution card posted outside resident room. Review of the Physician Order Activity Detail Report for Resident #1 dated 4/01/2025 through 6/04/2025 documented the resident had extended-spectrum beta-lactamase-producing bacteria in urine and was on Enhanced Barrier Precautions as of 8/30/2024. During an observation on 6/04/2025 at 10:11 AM, an Enhanced Barrier Precaution signage was posted on the wall outside of Resident #1 ' s room under their name tag. A bin with personal protective equipment next to Resident #1 ' s room door included gloves and gowns. During an incontinence care observation on 6/04/2025 at 10:11 AM, Certified Nurse Aide #1 was observed to enter Resident #1 ' s room, apply gloves, and did not put on appropriate personal equipment (a gown). Certified Nurse Aide #1 then removed Resident #1 ' s soiled brief, provided incontinent care by cleaning Resident #1 of feces and urine, turned and positioned the resident during care, and applied a clean brief. At no time did Certified Nurse Aide don (put on) a gown as recommended by the Enhanced Barrier Precaution signage. During an interview on 6/40/2025 at 10:19 AM, Certified Nurse Aide #1 stated the Enhanced Barrier Precaution signage outside Resident #1 ' s room door - hanging beneath Resident #1 ' s name tag - meant staff were to wear gloves and a gown while providing any hands-on care to a resident who was on precautions in that room. They stated they did not know if Resident #1 was on precautions or if it was their roommate. They stated they would need to ask the charge nurse. During another interview on 6/04/2025 at 1:50 PM, Certified Nurse Aide #1 stated they were informed precaution signage for a particular resident was posted under the resident ' s nametag located on the wall outside the resident ' s room. They stated they were informed Resident #1 was on precautions related to their history of urinary tract infections, and that they should have worn a gown while providing care to Resident #1 to prevent cross contamination to their uniform and potentially cross contamination to other residents. During an interview on 6/04/2025 at 2:24 PM, Registered Nurse #1 stated Certified Nurse Aide #1 informed them they were not wearing a gown while providing incontinent care to Resident #1 during the observation this morning and they should have. They stated Resident #1 was on Enhanced Barrier Precautions related to history of urinary tract infections and has extended-spectrum beta-lactamase-producing bacteria in their urine and expected all staff to follow the precaution guidelines posted outside the resident ' s rooms for infection control purposes. During an interview on 6/04/2025 at 3:16 PM, Director of Nursing #1 stated Resident #1 was on Enhanced Barrier Precautions and would have expected Certified Nurse Aide #1 to have worn a gown while providing care for infection control purposes, to prevent the potential of cross contamination to other residents. They stated they would have expected Certified Nurse Aide #1 to know Resident #1 was on Enhanced Barrier Precautions because the signage was posted beneath Resident #1 ' s name outside the room. Director of Nursing #1 stated they did not have a specific facility policy and procedure for Enhanced Barrier Precautions, and that the facility did not have specific infection control policies and procedures for each type of transmission-based precaution such as airborne precautions, droplet precautions, and contact precautions. During an interview on 6/05/2025 at 10:18 AM, Deputy Administrator #1 stated the facility did not have specific infection control policies and procedures for each type of transmission precaution, such as contact precaution, airborne precaution, droplet precaution and Enhanced Barrier Precautions. They further stated the facility ' s Infection Control Program referred staff to follow the Centers for Disease Control guidelines for Enhanced Barrier Precautions. During an interview on 6/05/2025 at 10:50 AM, Registered Nurse #2 stated they were the facility ' s Infection Preventionist, and Certified Nurse Aide #1 should have been wearing a gown while providing care to Resident #1 because the resident was on Enhanced Barrier Precautions related to Multidrug-Resistant Organisms in their urine. They stated the requirement to wear a gown while providing care was to prevent any cross contamination to another resident. They stated the facility did not have an Enhanced Barrier Precaution Policy. Additionally, they stated the facility did not have specific infection control policies and procedures for each type of transmission-based precaution such as airborne precautions, droplet precautions, and contact precautions. During a phone interview on 6/10/2025 at 10:16 AM, Medical Director #1 stated they would have expected Certified Nurse Aide #1 to wear a gown while providing care to Resident #1 and follow the Enhanced Barrier Precautions procedure to prevent cross contamination for infection control. They stated they recall reviewing specific signage the facility uses to notify staff what type of personal protective equipment to wear depending on the type of precaution such as airborne precautions, contact precautions, droplet precautions and Enhanced Barrier Precautions, but did not recall reviewing specific policies for each transmission-based precaution. They stated they were not aware the facility did not have transmission-based precautions, when and how isolation should be used for a resident, including but not limited to the type and duration of the isolation, depending on the infectious agent or organism involved. During another interview on 6/10/2025 at 11:36 AM, Director of Nursing #1 stated they did not know why the facility did not have policies and procedures written for each transmission-based precaution to prevent the spread of infections and they had initiated a process to develop the policies and procedures. During an interview on 6/10/2025 at 12:13 PM, Administrator #1 stated they would have expected Certified Nurse Aide #1 to wear a gown while providing care to Resident #1 and follow the Enhanced Barrier Precautions procedure to prevent cross contamination for infection control. They stated they were not aware the facility did not have transmission-based precautions policies, including a policy for airborne precaution, droplet precaution, contact precaution, and enhanced barrier precaution. They stated they would have expected the Infection Control Preventionist Nurse and Director of Nursing #1 to have policies in place. 10 New York Codes, Rules and Regulations 415.19(a)(2)

Based on observation, record review, and staff interviews during an abbreviated survey (Case # NY00358602), the facility did not ensure the resident's right to be free of abuse for 1 (Residents #2) of 3 residents reviewed for abuse and neglect. Specifically on 10/27/2024, Certified Nurse Aide #1 threw a water bottle toward Resident #2, picked the bottle up and again threw it at the resident, striking them on their back without injury. Additionally, the second throw was witnessed by Certified Nurse Aide #2, and there was a delay in removing Certified Nurse Aide #1 from resident care. This is evidenced by: Facility policy titled, Abuse/Neglect, or Mistreatment, updated 11/04/2024, documented it was the policy of the facility that all residents had the right to be free from neglect, verbal, sexual, physical, or mental abuse, corporal punishment, exploitation, and involuntary seclusion. 1. All abuse would be reported and investigated. 2. All new hires would be educated and reviewed through background checks. 3. It was the responsibility of all staff to notify their immediate supervisor if they were exhibiting burnout. 4. Facility staff were mandated reporters if they witness abuse, neglect, exploitation and or misappropriation of funds and belongings and or a crime. 5. Facility staff must report to the facility Administrator immediately if they witnessed or suspected abuse. They may also report directly to the local police. Resident #2 was admitted to the facility with the diagnoses of Non-Alzheimer's Dementia with mild psychotic disturbances (condition where someone is experiencing symptoms of dementia, not caused by Alzheimer's disease, alongside mild hallucinations or delusions, which are considered psychotic symptoms), osteoarthritis (joint disease), and age-related debility (a gradual decline in physical and mental function that occurs with aging). The Minimum Data Set (an assessment tool) dated 10/18/2024, documented the resident could understand and was understood by others with severe cognitive impairment for daily decision making. During the observation of a facility security video with no audio that was recorded on 10/27/2024 at 6:50 PM, there was an unobstructed view of the resident in a hallway. The resident was observed sitting in a wheelchair by the nurses' desk on their unit. Resident #2 attempted to open a door to a lounge area. Certified Nurse Aide #1 was seen verbally saying something to the resident. Certified Nurse Aide #1 was observed throwing a water bottle at the resident, which missed them. The Certified Nurse Aide #1 was then noted to go and pick up the bottle of water and return back behind the desk as another staff member came into the camera view. Certified Nurse Aide #1 was observed to throw the water bottle at the resident for a second time, which struck the resident on their right side. The water bottle cap separated from the bottle, and water sprayed onto the Resident #2's back. Certified Nurse Aide #1 then approached Resident #2 and pulled the lounge door closed. Certified Nurse Aide #2 is seen intervening, specifically going to Resident #2, guiding the resident wheelchair away from the situation and down the hall. The Comprehensive Care Plan for activities of daily living, initiated on 4/08/2024, documented the resident could self-propel in their wheelchair around the unit with supervision. They were not at risk of elopement but needed gentle redirection. cap flew off the bottle, and water sprayed all over the resident. During an observation on 11/04/2024 at 10:20 AM, Resident # 2 was found by the nursing station on their unit self-propelling in their wheelchair with no signs or symptoms of distress. The resident was in good spirits, talking and smiling with staff. The resident was clean and without odor and dressed appropriately. During an observation on 11/05/2024 at 5:00 PM, Resident #2 was in the main dining room on their unit having dinner with another. The resident demonstrated no signs or symptoms of distress. During an interview on 11/04/2024 at 11:07 AM, Certified Nurse Aide #2 stated they had been working on the evening shift of 10/27/2024 with Certified Nurse Aide #1. They stated they weren't aware that Certified Nurse Aide #1 had thrown the bottle at the Resident #1 more than once until the video was reviewed. They stated Certified Nurse Aide #1 was upset and angry when they reached the desk after caring for someone else; They were swearing and then threw the bottle at the resident and hit them in the back. Certified Nurse Aide #2 stated they were at first shocked and scared, but when the Certified Nurse Aide #1 went around the desk towards the resident, they went over and removed Resident #2 from the situation, 'and looked for someone to tell.' Certified Nurse Aide #2 stated they informed a Licensed Practical Nurse and went to keep an eye on Certified Nurse Aide 1. They stated that afterward, Resident #2 was not near Certified Nurse Aide #1 again; Registered Nurse Supervisor came to the unit and made Certified Nurse Aide #1 leave the facility. Certified Nurse Aide #2 stated staff reeducation was started because they should have called security immediately. During an interview on 11/04/2024 at 11:29 AM, Medical Director #1 stated they were aware of the incident but did not review the video. They stated Resident #2 had not shown any signs of injury after being assessed by the Registered Nurse and monitoring for signs of psychological abuse was continuing. During an interview on 11/04/2024 at 3:28 PM, Licensed Practical Nurse #2 stated that on 10/27/2024, Certified Nurse Aide #2 informed them that Certified Nurse Aide #1 had thrown a water bottle and swore at Resident #2. They stated they called Registered Nurse Supervisor, and there was a delay on them arriving to the unit. They stated that during that time, Licensed Practical Nurse #2 told the Certified Nurse Aide #2 to watch Certified Nurse Aide #1, and they sent another staff member to go find the Supervisor. Licensed Practical Nurse #2 stated that they 'made sure Certified Nurse Aide #1 didn't harm anyone else but couldn't make Certified Nurse Aide #1 leave. Once the supervisor arrived, they called security and Certified Nurse Aide #1 was walked out of the building by security.' During an interview on 11/04/2024 at 3:46 PM, Registered Nurse #4 stated they were called to the unit on 10/27/2024 around 6:55 PM and was informed that Certified Nurse Aide #1 had abused Resident #1. Registered Nurse #4 removed Certified Nurse Aide #1 from the floor, took them to the nurses' station and conducted an interview, notified security, and had the aide removed from the facility. Registered Nurse #4 further stated that Director of Nursing #1 and Administrator #1 were notified, both arriving to the facility around 7:15 PM that evening (10/27/2024). Registered Nurse #4 further stated Resident #1 was assessed for physical and psychosocial injury and was placed on 24-hour monitoring to ensure they had no injuries that had not been found could be addressed. Stated reeducation was given to Certified Nurse Aide #2 because there was a delay in removing the perpetrator, Certified Nurse Aide #1, and should have been removed immediately. Registered Nurse #4 further stated Certified Nurse Aide #2 expressed to them that they were afraid and removed the resident, told the Licensed Practical Nurse #2, and then followed Certified Nurse Aide #1 until the supervisor arrived. Registered Nurse #4 stated staff should have called security to the unit; when the Director of Nursing #1 arrived, they took over the investigation. Registered Nurse #4 stated local police were notified and arrived to review the video that had been retrieved by Director of Nursing #1, that is when it was discovered the gravity of the situation. The resident's family and the physician were notified of the abuse. Resident #2's Comprehensive Care Plan for abuse was implemented. During an interview on 11/04/2024 at 4:03 PM, Director of Nursing #1 stated they were notified around 7:00 PM on 10/27/2024 that a staff member had abused Resident #2. By the time Director of Nursing #1 and the Administrator #1 arrived at the building, Resident #2 had been assessed for injury and Certified Nurse Aide #1 was no longer in the facility. The physician was notified, and the video was viewed. The video demonstrated the aide had thrown the bottle at the resident twice and had struck them in the back once. Police were notified and the resident's family member was notified. Reporting to the New York State Department of Health reporting line was completed, an investigation began, and other residents that Certified Nurse Aide #1 had cared for over the last month were assessed for any signs or symptom or complaints of abuse. Director of Nursing #1 stated they reviewed video of units that Certified Nurse Aide #1 had worked on. They stated the facility investigation revealed the facility policy and procedure for reporting abuse had not been followed, and that there had been a delay in removing the perpetrator from any resident access. Director of Nursing #1 stated that as of result, all staff were immediately reeducated; facility-wide reeducation was started and by 11:00 PM on 10/27/2024, all staff in the building had completed it. They stated that after education by the staff educator and by all supervisors using a PowerPoint on abuse, a post-test with a required score of 100 percent was given to all staff from all departments prior to staff delivering care to any of the residents; calls and e-mails were completed to all staff that had not worked during the timeframe education was being given in the first 24 hours to report to education department for reeducation on abuse, neglect and reporting prior to providing resident care. They stated that it was determined no harm had occurred, but the resident had been monitored daily on every shift. They further stated that Certified Nurse Aide #1 had been suspended, and a hearing was held, and the facility were in the process of terminating them. During an interview on 11/05/2024 at 5:00 PM, Administrator #1 stated the Certified Nurse Aide #1 was suspended and in the process of being terminated for the 'obvious' abuse of Resident #2. They stated that video documenting the abuse had been viewed by the Police and it would be determined by the health care proxy whether charges would be filed against the perpetrator. They further stated that education was ongoing. During an interview on 1/31/2025 at 1:35 PM, Administrator #1 stated Director of Nursing #1--who was at the facility when the deficient practice was reported on 10/27/2024 and notified the New York State Department of Health--was no longer working at the facility. Administrator #1 stated they were involved from start to finish of education for all staff, from all departments, on the reeducation for abuse and neglect and reporting any concerns of resident abuse immediately. Administrator #1 stated Certified Nurse Aide #2 had been removed from the building by security on 10/27/2024 after being interviewed by the supervisor prior to their arrival at the facility. They further stated investigation and reporting began immediately, and everything was done to ensure the wellbeing of the resident who had been assessed for injury. Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: 1. Beginning on 10/27/2024 at 7:00 PM, both the Director of Nursing #1 and the Administrator #1 responded to the facility when informed of Resident #2 abuse incident. Reeducation immediately began and continued until completed on 11/04/2024. 2. Reeducation with Power Point on Policy and Procedure for Abuse and Neglect and Reporting with required post-test requiring 100 percent score. 3. Reeducation done on the spot for anyone unable to verbalize proper sequence on reporting abuse and neglect. 100 percent of reeducation was completed on 11/04/2024 prior to survey entrance at 9:00 AM. 4. Facility Quality Assurance reviewed for abuse/neglect and reporting education with updating of the Policy and Procedure and orientation of all staff on hire. 5. Reeducation of all staff on reporting other staff if policy and procedures are not followed by Supervisors or staff was completed by 11/04/2024 at 9:00 AM. 6. Beginning on 10/27/2024 at 7:00 PM, 100 percent facility-wide education on abuse/neglect and reporting was completed with all facility staff before beginning their shift and caring for any residents. All reeducation for staff had been completed by 11/04/2024 either in person or by phone with testing being required before the beginning of their next shift for resident care. Education was given to all facility staff which included nursing, maintenance, administration, housekeeping, security, activities department, and dietary. Anyone with any access to the residents were required to have the updated in-service on abuse and neglect and complete the post-test before beginning their shift. This was accomplished by 11/04/2024. A record of who had received the training and post-test was provided to the surveyor on 11/04/2024 by Administrator #1. 7. 100 percent of all staff had been notified by phone or email to report for reeducation and in-servicing on policy changes with abuse/neglect and reporting before beginning their shift and completing posttest required with a score of 100 percent. This was completed by 11/04/2025 by 9:00 AM. 8. Above actions of correction had been completed prior to survey enter on 11/04/2024 at 9:00 AM. 9. Facility reported within regulatory timelines to New York State Department of Health per regulation. 10. Facility investigation of the incident initiated upon notification with Resident #2 and staff failure to follow immediate reporting. 11. On 10/27/2024, Certified Nursing Aide #1 was removed from resident care and suspended pending outcome of the investigation on abuse prior to video review. 12. On 10/27/2024, Family and Physician Notification completed immediately upon review of the video demonstrating abuse had occurred. 13. Resident #2 Comprehensive Care plan for victim of abuse implemented on 10/27/2024 with interventions and person-centered plan. 14. Reporting to local police with referral to health care proxy completed on 10/27/2024 at 9:00 PM. 15. Reporting to New York State and Attorney General and New York State Nurse Aide Registry detailing abuse by Certified Nurse Aide #1 against Resident #2 completed on 10/27/2024. 16. Review of video of the unit of the prior two weeks leading into event, specifically when Certified Nurse Aide #1 was working. 17. All residents reviewed for any unusual finding and incidents that had occurred if they had been cared for by Certified Nurse Aide #1. 10 New York Codes, Rules and Regulations 415.4(b)(1)(i)

Based on observation, record review, and interviews during a recertification survey from 4/25/2023 to 5/2/2023, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 4 (Resident #'s 43 92, 98, and 174) of 4 residents reviewed for Activities of Daily Living related to sufficient staffing. Specifically, for Resident #92, 98, and 174, the facility did not ensure residents, who were unable to carry out activities of daily living, received their weekly showers to maintain good personal hygiene. Additionally, for Resident #43, the facility did not ensure the resident received staff assistance with eating on 4/27/2023 in accordance with the comprehensive care plan. This is evidenced by: Finding #1: Specifically, for Resident #92, 98, and 174, the facility did not ensure the residents, who were unable to carry out activities of daily living, received their weekly showers to maintain good personal hygiene. The Policy and Procedure (P&P) titled Bathing, dated 4/8/2020, documented it was the policy of the facility that residents would receive either a shower or tub bath at least once a week. Resident #92: Resident #92 was admitted to the facility with diagnoses of dementia, depression, and generalized osteoarthritis. The Minimum Data Set (MDS - an assessment tool) dated 1/17/2023, documented the resident had severely impaired cognition, could sometimes understand others, and could sometimes make themselves understood. The Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADLs), dated 1/10/2023, documented the resident needed maximal assist for ADLs. The CNA (Certified Nursing Assistant) Assignments Summary, print date 5/1/2023, documented the resident's bathing schedule was Friday on the 3 PM - 11 PM shift. The CNA documentation titled Bathing, dated 4/28/2023, documented Not Performed - N/A for the resident's bathing on the 3 PM - 11 PM shift. B1 Nursing Unit staffing sheets, dated 4/28/2023, documented: - 3:00 PM - 11:00 PM, 1 Licensed Practical Nurse (LPN) and 2 CNAs. A review of progress notes dated 4/28/2023 did not include documentation the resident refused their shower. During an interview on 4/28/2023 at 6:03 PM, LPN #9 stated on B1 there was 1 nurse and 2 CNAs for the evening shift. The LPN stated that was typical staffing and the staff tried their best. The LPN stated they did not know if the residents got their showers on the evening shift and stated the CNAs would be able to comment on the residents' showers. During an interview on 4/28/2023 at 6:08 PM, CNA #6 stated 3 or 4 residents were scheduled on the evening shift for showers, including Resident #92. The CNA stated they probably would not get a chance to give the residents' their showers this evening due to staffing. The CNA stated when there were 2 CNAs and 1 Nurse on the evening shift, the staff tried their best, but did not have time to give showers. During an interview on 5/01/2023 at 11:24 AM, LPN #6 stated the CNAs were supposed to report to a nurse when shower was not given. The LPN stated it should also be documented. The LPN stated when a CNA documented a shower or bath was not performed that meant the shower was not given on that shift. During an interview on 5/01/2023 at 1:07 PM, the Director of Nursing (DON) stated if showers could not be given on their scheduled shift, then showers were done another day when there was extra staff. The DON stated staff should let the nurse know when they were unable to give a shower. The DON stated it had been reported to them that staff were not able to get showers done due to staffing. The DON stated the facility had started a shower team but having that team in place was also dependent on having staff available. Resident #98: Resident #98 was admitted to the facility with diagnoses of chronic atrial fibrillation, hypertension, and chronic pain. The Minimum Data Set (MDS - an assessment tool) dated 3/17/2023, documented the resident was able to make themselves understood, able to understand others, and was cognitively intact. The Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADLs), reviewed 4/20/2023, documented the resident had showers scheduled every Friday on the 7 AM - 3 PM shift; one-person physical assist with upper body supervision was documented. The CNA documentation titled Bathing, dated 4/21/2023, documented Activity did not occur for the resident's scheduled shower by Certified Nurse Aid (CNA) #2. B3 Nursing Unit staffing sheets, dated 4/21/2023, documented: - 7 AM - 7:30 AM: 2 Licensed Practical Nurse (LPN) and 2 CNAs. - 7:30 AM - 3 PM: 1 Registered Nurse (RN), 1 LPN, and 2 CNA. - The facility census, dated 4/21/2023, documented 38 beds on the B3 Nursing Unit Progress notes dated 4/21/2023 were reviewed, they did not include documentation that the resident refused a shower. During an interview on 04/27/23 at 03:44 PM, RN #2 stated it was not uncommon for residents on the evening shift to have showers delayed or not performed due to staffing. When there were only 1 or 2 CNAs assigned to a unit, it was extremely difficult to get all the assigned showers completed and they did not always get done. Sometimes the residents could get their shower completed on an alternative day, but this did not always happen. The residents have complained about this. During an interview on 04/28/23 at 04:34 PM, CNA #2 stated they were unable to complete all their assigned daily resident showers because there was typically only 1 or 2 CNAs assigned to the unit, and that was not enough staff to complete the showers. When residents did not receive get their showers, they would try and provide them on another day, but this was not always possible. The facility tried to implement a shower team, but they did not always have the staff to provide this and they were not available on the evening shift. Resident #98 has complained about not having their showers provided. During an interview on 04/28/23 at 05:04 PM, Resident #98 stated their showers were scheduled every Friday, but they were not always provided because they had been told there was not enough staff to provide the showers. When their regularly scheduled showers were not provided, sometimes the staff would provide them the following week, but they would prefer to have their showers provided every Friday when they are scheduled. During an interview on 05/01/23 at 10:42 AM, LPN #2 stated Resident #98 had showers scheduled every Friday; these were typically performed by the CNAs and documented in the CNA documentation section in the Electronic Medical Record (EMR). Sometimes, Resident #98 did not receive their scheduled showers every Friday because there was not enough staff on the unit to provide them; the residents on the unit have complained about this. When showers were unable to be provided on the day they were scheduled, another shower should be provided and documented. According to the CNA documentation, Resident #98 last received a shower on 4/14/2023. During an interview on 05/01/23 at 10:59 AM, CNA #3 stated the residents all had showers scheduled weekly; the CNAs performed most of these. When there were only 2 CNAs on the unit, it was very difficult to complete all the resident showers as scheduled. On 4/21/2023, they thought Resident #98 may have refused their shower, but if they did it should have been documented as refused and reported to the nurse. They documented Resident #98's shower as Activity did not occur and did not recall reporting a refusal of shower to anyone that shift. Since there were only 2 CNAs working that night, it would have been very difficult to complete all the scheduled showers. During an interview on 05/01/23 at 11:10 AM, Resident #98 stated they refused a shower on 4/28/2023 because they were feeling ill but did not refuse their shower on 4/21/2023. They rarely refused showers, because they typically had hair appointments scheduled on Fridays, and they liked to go to their hair appointments after their shower; this was why they preferred to have their showers provided as scheduled on Fridays. During an interview on 05/01/23 at 12:18 PM, the Director of Nursing (DON) stated sometimes residents did not receive their scheduled showers because of short staffing. There was no documentation from 4/21/2023, documenting refusal of a shower by Resident #98. When residents refused a shower, it should be documented as refused, the charge nurse should be notified, and a progress note should be written. They were aware of complaints from residents related to not receiving showers. The facility implemented a shower team to support the units with resident showers. This was available from Monday - Friday on dayshift, but typically the members of this team had to be pulled into resident assignments at least twice a week due to staffing shortages, and the shower team was unavailable on these days. Resident #174: Resident #174 was admitted to the facility with diagnoses of vascular dementia, hypertension, and irritable bowel syndrome. The Minimum Data Set (MDS - an assessment tool) dated 1/27/2023, documented the resident had severely impaired cognition, could usually understand others, and could usually make themselves understood. The Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADLs), dated 7/27/2022, documented the resident needed minimal assist for ADLs. The CNA (Certified Nursing Assistant) Assignments Summary, print date 5/1/2023, documented the resident's bathing schedule was Wednesday on the 3 PM - 11 PM shift. The CNA documentation titled Bathing, dated 4/26/2023, documented Not Performed - N/A for the resident's bathing on the 3 PM - 11 PM shift. B1 Nursing Unit staffing sheets, dated 4/26/2023, documented: - 3:00 PM - 11:00 PM, 1 Licensed Practical Nurse (LPN) and 2.5 CNAs. A review of progress notes dated 4/26/2023 did not include documentation the resident refused their shower. During an interview on 4/28/2023 at 6:03 PM, LPN #9 stated on B1 there was 1 nurse and 2 CNAs for the evening shift. The LPN stated that was typical staffing and the staff tried their best. The LPN stated they did not know if the residents got their showers on the evening shift and stated the CNAs would be able to comment on the residents' showers. During an interview on 4/28/2023 at 6:08 PM, CNA #6 stated 3 or 4 residents were scheduled on the evening shift for showers, including Resident #174. The CNA stated when there were 2 CNAs and 1 Nurse on the evening shift, the staff tried their best, but did not have time to give showers. During an interview on 5/01/2023 at 11:24 AM, LPN #6 stated the CNAs were supposed to report to a nurse when shower was not given. The LPN stated it should also be documented. The LPN stated when a CNA documented a shower or bath was not performed that meant the shower was not given on that shift. During an interview on 5/01/2023 at 1:07 PM, the Director of Nursing (DON) stated if showers could not be given on their scheduled shift, then showers were done another day when there was extra staff. The DON stated staff should let the nurse know when they were unable to give a shower. The DON stated it had been reported to them that staff were not able to get showers done due to staffing. The DON stated the facility had started a shower team but having that team in place was also dependent on having staff available. Finding #2: Specifically, for Resident #43, the facility did not ensure the resident received staff assistance with eating on 4/27/2023 in accordance with the comprehensive care plan. Resident #43: Resident #43 was admitted with diagnoses including Alzheimer's Disease, old Cerebral Vascular Accident (CVA) with pseudobulbar affect, and delusional disorder. The Minimum Data Set (MDS, an assessment tool) dated 3/28/2023, documented the resident was sometimes understood and could sometimes understand others and was severely cognitively impaired. The Policy and Procedure (P&P) titled ADLs, dated 4/8/2020, documented it was the policy of the facility to do encourage the residents to do as much of their own care as possible and resident would receive assistance as needed and as care planned. The Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADLs), dated 3/21/2023, documented the resident limited assistance of one for eating. During an observation on 04/27/23 at 10:15 AM to 11:03 AM, Resident #43 was sitting in their wheelchair in the main dining area on Unit A2. The resident had a glass of orange juice (OJ) and a donut on the table in front of them. The resident had attempted to eat the donut and drink the OJ. The resident was having difficulty bringing the cup of juice to their mouth and had difficulty eating the donut. There were no staff was present in the dining room. The resident was spilling the food and drink on themselves with continued attempts to feed themselves. At 11:07 AM, Certified Nursing Assistant (CNA) #7 removed resident #43 from the dining room and wheeled the resident down to their room. During an interview on 4/27/2023 at 11:17 AM, CNA #7 stated the resident had been brought to the dining room and should have received help while eating. The resident had required more assistance with eating and drinking recently. The CNA was not aware if the nurse had been told that the resident was needing more assistance. During an interview on 4/27/2023 at 11:26 PM, Licensed Practical Nurse (LPN) #5 stated the resident had not eaten breakfast and someone should have assisted the resident once they brought them to the dining area. LPN #5 was not in their usual area where they could observe the resident and had not been told the resident was in the dining room eating. The LPN stated residents needing help with ADLs should not be left alone while eating. During an interview on 4/28/2023 at 11:17 AM, Registered Nurse Unit Manager (RNUM) #1 stated staff should have been present in the dining room assisting the resident as needed and should have documented the difficulty the resident was having feeding themselves. 10 NYCRR 415.12(a)(3)

Based on observation, interview, and record review during the recertification survey on 4/25/2023 through 5/1/2023, the facility did not ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for 2 (Resident #44 and 244) of 4 residents reviewed for dementia care. Specifically, for Resident #44 and #244, the facility did not ensure the development and implementation of person-centered care plans that included interventions specific to the residents and did not address the residents' customary routines, interests, preferences, or choices to enhance the resident's well-being related to their cognitive status. This is evidenced by: Resident #44: Resident #44 was admitted with diagnoses of dementia with behavioral disturbance, psychotic disorder with delusions due to known physical condition, and cerebral infarction. The Minimum Data Set (MDS-an assessment tool) dated 3/17/2023 documented the resident had severely impaired cognition, could sometimes understand others and could sometimes make themselves understood. The Comprehensive Care Plan (CCP) for Cognition dated 12/16/2019, documented the resident had dementia, with short-term and long-term memory loss. Interventions included: engage in appropriate social conversation, use external aids and cues to provide reminder to resident and to see the Activity Participation care plan. The CCP for Activity Participation dated 12/23/2019, documented the resident had impaired cognition. Interventions included: participate in music programs, pet therapy visits, provide 1:1 visits, and to provide monthly activity calendar. The care plan did not include interventions specific to the resident and did not address the resident's customary routines, interests, preferences, or choices to enhance the resident's well-being related to their cognitive status. During observations made on 4/25/2023 at 12:16 PM, 4/27/2023 at 10:00 AM and 12:10 PM, and 4/28/2023 at 2:15 PM and 5:25 PM, the resident was not observed interacting with other residents or staff. The resident was observed in their wheelchair in front of TV where they ate their meals with their back was to staff and residents, or was observed down left side hallway on the unit sitting in their wheelchair in front of the TV. Resident #244: Resident #244 was admitted with diagnoses of Alzheimer's disease, depressive disorders, and anxiety disorder. The Minimum Data Set (MDS-an assessment tool) dated 2/17/2023 documented the resident had severely impaired cognition, could usually understand others and could usually make themselves understood. The Comprehensive Care Plan (CCP) for Cognition 10/24/2022, documented the resident had Alzheimer's disease. Intervention included: observe for comprehension/understanding of task at hand, observe for facial expressions and resident attempts at gestures for indicators of comprehension, see Activity Participation care plan. The CCP for Activity Participation dated 10/24/2022, documented interventions that included: Provide 1:1 visit, participate in music programs, and provide pet therapy visits. The care plan did not include interventions specific to the resident and did not address the resident's customary routines, interests, preferences, or choices to enhance the resident's well-being related to their cognitive status. During an observation on: -4/25/2023 at 10:30 AM, the resident was in the dining room after breakfast and made attempts to stand from their chair. The resident's chair alarm went off. The staff asked the resident to sit back down. -4/28/2023 at 4:33 PM, the resident was in the dining room and stood up from their wheelchair. The chair alarm went off. The nurse asked the resident to sit back down. Another resident saw this interaction and stated, look at [Resident #244]. They have no compassion for these people. Look at [Resident #244] standing up. They won't help him. At 4:35 PM, Resident #244 stood up from their wheelchair and the alarm went off. The resident sat back down. At 5:27 PM, the resident stated they had to go to the bathroom and staff told the resident to sit down and get closer to the dining room table because dinner was coming. -4/28/2023 at 6:08 PM, the resident was in their wheelchair in front of the TV down the left side hallway on the unit. The resident attempt to stand from their wheelchair, and their chair alarm went off. The CNA asked the resident to sit back down. A review of Progress Notes documented: -4/23/2023 at 8:47 PM, the resident continued to attempt self-transfer out of wheelchair. -4/25/2023 at 10:17 PM, the resident was continuing to attempt self-transfers, needing frequent reminders to sit down and ask for assistance. -4/26/2023 at 10:49 PM, the resident was standing up in front of their wheelchair numerous times but when asked to sit back down, the resident did with no issues. -4/28/2023 at 9:09 PM. the resident continued to attempt to self-transfer through the entire shift, needing constant reminders. Interviews: During an interview on 4/28/2023 at 6:08 PM, Certified Nursing Assistant (CNA) #6 stated Resident #244 had a lot of falls and when there were 2 CNAs and 1 Nurse on the unit, it was difficult to keep an eye on the resident. The CNA stated the resident tried to get up from their wheelchair and their chair alarm would go off alerting staff the resident was trying to stand up. The staff would have the resident sit back down. The CNA stated they tried to keep an eye on the resident, but it was hard when they were in other resident's rooms providing care to watch Resident #244. During an interview on 5/01/2023 at 9:31 AM, Personal Care Aide (PCA) #1 stated Resident #244 stood up from their chair a lot and the chair alarm would go off. The PCA stated it was difficult to watch all the residents when there was not enough staff. The PCA stated they would offer the resident coffee, cookies, and 1:1 visits when there was time, but it was difficult to do those things when there was not enough staff to do activities with the residents. The PCA stated they tried their best to keep the residents occupied. During an interview on 5/01/2023 at 10:29 AM, CNA #4 stated Resident #244 wanted to walk, but there was not enough staff to help the resident walk. The resident needed to 2 staff to walk with them; one staff to help the resident with their walker, and one staff to follow with the resident's wheelchair. The CNA stated the staff used to be able to entertain the residents when they had more staff. The CNA stated staff tried to keep residents in the dining room or at nursing station so the nurses could watch them because it was hard for the CNAs to watch the residents when they were in rooms giving care. During an interview on 5/01/2023 at 10:41 AM, CNA #5 stated Resident #244 did not stay occupied with much of anything. They used to offer the resident fidget cubes or to watch TV, but the resident did not seem interested in those anymore. The resident used to walk but was now in a wheelchair so sitting in a wheelchair was agitating to the resident because the resident was used to being able to walk. For Resident #44, the CNA stated they had a hard time communicating with Resident #44. The CNA stated Resident #44 did not always respond to them and would just stare at the CNA when they spoke to them. The CNA stated Resident #44 did not do too much except watch TV, listen to music, and nap. During an interview on 5/01/2023 at 12:07 PM, the Director of Activities stated the activity participation care plans were an area that needed improvement and the care plans needed to be more person centered with the residents' likes and dislikes and with resident specific goals. An activities staff member was assigned to each unit, and that staff member was responsible for the activity participation care plan. The Director of Activities stated the behavior and cognition care plans were more of an interdisciplinary approach. The Director of Activities stated dementia care planning needed improvement, specifically for the facility's 2 designated dementia units A1 and B1, but also needed improvement for any resident in the facility who required a dementia care plan. The designated dementia units had assigned activities staff members on those units to run unit activities, but activities staff were not on the units after 4:00 PM. The Director of Activities stated since the COVID-19 pandemic they have not been able to put out a monthly activity calendar and it had been over 10 years since activities staff worked into the evening shift. During an interview on 5/01/2023 at 12:28 PM, the Activity Manager for Dementia Care stated the facility's 2 dementia units were secured units for resident's who wandered. The Activity Manager stated B1 (where resident #44 and #244 resided) was the higher functioning unit of the 2 dementia units. The Activity Manager stated the care plans for dementia care and activity participation should be resident-centered to reflect the resident's current interests and abilities related to their cognition. The Activity Manager stated the electronic medical record system had a library of interventions that staff were able to choose from, but those interventions should then be tailored to the resident's specific preferences. The Activity Manager stated this was important because the care plan was the staff's guide to managing the resident's needs. During an interview on 5/01/2023 at 12:59 PM, the Director of Nursing (DON) stated the facility did not have a policy specific to dementia care. The DON stated the charge nurses on the units and supervisors were responsible for care planning dementia care. The DON stated the activity staff played a role in the care planning, and nursing should be collaborating with activities when developing the care plans for dementia care. The DON stated nursing was responsible for individualizing the care plans for each resident and it was an all hands on deck approach when it came to care planning. 10NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during a recertification survey dated 4/25/2023 through 5/1/2023, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 6 (Resident #'s 3, 43, 91, 120, 219 and 243) of 35 residents reviewed. Specifically, for Resident #3, the facility did not ensure a comprehensive care plan was in place to address care of a suprapubic urinary catheter; for Resident #43, the facility did not ensure comprehensive care plans were developed and implemented for psychotropic medication monitoring, activities of daily living (ADLs) related to the resident's feeding ability, behavior monitoring, and participation in activities; for Resident #91, the facility did not ensure a CCP was implemented for activities and urinary catheter that was resident specific with goals and interventions; for Resident #120, the facility did not ensure a communication care plan to address the needs of the resident with aphasia and impaired communication was developed and implemented; for Resident #219, the facility did not ensure an activity care plan for a resident with specific needs due to age and disability was developed and implemented; and for Resident #243, the facility did not ensure the Behavior Symptoms care plan was implemented when the resident's whereabouts on the unit was not monitored by staff in accordance with the care plan to prevent injury from wandering into the rooms of the other residents and did not ensure the Activity Participation care plan included person-centered interventions and meaningful activities. This is evidenced by: The Policy and Procedure titled Care Planning dated 5/2022, documented residents will have a comprehensive person-centered care plan identifying resident's strength, goals, life history and preferences in place to guide their care. Resident #3: Resident #3 was admitted with diagnoses of diabetes mellitus, neurogenic bladder, and end stage renal disease (ESRD). The Minimum Data Set (MDS- an assessment tool) dated 3/10/2023 documented the resident was cognitively intact, was understood by others and was able to make their needs known. The Comprehensive Care Plan did not include a care plan to address the care and management of the resident's suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow). A physician order dated 2/28/2023 documented suprapubic catheter care every shift. A physician order dated 2/28/2023 documented flush suprapubic catheter with 60 cc of normal saline once a day and as needed. During an interview on 5/1/2023 at 11:09 AM, the Assistant Director of Nursing (ADON) stated the care plans were initiated by the supervisors and reviewed with the MDS assessments. During an interview on 5/1/2023 at 11:27 AM, the Director of Nursing (DON) stated the nursing supervisor, or the admission nurse was responsible to initiate care plans for every diagnosis that was being treated. A care plan with goals and interventions for the care and management of a suprapubic catheter should have been initiated when the resident was readmitted with the new diagnosis. Resident #120: Resident #120 was admitted to the facility with diagnoses of Aphasia (loss of ability to understand of express speech caused by brain damage), diabetes mellitus, and hypertension. The Minimum Data Set (MDS- an assessment tool) dated 3/24/2023 documented the resident had moderate cognitive impairment, was usually able to understand others and usually able to make themselves understood. During an interview on 4/26/2023 at 10:27 AM, resident #120 reported feeling frustrated and demonstrated frustration by shaking their hands and holding their head when they struggled to say the words they wanted to say. On 4/27/2023 at 10:08 AM, the CCP did not include a care plan to address the care needs of the resident with impaired communication skills related to aphasia. During an interview on 4/27/2023 at 10:17 AM, Licensed Practical Nurse (LPN) #6 said they thought there was a communication care plan in place for resident #120 but was not able to locate it in the medical record, a care plan with interventions to assist the resident and staff to improve communication should be developed. LPN #6 also said the care plans are initiated by the Registered Nurse (RN) and then the LPN's have access to review and update the care plans as needed. During an interview on 4/27/2023 at 10:49 AM, the LPN unit manager; LPN #7 said the communication care plan was discontinued on 11/27/2022 when the resident was discharged to the hospital, and it should have been reactivated upon readmission on [DATE]. LPN #7 said the admission nurse initiates or reactivate the care plans and the LPN's review and update them. The communication care plan interventions should include to encourage slow speech, to ask yes or no type questions, and non-pressured communication. During an interview on 5/1/2023 at 12:39 PM, the Administrator said a communication care plan with person centered interventions should have been implemented for resident #120. Care plans are reviewed and reactivated upon readmission from a hospitalization and quarterly during care conferences and this should have been identified and updated. During an interview on 5/1/2023 at 12:47 PM, the Director of Nursing (DON) said the baseline care plan is developed by the admission nurse, the unit managers and the interdisciplinary team (IDT) review and revise the care plans with quarterly assessments and as needed. A communication care plan with person centered interventions and measurable goals should have been developed for the resident with the diagnosis of aphasia. Resident #243: Resident #243 was admitted with diagnoses of dementia with behavioral disturbance, post-polio syndrome, and pain. The Minimum Data Set (MDS-an assessment tool) dated 1/27/2023 documented the resident had severely impaired cognition, could rarely/never understand others and could rarely/never make themselves understood. The Comprehensive Care Plan (CCP) for Behavior Symptoms dated 11/1/2022 documented the resident was noted to be wandering on unit and in and out of resident's rooms at times. The goal was that the resident would not sustain injury due to wandering through the next review. Interventions included: Monitor resident's whereabouts, see Activity Participation Care Plan and redirect negative behaviors. The CCP for Activity Participation dated 7/28/2022 documented the resident had impaired cognition and was pleasantly confused. Interventions included: provide 1:1 visit, participate in music programs, and provide pet therapy visits. During an observation on 4/25/2023 at 2:25 PM, Resident #243 was wandering in their wheelchair and went into another resident's room. The resident wheeled into the bathroom of the other resident's room. Staff were not present. The surveyor made the staff aware who were seated at the nurses station. Certified Nursing Assistant (CNA) #5 stated they were not aware the resident was in another resident's room and got up from the nurses station to assist the resident out of the other resident's room. During an observation on 4/28/2023 from 4:37 PM to 5:35 PM, Resident #243 was in the dining room at a table, sitting in their wheelchair. The resident's back to the windows and they were blocked in at the table by other residents' in reclining, high back wheelchairs who were also seated at the table. Resident #243 was unable to move away from the table, was not offered an activity at the table, was unable to look out the window or see the TV, and was not seated with other residents who were awake. During an interview on 5/01/2023 at 9:31 AM, Personal Care Aide (PCA) #1 stated Resident #243 wandered in the wheelchair every day and on every shift. The PCA stated the resident went in and out of other resident rooms and it could get other residents upset. The staff tried to keep an eye out for the resident, but the resident wandered every day. During an interview on 5/01/2023 at 10:29 AM, CNA #4 stated Resident #243 wandered room to room in their wheelchair and other residents did not want them in their rooms. The CNA stated the staff tried to keep the resident in the dining room or near the nursing station so the nurses could watch them. The CNA stated it was difficult to watch the resident when the staff were in resident rooms providing care. The CNA stated staff used to be able to entertain the residents more when they had more staff but were no longer able to do that. During an interview on 5/01/2023 at 10:41 AM, CNA #5 stated Resident #243 wandered in and out of resident rooms at random. Other residents would yell at them to get out of their rooms. The CNA stated they tried to monitor where the resident was by walking around the unit, but stated they were often busy caring for other residents and could not keep up with Resident #243. The CNA stated the staff did the best they could watching the residents with 2 CNAs caring for 40 residents on the unit. The CNA stated activity came down to the unit and did some activities with the residents, but the CNA wished the staff on the unit had more time to do individual activities with the residents. During an interview on 5/01/2023 at 11:24 AM, Licensed Practical Nurse (LPN) #6 stated they did not typically work on this unit, and they were unable to discuss specifics related to Resident 243's care plan. The LPN stated they did not know the resident. The LPN stated not much happened for activities on unit after 4:00 PM and they tried to keep the residents in areas that had high visibility. During an interview on 5/01/2023 at 12:56 PM, the Director of Nursing (DON) stated it was the responsibility of the LPN on the unit to ensure care plans were implemented. If the LPN on the unit was not familiar with the residents, they should talk to the nursing supervisor and the supervisor would be able to walk them through the resident's care plans. The DON stated the staff should be monitoring that residents did not wander into other resident rooms as this puts the wandering resident at a higher risk for resident-to-resident altercations. 10NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during a recertification survey the facility did not ensure that it 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 three (Resident #'s 43, 91, and 219) of 3 residents reviewed for activities. Specifically, the facility did not ensure that Resident #'s 43, 91 & 219 were provided with activities on an ongoing basis according to the residents' Comprehensive Care Plans and that activities provided met the residents' preferences. This is evidenced by: Resident #43 Resident #43 was admitted with diagnoses including Alzheimer's Disease, old Cerebral Vascular Accident (CVA) with pseudobulbar affect, and delusional disorder. The Minimum Data Set (MDS, an assessment tool) dated 3/28/2023, documented the resident was sometimes understood and could sometimes understand others and was severely cognitively impaired; required extensive assistance for most activities of daily living (ADLs). The CCP for Activity Participation dated 3/21/2023 documented the resident had impaired cognition as evidenced by dementia. Goals included: Resident will receive social stimulation in room, provide 1:1 visit, pet therapy for the next 90 days, Resident will attend bingo 1-2 times per month. Resident will continue to plan own leisure time activities by watching TV shows and or reading magazines for the next 90 days. Interventions included: Provide 1:1 visits especially when resident is presenting with combative behaviors. Pet therapy visits, promote participation in spiritual or religious activities. Maintain preferred independent leisure activities. Updated 4/28/23: When resident is combative and having behaviors, activities will provide music in the room or quiet space or radio in the dining room to de-escalate behaviors. See activity assessment note written 3-24-2023. Record Review of the Activity Log for Resident #43 for March and April 2023 provided documentation of three 1:1 visits on the following dates 4/05, 4/14, and 4/16/2023. Documentation did not include the length of the visit , who conducted the visit,or details of visit outcome. During an observation an on 04/26/23 10:29 AM, Resident #43 was lying in bed awake. No activities were scheduled for Unit A-2. During an observation on 4/27/2023 at 10:15 AM to 10:45 AM, Resident #43 was observed alone in the dining area sitting in a wheelchair. No music or activities were being provided. During an observation on 4/28/2023 at 5:00 PM, Resident #43 was sitting in their designated room sleeping in their wheelchair. During an interview on 4/27/2023 at 10:50 AM, Certified Nursing Assistant (CNA) #7 stated there were no activities planned for the residents. The activity person for the unit had left about a month ago and hadn't been replaced. Because of staffing levels unit staff were not able to provide activities. The residents watched TV most of the time and group acuities had been suspended since the pandemic. No activity calendars were available, and they weren't sure how residents were notified about activities. They were not aware if Resident #43 received 1:1 visits or who would have done those visits. During an interview with on 4/27/2023 at 11:07 AM, Licensed Practical Nurse #5 (LPN) no activities occurred in the facility after 3:30 PM. There is only one activity staff in the facility on the weekend. A chalk board on the unit sometimes had an activity on it but the residents did not receive an activity calendar. Unit A2 had no designated activity person since the previous one left and no pet visits had occurred for a long time. Residents that have behaviors could benefit from activities staff to keep them occupied but staffing doesn't allow other staff to provide activities to residents. During an interview on 4/27/2023 at 4:07 PM, the Director of Activity (DA) reviewed the activity care plan for Resident #43 implemented on 3/21/2023 and stated the resident had no documented hours for any activities. The activity person assigned to Unit A2 had left and the facility had been unable to replace that person. There were no activities after 3:30 PM. Activity staff hours had been adjusted because most of the staff were CNAs and were needed to provide care to the residents. There was only one activity staff on the weekend for the whole facility. Group activities had been stopped during COVID and the calendar for activities had been discontinued. Resident #91 Resident #91 was admitted with diagnoses including peripheral vascular disease (PVD), Cerebral Vascular Accident (CVA) and obstructive uropathy. The MDS dated [DATE], documented the resident was understood and could understand others and was cognitively intact. for decisions of daily living. The CCP for Activity Participation dated 2/21/2023 documented the resident preferred solitary activities. Goals included: Resident will receive social stimulation in room, provide 1:1 visit, pet therapy for the next 90 days, Resident will continue to plan own leisure time activities by watching TV shows and or reading for the next 90 days. Interventions included: Provide 1:1 visit, Pet therapy visits, Maintain preferred independent leisure activities. Updated 4/17/23: Quarterly Review Due to COVID 19 we no longer doing large group activities we are doing more one to one due to unit closures per CDC guidelines. When unit is open, we are doing small groups on the unit. Current plan continued. Record Review of the Activity Log for Resident #91 for February, March, and April 2023 provided documentation of five 1:1 visits on the following dates 2/22, 3/2, 3/10, 3/31, 4/17, 4/19, and 4/27/2023. Documentation did not include the length of the visit , who conducted the visit,or details of visit outcome. During an interview on 04/26/23 at 10:15 AM, Resident #91 stated they hadn't been at the facility very long. We sit around there is nothing to do. During an interview on 04/27/23 at 09:30 AM, The Registered Nurse Unit Manager #1 (RNUM) stated the resident was alert and able decide if they would like to participate in activities, but no activities were available most days. The RNUM was unaware of any pet visits or 1: 1 visits for Resident #91. The resident is usually either in their room or in a sitting area watching TV. Staff are unable to provide any activities due to staffing . During an interview on 4/28/2023, The Quality Control Registered Nurse (QCRN) stated they have been trying to focus on the Activity Program. Activities like crafts and group activities had been stopped during COVID . Staffing is a problem when it comes to floor staff providing any activities. Residents that are alert and oriented but need assistance need something more than what had been currently provided. Resident #219 Resident #219 was admitted with diagnoses including Quadriplegia, hypertension, neurogenic bladder, and depression. The MDS dated [DATE], documented the resident was understood and could understand others and was cognitively intact for decisions of daily living. Record Review of the Activity Log for Resident #43 for January to April 2023 provided documentation of 10 1:1 visits on the following dates 1/24, 2/1, 2/6, 2/17, 2/24, 3/1, 3/8, 3/14, 3/24, and 4/16/2023. Documentation did not include the length of the visit , who conducted the visit,or details of visit outcome. The Activities Comprehensive Care Plan implemented on 4/20/22, Resident #219 was care planned for 1:1 visits. The CCP updated 4/13/2023 documented the following: Due to Covid -19 we are no longer doing group activities, due to unit closures per CDC guidelines. When unit is open, we are doing small group activities on the unit. Resident continues to plan their own leisure time activities evidenced by watching TV shows daily and watching Netflix and using their tablet. During an interview on 04/26/2023 at 11:49 AM. The RNUM stated there had been few activities since the pandemic. There is no activities calendar and if there are activities, they are written on the chalk board as you enter the unit. Residents watch television or just sit in the dining room. No music is played during meals and due to staffing challenges the CNAs are not able to provide any activities in the evening or weekends. During an interview on 4/27/2023 at 11:17 AM, Resident #219 stated we have no activity person for this unit. The resident stated they leave the facility as much as they can. During an interview on 04/27/23 04:14 PM, the Activities Director stated activities had been difficult and challenging during the pandemic. The facility was down one fulltime position for Unit A2. No activities were available after 3:30 PM and only one activity staff is scheduled for the entire facility on weekends. Many of the activity staff were CNA's and often diverted to do resident care when the facility was short staffed. Resident #219 calls star Bus and has no interest in group activities the facility offers as they don't appeal to young residents. Additionally, 1:1 visit are rare. We are still recovering from the COVID pandemic it is hard to get anyone to come and volunteer for music and pet therapy. The residents need more activity and we are attempting to get things back up and running but staffing has also impacted the quality and types of activities the residents receive. During an interview on 5/1/2023 at 1:57 PM, the Administrator (ADM) stated the Activity Program had suffered due to staffing and COVID. The facility was working on how to provide activities for all the residents. Currently there were no activities after 3:30 PM or on weekends due to staffing challenges. 10NYCRR 415.5(f)(1)

Based on observations, interviews and record review during the recertification survey, the facility did not ensure provision of sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility did not ensure the desired staffing levels for Nurses and Certified Nurse's Aides (CNAs) as documented in the Facility Assessment and reported by the Staffing Coordinator, were met 7 of 7 calendar days from 4/24/2023 to 4/30/2023. As a result of the insufficient staffing, the Resident Council and nursing staff reported resident care activities were unable to be completed and specifically, for Resident #92, 98, and 174, the facility did not ensure residents, who were unable to carry out activities of daily living, received their weekly showers to maintain good personal hygiene related to insufficient staffing. This is evidenced by: Refer to 677 Finding #1: Specifically, the facility did not ensure the desired staffing levels for Nurses and Certified Nurse's Aides (CNAs) as documented in the Facility Assessment and reported by the Staffing Coordinator, were met 7 of 7 calendar days from 4/24/2023 to 4/30/2023. As a result of the insufficient staffing, the Resident Council and nursing staff reported resident care activities were unable to be completed. During a Resident Council Meeting on 4/26/2023 at 10:30 AM, the Council stated that staffing levels in the facility were a concern. The Council stated at times, there were 1 CNA and 1 Nurse on the day shift for 40 residents, but it was common for staffing to be 2 CNAs and 1 nurse for 40 residents. The Council stated there were several issues related to the facility not having enough staff, which included long wait times to use the bathroom (up to 1 hour), residents having episodes of incontinence because they have to wait too long to use the bathroom, residents falling on the floor because staff were not around, and residents missing breakfast because there was not enough staff to get everyone up timely. The Council stated their concerns related to staffing have been reported during Resident Council Meetings. A review of Resident Council Meeting Minutes dated 4/13/2023, documented a resident spoke of concerns related to staffing shortages at night. The resident stated they heard other residents yelling out for assistance but there was not enough staff on the floor to assist them in a timely manner. The DON agreed that staffing had been an issue and the facility was working very hard to recruit and hire staff. The Facility assessment dated 1/2023, documented the average daily census was 258 with a daily staff assignment as follows; day shift - 27 nurses and 45 CNAs, evening shift - 10 nurses and 13 CNAs, and night shift - 10 nurses and 15 CNAs. A handwritten note sheet provided by the facility Staffing Coordinator and reported to be the current minimum staffing given to them by the Director of Nursing (DON), documented; 7-3 nurses 16, CNAs 18. 3-11 nurses 12, CNAs 18. 11-7 nurses 9, CNAs 12. A review of the Daily Staff Reports dated 4/24/2023 to 4/30/2023 documented the facility did not meet their assessed minimum number of nurses on: 4/24/23 evening shift - 10 4/25/23 day shift - 13.5; evening shift - 10.5 4/26/23 evening shift - 9 4/27/23 day shift -15; evening shift 11; night shift 8 4/28/23 evening shift - 9 4/29/23 evening shift - 7; night shift - 6 4/30/23 evening shift - 9 A review of the Daily Staff Reports dated 4/24/2023 to 4/30/2023 documented the facility did not meet their assessed minimum number of CNAs on: 4/24/23 evening shift - 15; night shift - 9 4/25/23 day shift - 16; evening shift - 15.5; night shift - 10 4/26/23 evening shift - 17 4/27/23 day shift -17; evening shift 12 4/28/23 day shift - 12; evening shift - 16 4/29/23 day shift - 15; evening shift - 9; night shift - 9 4/30/23 evening shift - 12 During an interview on 4/27/2023 at 10:50 AM CNA #1 stated it was very difficult to provide good care to the residents when there are only 2 CNAs on the unit. CNA #1 stated they often come in 1-2 hours before their shift starts to make sure everything gets done. During an interview on 05/01/23 at 11:27 AM the facility Staffing Coordinator stated they did not use the minimum staffing numbers from the Facility Assessment. The DON provides updates to the minimum staffing as needed. The current numbers are 7-3 is 16 nurses and 18 CNAs, 3-11 is 12 nurses and 18 CNAs, and 11-7 is 9 nurses and 12 CNAs. We frequently do not meet the minimum numbers or when we do there are call outs and no shows. We will call the agencies and offer $100 bonus to staff that will stay or come in for a 4-hour shift. I let the DON know if we are short and she will make some calls and offers to staff to get them to come in. We just don't have enough staff, the ones we have are great, but they can only work so much. During an interview on 05/01/23 at 11:48 AM the DON stated we meet the minimum staffing about 50% of the time. We offer incentives and bonuses to encourage our staff to work extra shifts. We are always trying to recruit new staff, but it is difficult because our pay rate is not competitive with other local facilities. Finding #2: Specifically, for Resident #92, 98, and 174, the facility did not ensure residents, who were unable to carry out activities of daily living, received their weekly showers to maintain good personal hygiene related to insufficient staffing. The Policy and Procedure (P&P) titled Bathing, dated 4/8/2020, documented it was the policy of the facility that residents would receive either a shower or tub bath at least once a week. Resident #92: The Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADLs), dated 1/10/2023, documented the resident needed maximal assist for ADLs. The CNA (Certified Nursing Assistant) Assignments Summary, print date 5/1/2023, documented the resident's bathing schedule was Friday on the 3 PM - 11 PM shift. The CNA documentation titled Bathing, dated 4/28/2023, documented Not Performed - N/A for the resident's bathing on the 3 PM - 11 PM shift. B1 Nursing Unit staffing sheets, dated 4/28/2023, documented: - 3:00 PM - 11:00 PM, 1 Licensed Practical Nurse (LPN) and 2 CNAs. A review of progress notes dated 4/28/2023 did not include documentation the resident refused their shower. During an interview on 4/28/2023 at 6:08 PM, CNA #6 stated 3 or 4 residents were scheduled on the evening shift for showers, including Resident #92. The CNA stated they probably would not get a chance to give the residents' their showers this evening due to staffing. The CNA stated when there were 2 CNAs and 1 Nurse on the evening shift, the staff tried their best, but did not have time to give showers. During an interview on 5/01/2023 at 11:24 AM, LPN #6 stated the CNAs were supposed to report to a nurse when shower was not given. The LPN stated it should also be documented. The LPN stated when a CNA documented a shower or bath was not performed that meant the shower was not given on that shift. Resident #98: The Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADLs), reviewed 4/20/2023, documented the resident had showers scheduled every Friday on the 7 AM - 3 PM shift; one-person physical assist with upper body supervision was documented. The CNA documentation titled Bathing, dated 4/21/2023, documented Activity did not occur for the resident's scheduled shower by Certified Nurse Aid (CNA) #2. B3 Nursing Unit staffing sheets, dated 4/21/2023, documented: - 7 AM - 7:30 AM: 2 Licensed Practical Nurse (LPN) and 2 CNAs. - 7:30 AM - 3 PM: 1 Registered Nurse (RN), 1 LPN, and 2 CNA. - The facility census, dated 4/21/2023, documented 38 beds on the B3 Nursing Unit Progress notes dated 4/21/2023 were reviewed, they did not include documentation that the resident refused a shower. During an interview on 04/28/23 at 04:34 PM, CNA #2 stated they were unable to complete all their assigned daily resident showers because there was typically only 1 or 2 CNAs assigned to the unit, and that was not enough staff to complete the showers. When residents did not receive get their showers, they would try and provide them on another day, but this was not always possible. The facility tried to implement a shower team, but they did not always have the staff to provide this and they were not available on the evening shift. Resident #98 has complained about not having their showers provided. During an interview on 04/28/23 at 05:04 PM, Resident #98 stated their showers were scheduled every Friday, but they were not always provided because they had been told there was not enough staff to provide the showers. When their regularly scheduled showers were not provided, sometimes the staff would provide them the following week, but they would prefer to have their showers provided every Friday when they are scheduled. During an interview on 05/01/23 at 10:42 AM, LPN #2 stated Resident #98 had showers scheduled every Friday; these were typically performed by the CNAs and documented in the CNA documentation section in the Electronic Medical Record (EMR). Sometimes, Resident #98 did not receive their scheduled showers every Friday because there was not enough staff on the unit to provide them; the residents on the unit have complained about this. When showers were unable to be provided on the day they were scheduled, another shower should be provided and documented. According to the CNA documentation, Resident #98 last received a shower on 4/14/2023. During an interview on 05/01/23 at 10:59 AM, CNA #3 stated the residents all had showers scheduled weekly; the CNAs performed most of these. When there were only 2 CNAs on the unit, it was very difficult to complete all the resident showers as scheduled. On 4/21/2023, they thought Resident #98 may have refused their shower, but if they did it should have been documented as refused and reported to the nurse. They documented Resident #98's shower as Activity did not occur and did not recall reporting a refusal of shower to anyone that shift. Since there were only 2 CNAs working that night, it would have been very difficult to complete all the scheduled showers. During an interview on 05/01/23 at 11:10 AM, Resident #98 stated they refused a shower on 4/28/2023 because they were feeling ill but did not refuse their shower on 4/21/2023. They rarely refused showers, because they typically had hair appointments scheduled on Fridays, and they liked to go to their hair appointments after their shower; this was why they preferred to have their showers provided as scheduled on Fridays. Resident #174: The Comprehensive Care Plan (CCP) titled Activities of Daily Living (ADLs), dated 7/27/2022, documented the resident needed minimal assist for ADLs. The CNA (Certified Nursing Assistant) Assignments Summary, print date 5/1/2023, documented the resident's bathing schedule was Wednesday on the 3 PM - 11 PM shift. The CNA documentation titled Bathing, dated 4/26/2023, documented Not Performed - N/A for the resident's bathing on the 3 PM - 11 PM shift. B1 Nursing Unit staffing sheets, dated 4/26/2023, documented: - 3:00 PM - 11:00 PM, 1 Licensed Practical Nurse (LPN) and 2.5 CNAs. A review of progress notes dated 4/26/2023 did not include documentation the resident refused their shower. During an interview on 4/28/2023 at 6:08 PM, CNA #6 stated 3 or 4 residents were scheduled on the evening shift for showers, including Resident #174. The CNA stated when there were 2 CNAs and 1 Nurse on the evening shift, the staff tried their best, but did not have time to give showers. During an interview on 5/01/2023 at 11:24 AM, LPN #6 stated the CNAs were supposed to report to a nurse when shower was not given. The LPN stated it should also be documented. The LPN stated when a CNA documented a shower or bath was not performed that meant the shower was not given on that shift. Additional Interviews: During an interview on 04/27/23 at 03:44 PM, RN #2 stated it was not uncommon for residents on the evening shift to have showers delayed or not performed due to staffing. When there were only 1 or 2 CNAs assigned to a unit, it was extremely difficult to get all the assigned showers completed and they did not always get done. Sometimes the residents could get their shower completed on an alternative day, but this did not always happen. The residents have complained about this. During an interview on 05/01/23 at 12:18 PM, the Director of Nursing (DON) stated sometimes residents did not receive their scheduled showers because of short staffing. When residents refused a shower, it should be documented as refused, the charge nurse should be notified, and a progress note should be written. They were aware of complaints from residents related to not receiving showers. The facility implemented a shower team to support the units with resident showers. This was available from Monday - Friday on dayshift, but typically the members of this team had to be pulled into resident assignments at least twice a week due to staffing shortages, and the shower team was unavailable on these days. 10NYCRR415.13(a)(1)(i-iii)

Based on observation, record review and interviews during the recertification survey, the facility did not ensure safe and secure storage of all medications for 3 (Unit # A2, A3, and C3 ) of 7 units for medication storage. Specifically, for Units A2, A3, and C3, the facility did not ensure controlled substances were kept in a separately locked, permanently affixed compartment for storage and for Unit A3, the facility did not ensure that the medication cart was locked when unattended. This is evidenced by: Finding 1: Units A2, A3, and C3 During an observation on 04/27/2023 at 10:01 AM, the A2 medication storage room refrigerator was not permanently affixed to the wall or countertop; maintenance was working on securing it to the countertop with a metal wire. During an observation on 04/27/23 at 10:50 AM, the medication refrigerator in the C3 medication room had an outer lock in place, and a double locked internal medication box with the following controlled substances present: - Dronabinol 2.5 mg x 5 capsules - Dronabinol 10 mg x 31 capsules - Lorazepam 2 mg/ml x 6 vials The refrigerator was not permanently affixed to the countertop or the wall. During an interview on 04/27/23 at 10:50 AM, Licensed Practical Nurse (LPN) #8 stated they thought if the medication refrigerator was externally locked, and the internal narcotic box was attached and double locked, the refrigerator was meeting all of the necessary medication storage requirements. They were not aware that the refrigerator had to be permanently affixed to a surface. During an interview on 04/27/23 at 12:57 PM, the outside of the refrigerator in the A3 medication room contained an external locking mechanism and the inside of the refrigerator contained an empty secured double locked box; there were no controlled substances inside. LPN #4 stated the refrigerator had not been secured to the countertop earlier in the day, but maintenance recently secured it to the countertop with a thin metal wire. During an interview on 05/01/23 at 12:18 PM, the Director of Nursing (DON) stated controlled substances were stored behind a locked door in the med room, in a double locked med cabinet; the same standard applied for medication refrigerators. The medication cabinets were affixed to the wall, the medication refrigerators had not been permanently affixed to the countertops prior to 4/27/2023; they were now affixed to the countertops with a thin length of metal wire. They were not aware of regulation requiring the facility to provide separately locked, permanently affixed compartments for storage of controlled drugs. Finding 2: Unit A3 The Policy and Procedure (P&P) titled Guidelines for Medication Administration dated 5/2021 documented the nurse will keep the medication/treatment cart within view at all times and assure that the cart is not left unlocked while unattended. When unattended, all medications should be removed from the top of the cart and the computer must be in locked mode to maintain resident privacy. During an observation on 4/27/2023 from 9:36 AM - 9:43 AM Medication Cart #1 on A3 unit was unattended and unlocked. A medicine cup of 5 pills, a nasal spray, an inhaler and an eye drop bottle were observed on top of the cart. The laptop screen was visible with resident information. Licensed Practical Nurse (LPN) #3 returned to the cart at 9:43 AM. During an interview on 4/27/2023 at 9:43 AM, LPN #3 stated they stepped away from the cart to answer a phone call. LPN #3 stated they just stepped away to take a phone call and wasn't thinking about the cart. During an interview on 4/27/2023 at 9:54 AM, LPN #4 stated a medication cart should never be left unattended when unlocked and the assistant director of nursing had been informed and LPN #3 would be re-educated. During an interview on 5/1/2023 at 11:33 AM, the Director of Nursing (DON) stated that when a medication nurse steps away from the medication cart, the medication cart should be locked, and any resident information hidden. The DON stated that there should never be medications already poured and left unattended on top of a medication cart. 10 NYCRR 415.18(e)(1-4)

Based on observation, record review, and interviews during the recertification survey dated 4/25/2023 through 5/01/2023, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety in the main kitchen and six (6) of 7 units kitchenettes. Specifically, in the main kitchen, the final rinse on the automatic dishwashing machine was 183 degrees Fahrenheit (F) at 33 pounds per square inch (psi): the information placard on the dishwashing machine requires the final rinse to be between 20 psi and 25 psi; the chemical test kit used to measure the chemical solution used to sanitize food contact equipment did not provide color graduations to indicate if the solution is at the minimum concentration or is too concentrated: the bottle of chemical concentrate stated the dilution is to be between 150 parts per million (ppm) quaternary ammonium compound (QAC) to 400 ppm QAC; the slicer, floor mixer, and refrigerator door gaskets were soiled with food particles. The microwave ovens and/or refrigerator doors gaskets were soiled with food particles in the following unit kitchenettes: B-1, A-2, B-2, A-3, B-3, and C-3; the refrigerator door gasket in the A-3 kitchenette was split and not cleanable. This is evidenced as follows: Finding #1: Main Kitchen automatic dishwashing machine final rinse, chemical test kit, cleanliness During observations on 04/25/23 at 9:50 AM in the main kitchen, the final rinse on the automatic dishwashing machine was 183F at 33 psi: the information placard on the dishwashing machine requires the final rinse to be between 20 psi and 25 psi; the chemical test kit used to measure the chemical solution used to sanitize food contact equipment did not provide color graduations to indicate if the solution is at the minimum concentration or is too concentrated: the bottle of chemical concentrate stated the dilution is to be between 150 ppm QAC to 400 ppm QAC; the slicer, floor mixer, and refrigerator door gaskets were soiled with food particles. Finding #2: Kitchenette cleanliness and refrigerator door gaskets During observations on 04/25/23 at 10:32 AM, the microwave ovens and/or refrigerator doors gaskets were soiled with food particles in the following unit kitchenettes: B-1, A-2, B-2, A-3, B-3, and C-3. The refrigerator door gasket in the A-3 kitchenette was split and not cleanable. Interview: During an interview on 05/01/23 at 1:56 PM, the Administrator and Dietary Director stated that the cleaning items will be addressed, the split refrigerator door gasket will be replaced, the correct sanitizing solution test papers will be purchased, and the final rinse water pressure on the dishwashing machine will be adjusted. The Dietary Director stated that the dishwashing machine water pressure is checked each meal, but the correct pressure range will be added to daily dishwashing machine log; it was not realized that the facility had the wrong test papers; and the kitchenettes are checked for cleanliness each afternoon, but supervisors and staff will be re-trained to keep the microwaves and refrigerators clean and to check the refrigerator doors gaskets. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews during a recertification survey, the facility did not ensure residents were free from physical or chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms for 2 (Resident #81 and #203) of 2 resident reviewed for restraints. Specifically, for Resident #81, the facility did not ensure the resident's alarmed clip seat belt was released every 2 hours as documented on the comprehensive care plan, that the physician order identified a medical symptom that necessitated the use of the restraint, and that the resident representative was informed of potential risks and benefits of using an alarmed clip seat belt as a restraint, and for Resident #203, the facility did not ensure the Velcro belt, that was not easily removed by the resident, was assessed as a restraint. This is evidenced by: A facility Policy and Procedure (P&P) titled Physical Restraints dated 2/2017, documented physical restraints were any manual, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual could not remove easily or upon demand, which restricted freedom of movement or normal access to one's body. The P&P documented a physical restraint would be applied after: an assessment for restraint need was determined by the interdisciplinary team, risk/benefit/alternative factors was explained to the resident/family/resident representative, and a Medical Doctor (MD) order was obtained. The P&P also documented restraints would be released at least every two hours and the resident would be ambulated, repositioned or toileted based on the resident need. Resident #81: Resident #81 was admitted to the facility with the diagnoses of Alzheimer's disease, depressive episodes, and chronic obstructive pulmonary disease. The Minimum Data Set (MDS - an assessment tool) dated 1/8/21 documented the resident had severely impaired cognition, could rarely/never understand others and could sometimes make self understood. During an observation on 3/31/21 from 8:15 AM to 11:25 AM, the resident was in his/her wheelchair with an alarmed clip seat belt in place. Staff did not release the seat belt for the duration of the 3 hour and 10-minute observation. The Comprehensive Care Plan (CCP) for Restraint Use, last revised 4/4/20, documented the resident had poor safety awareness, repeated falls and was unable to understand limitations. The care plan documented the restraint was an alarmed seat belt that was to be released every 2 hours for 15 minutes. A physician order dated 7/17/20, documented an alarmed seat belt in the wheelchair was a restraint and to release per facility P&P. The physician order did not include the resident's medical symptom that necessitated the use of an alarmed seat belt. The medical record did not include a Family Notification/Agreement for the restraint. An email from the Administrator dated 4/2/21 at 9:17 AM, documented a Family Notification/Agreement for the restraint was not found. A nursing progress note dated 10/12/20, documented the restraint was initiated on 4/1/20 per the agreement of members at an interdisciplinary team meeting after review of a fall on 3/28/20. The note documented the restraint continued to be released per facility policy and procedure. A Physical Restraint Assessment completed 10/12/20, documented the type of restraint was a clip belt. The assessment documented the resident could not release the device at will and upon command, restricted function of movement or access to body, was not a positioning device and was a restraint. The reason for the restraint was dementia/poor safety awareness, inflicting injury to self, and poor balance sitting/standing. The section of the assessment regarding family notification was blank/not completed. A Physical Restraint Assessment completed 1/4/21, documented the type of restraint used was a clip belt. The assessment documented the resident could not release the device at will and upon command, restricted function of movement or access to body, was a positioning device and was not a restraint. The reason for the restraint was dementia/poor safety awareness, inflicting injury to self, and poor balance sitting/standing. The section of the assessment regarding family notification was blank/not completed. During an interview on 4/01/21 at 10:18 AM, Certified Nursing Assistant (CNA) #3 stated Resident #81 did not try to take off the alarmed seat belt and only tried to get up when he/she was anxious. CNA #3 stated she assumed the seat belt was for safety reasons. CNA #3 stated the staff released restraints when they toileted the residents. She stated Resident #81 had the seat belt on all the time in the wheelchair and she released it when she took him/her to the bathroom. CNA #3 asked the resident to release the alarmed clip seat belt and the resident was unable to release it. During an interview on 4/01/21 at 10:39 AM, Registered Nurse (RN) #1 stated Resident #81 had an alarmed clip seat belt that was a restraint. She stated the resident was very unsafe and would try to stand up to walk. She stated the restraint was reviewed quarterly and the last restraint reduction note was dated 10/2020. She stated the staff should release the restraint at meals, and for toileting and naps. She stated the restraint should be released at least every 2 hours and Resident #81 was toileted every 2 hours so that was when the restraint would be released. During an interview on 4/2/21 at 11:11 AM, Director of Nursing (DON) stated the resident had an alarmed clip seat belt that was a restraint. She stated the physician order for the restraint did not have a specific diagnosis or indication for the use of the restraint. She stated the restraint was used due to the resident's dementia and poor safety awareness. The DON stated the restraint should be released at least every 2 hours per the policy and the staff were trained about the use of restraints and when to release a restraint. The DON stated after reviewing the restraint assessments for Resident #81, the assessments did not have marked that the family was notified of the restraint and the staff should have documented the family was notified but did not. During an interview on 4/2/21 at 11:45 AM, the Assistant Director of Nursing (ADON) stated restraints were released every 2 hours for 15 minutes, and for ambulation and toileting. The ADON stated the restraint was not for the convenience of staff because the resident had a history of falls and was not steady on his/her feet. She stated the restraint was to keep him/her safe because he/she did not have the ability to determine what was or was not safe. The ADON stated the nurses or social workers would notify families about the use of the restraint. Resident #203 Resident #203 was admitted to the facility with diagnoses of failure to thrive, Parkinson's disease, and chronic atrial fibrillation. The Minimum Data Set (MDS-an assessment tool) dated 11/28/20, assessed the resident as having moderately impaired cognitive skills for daily decision making. The MDS dated [DATE] documented that restraints were not being used in the resident's chair. The following observations were made: - 04/01/21 at 09:40 AM, 10:20 AM, and 4:21 PM, the resident was sitting in a wheelchair with a Velcro belt in place. - 04/02/21 at 08:58 AM, the resident was eating breakfast in the dining room sitting in her wheelchair with a Velcro belt on. This was not released during the meal. - 04/02/21 at 9:30 AM, Licensed Practical Nurse (LPN) #6 asked the resident to remove this, while shaking the velcro belt. The LPN then had to coax the resident several times before the resident was able to release the belt. Registered Nursing Supervisor came to the unit as this was occurring and witnessed the demonstration. The Comprehensive Care Plan dated 2/8/21, for Restraints, documented to release the restraint every 2 hours and at meals. The Certified Nursing Assistant (CNA) [NAME] (gives CNAs instructions of how to care for the resident) did not include instructions for releasing the velcro belt. The medical record did not include Medical Doctor (MD) orders for the velcro belt. A Physical Restraint assessment dated [DATE], documented an assessment was not needed because there were no devices in use. The MDS dated [DATE], documented that physical restraints were not used in a chair or out of bed. During an interview on 04/02/21 09:08 AM, CNA #5 stated the Velcro belt was placed on the resident after she had a fall from her chair. The resident cannot remove the velcro belt and there were no special instructions for the CNAs regarding its use. During an interview on 04/02/21 09:34 AM, Licensed Practical Nurse (LPN) #6 stated the resident had a velcro belt because she was falling. They would not put a restraint on without a Medical Doctors (MD) order. The resident had a velcro belt because she was falling. During an interview on 04/02/21 at 09:52 AM, Registered Nursing Supervisor (RNS) #1 stated based on what she saw when the resident was asked to remove the belt, she would consider it a restraint as the resident was not able to easily remove the belt on command without prompting. The care card should tell staff to release the belt every 2 hours. She was the one who completed the restraint assessment and MDS, but did it incorrectly; the residents assessment and MDS should reflect that the resident had a restraint. Also, there was not a MD order for the Velcro belt, but there should have been one. 10NYCRR 415.4(a)(2-7)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey, the facility did not ensure written notice of the facility's bed hold policy was provided to the resident and the resident representative for 3 (Residents #'s 5, 59 and #161) of 3 residents reviewed for hospitalization. Specifically, the facility did not ensure there was documented evidence that the resident and the resident representatives' received written notice of the bed hold policy when the residents' were transferred to the hospital. This was evidenced by: The Administrator stated that the policy and procedure for bed holds was included in the resident admission packet. The resident admission packet provided documented that a written bed hold notification would be provided to residents or their representatives when transferred to the hospital. Resident #5: Resident #5 was admitted to the facility with diagnosis of congestive heart failure (CHF), diabetes mellitus, and hypertension. The Minimum Data Set (MDS- an assessment tool) dated 12/11/20 documented the resident had mild cognitive impairment and was able to make needs known. Review of the resident's medical record documented the resident was hospitalized from [DATE] to 2/12/21, from 2/17/2021 to 2/22/2021, and from 2/24/2021 to 3/4/2021. The medical record did not include documentation that a written bed hold policy was provided to the resident or the residents representative. Resident #59: Resident #59 was admitted to the facility with diagnoses of cerebral vascular accident (CVA), obstructive uropathy, and hypertension. The MDS dated [DATE] documented the resident had severe cognitive impairment and sometimes able to make needs known. Review of the residents record documented the resident was hospitalized from [DATE] to 11/16/2020 and from 12/22/20 to 12/31/2020. The medical record did not include documentation that a written bed hold policy was provided to the resident or the residents representative. Resident #161: Resident #161 was admitted to the facility with diagnosis of cerebrovascular accident, dementia, anxiety, and depression. The Minimum Data Set (MDS- an assessment tool) dated 2/4/2021 documented the resident had moderate cognitive impairment and was able to make needs known. Review of the residents record documented the resident was hospitalized from [DATE] to 1/17/2021. The medical record did not include documentation that a written bed hold policy was provided to the resident or the residents representative. During an interview on 4/2/21 at 9:59 AM, the Assistant Administrator stated the facility has not provided written notice of the bed hold policy at the time of transfer to residents or the residents representative because when the Director of Social Work resigned the task was not reassigned and it should have been. During an interview on 4/2/21 at 10:10 AM, the Director of Nursing (DON) stated written notification of the bed hold policy should have been provided to residents or the residents representatives at the time of transfer. During an interview on 4/2/21 at 10:26 AM, the Administrator stated that the facility has not requested, required, or accepted payment for bed hold since the pandemic started. 10NYCRR 415.3(h)(4)(i)(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during a recertification survey completed on 4/2/2021, the facility failed to 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 infection. Specifically, the facility did not ensure staff on B2, a quarantined unit where all residents were on contact and respiratory precautions, consistently wore gowns and changed them between resident encounters, and performed hand hygiene between resident encounters; further, the facility did not ensure residents were socially distanced while dining, and the facility did not ensure reusable equipment was properly sanitized. This is evidenced by: The Centers for Disease Control and Prevention (CDC) guidance titled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated on 3/29/21 provides: Because of the high risk of unrecognized infection among residents, a single new case of SARS-CoV-2 infection in any HCP (healthcare provider), or a nursing home-onset SARS-CoV-2 infection in a resident should be evaluated as a potential outbreak and although most care activities require close physical contact between residents and HCP, when possible, maintaining physical distance between people (at least 6 feet) is an important strategy to prevent SARS-CoV-2 transmission. The CDC guidance also documented: -HCP should care for residents using an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. -Residents should generally be restricted to their rooms and serial SARS-CoV-2 testing performed. -Consideration should be given to halting social activities and communal dining; if these activities must continue for uninfected residents, they should be conducted using source control and physical distancing for all participants. CDC guidance titled Transmission-Based Precautions (undated), provides: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal Protective Equipment (PPE) upon room entry and properly discarding before exiting the patient room is done to contain pathogens. CDC guidance titled Using Personal Protective Equipment (PPE), updated 08/19/2020, further documents that gloves and gown shall be removed (doffed) before exiting a patient's room. CDC guidance titled Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, dated March 19, 2020, recommended the following additional strategies to minimize chances for exposure to COVID-19: Hand Hygiene: HCP [healthcare personnel] should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. The New York State Department of Health (NYSDOH) Revised Health Advisory entitled COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 3/13/20 and updated 7/10/2020, documented that if there are confirmed cases of COVID-19 in a Nursing Home, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. HCP and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e. do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed, and hand hygiene must be performed. The facility PPE Guidelines last revised 2/2021, documented Closed Unit - Residents remain in their rooms. Residents requiring meal assistance can be socially distanced in the dining room for meals. A facility line list of staff who tested positive for COVID-19, documented new positive cases in staff members on 3/25/21, 3/26/21, and 3/31/21. During an interview on 3/29/21, the Administrator stated the entire B2 unit was on quarantine secondary to potential exposure to a positive staff member this weekend. Finding #1 The facility did not ensure staff on B2, a quarantined unit where all residents were on contact and respiratory precautions, consistently wore gowns and changed them between resident encounters and performed hand hygiene between resident encounters. During an observation on 03/29/2021 at 12:28 PM, 5 staff on the B2 Unit were in the dining area assisting residents to eat. The staff were sitting next to the residents and were not wearing gowns or gloves. Certified Nursing Assistant (CNA) #9 was observed assisting Resident #6 to eat before going to Resident #146 to assist him/her with a drink by holding the straw in front of the resident's mouth. The CNA did not wash his/her hands after assisting Resident #6 and before assisting Resident #146. The CNA touched Resident #146's plate while providing the assistance. After assisting Resident #146, the CNA returned to Resident #6 and picked up the resident's cup with a straw to assist the resident to drink; the CNA then picked up a spoon and began to feed Resident #6, without performing hand hygiene between these resident encounters. During an observation on 03/29/21 at 12:39 PM, Licensed Practical Nurse (LPN) #11 sat next to Resident #157, who was coughing at the table. The LPN had gloves on but did not have a gown on. The LPN removed her gloves and wheeled the resident to his/her room. During an observation on 4/01/21 at 8:50 AM, the Speech Language Pathologist (SLP) was wearing a gown in the dining area. She stood within 1 foot of Resident #224, who was coughing, with her gown touching the wheelchair as she encouraged Resident #158 to eat. The SLP picked up a cup and gave it to Resident #224 to drink. The SLP touched Resident #224's arm and removed the clothing protector without gloves. The SLP cleansed her hands and sat next to Resident #158. The SLP put her right arm around the resident's shoulders and leaned in front of the resident while sitting next to her to put a straw in her cup. The SLP patted the front of her gown with her hands looking for a pen. She lifted up her gown and removed pen from her pocket. She handed the resident a cup and refilled the cup with another cup on the resident's tray. The SLP moved the gown with her hands again and placed pen in her pocket. She picked up a covered plate and attempted to remove her gown without success. The SLP then she reached over the resident sitting in the doorway of Room B213, who was eating breakfast and placed the contaminated gown in a receptacle. During an interview on 3/29/21 at 1:08 PM, CNA #8 stated the facility had cases of new COVID-19 positive staff this weekend but none of the residents were on isolation. The CNA stated the staff wore gowns, so they did not contaminate their clothes. The CNA stated the staff wore the gowns when they toileted residents or when they got residents in or out of bed. During an interview on 4/01/21 at 9:07 AM, the SLP stated B2 unit a closed unit and because of that the residents cannot leave the unit. She stated there were signs on the doors that said you had to wear a gown on the unit, and it was part of the facility protocol for the units that were closed. She stated when she saw residents in the dining room, she would wear the same gown because otherwise, she stated, How can I treat two residents in the dining room at the same time if they are both on isolation. She stated she supposed she should not have discarded the gown she wore treating other residents over the resident in room B213. During an interview on 4/02/2021 at 9:41 AM, the Infection Control Preventionist (ICP) stated a CNA on the B2 unit tested positive for COVID-19 over the weekend, so B2 unit was closed. The ICP stated if a unit was closed, full PPE was required when providing direct care that included face shield, N95, gown and gloves and residents were to be socially distanced on the unit. The ICP stated when staff were assisting residents to eat, a face shield and N95 was always needed and a gown was needed if you are sticking things in the resident's mouth and the resident was on quarantine. The ICP stated she would expect staff to perform hand hygiene between residents and she would also expect staff who were repositioning a resident and feeding a resident to have a gown and gloves on. She stated staff should separate residents who cannot move themselves, so they are 6 feet apart especially when a resident was coughing. The ICP stated staff were expected to put a gown on before interaction with the resident and remove the gown before contact with the next resident. She stated the staff should have a plastic bag in their pocket to put a gown in if they were not in an area where there was a receptacle so they can walk it to the soiled utility room. She stated she would have expected that the SLP not lean in front of the resident to place a contaminated gown in the room. During an interview on 4/02/21 at 1:55 PM, the Director of Nursing (DON) stated a CNA on B2 was asymptomatic and tested positive for COVID-19 over the weekend through routine testing. She stated B2 was on droplet and contact precautions and considered a non-COVID-19 unit. The DON stated when staff were feeding a resident. staff would need to have a face shield and mask on and if staff were feeding someone that may touch them, they always wore more. She stated her expectation would be that staff wear a gown and gloves with direct resident care, so staff should have worn a gown and gloves when repositioning a resident in a chair and to feed the resident who was coughing during the meal. Staff should have performed hand hygiene between residents when assisting them with eating and drinking. Additionally, the staff should have changed gowns between residents and should not have discarded a soiled gown in another resident room; it should have been brought to the dirty utility room. Finding #2 The facility did not ensure residents were socially distanced while dining. The Department of Health guidance titled, Health Advisory: Revised Skilled Nursing Facility Visitation, dated March 25, 2021, provides: Communal dining and activities may occur while adhering to the core principles of COVID-19 infection prevention. Residents may eat in the same room with social distancing (e.g., limited number of people at each table and with at least six feet between each person). Nursing homes should consider additional limitations based on status of COVID-19 infections in the facility and the size of the room being used and the ability to socially distance residents (e.g. limit to 10 residents and staff in smaller spaces. Per this guidance, core principles include The use of face coverings or masks (covering mouth and nose) and Social distancing at least six feet between persons. During an observation on 4/01/21 at 8:45 AM, Resident #224 was coughing and was seated 5 feet away from Resident #158 on the same side of a round table in the dining area. There were 5 12-inch tiles from center of Resident #224's chair to center of Resident #158's chair. The residents were not 6 feet apart and were not wearing masks. During an interview on 4/01/21 at 8:50 AM, Registered Nurse #5 stated the residents were not 6 feet apart at the table and they should be. She stated the residents were not wearing masks and Resident #224 was coughing. RN #5 stated staff placed Resident #224 and Resident #158 at the table since neither resident could mobilize themself. The RN stated staff were expected to keep residents 6 feet apart and if a resident was coughing to reposition the resident. During an interview on 4/02/21 at 1:55 PM, the Director of Nursing stated she would expect residents to be spaced 6 feet apart when they were brought into the dining room. Finding #3 The facility did not ensure reusable equipment was properly sanitized. During an observation on 3/29/21 at 12:58 PM, Certified Nursing Assistant (CNA) #8 exited room B 220-P with a Hoyer lift (a mechanical lift). She did not wipe the Hoyer down outside of the room or at the door prior to exiting the room and placed the Hoyer in the hallway. Another CNA took the Hoyer lift from the hallway and entered room [ROOM NUMBER]B with CNA #8. When they exited the room the Hoyer lift was placed in the common area at the end of the unit. During an interview on 3/29/21 at 1:08 PM, CNA #6 stated she used a regular wipe that the staff use to cleanse the residents with to wipe off the Hoyer. They were supposed to use germicidal wipes, but there were no (named) germicidal wipes in the hallway. The CNA stated she could have asked the Nurse Manager for some but did not and she just used the resident care wipes to clean the Hoyer after using it. During an interview on 4/2/2021 at 9:41 AM, the Infection Control Preventionist (ICP) stated she did not know who was responsible to educate staff on the use of the germicidal wipes on equipment. Housekeeping had a schedule to disinfect the equipment daily, but she would think if it was visibly soiled it should be cleaned but she would have to look up the policy. Her thoughts would be to disinfect between each resident. The germicidal wipes should be all around the unit and on isolation carts. She would expect that if there was not any around, they would go and get some. During an interview on 4/02/21 at 01:55 PM, the Director of Nursing (DON) stated the Hoyer lift should be cleaned when it was touched or if the resident was on contact and droplet precautions. The DON stated they had a germicidal cleanser for the equipment, not the cleanser that was for use on skin. 10NYCRR 415.19; 400.2

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the recertification survey the facility did not maintain drugs and biologicals labeled in accordance with currently accepted professional standards, and include the appropriate accessory and cautionary instructions for 4 (Medication Carts A1, A3, B2 and C3) of 8 and 2 (B2 and C2) Medication Rooms of 4 inspected. Specifically, the facility did not ensure medication carts and medication rooms on the nursing units did not contain expired or outdated beyond the date listed on the medication container labels. This is evidenced by the following: Inspections of Medication Carts were as follows: - [DATE] at 2:48 PM, a Unit A1 medication cart contained a bottle of Tavavite (multivitamin), 100 tablet bottle was opened and had an expiration date of [DATE] and a bottle of Loratadine (antihistamine), 90 tablet bottle was opened and had an expiration date of 12/2020. - [DATE] at 01:40 PM, the Unit B2, team 2, medication cart contained Magnesium oxide with an expiration date of 11/2020. - [DATE] at 1:51 PM, the Unit C3 low side medication cart contained Calcium 500 mg +Vitamin D with an expiration date of 9/2020. - [DATE] at 02:05 PM, the Unit A3, low side Medication cart contained Vitamin D with an expiration date of 6/2020, Resident #10's Senna (a laxative) with an expiration date of [DATE]. Inspections of the Medication Rooms were as follows; - [DATE] at 1:18 PM, the Unit C2 medication room refrigerator contained Tylenol 650 milligrams (mg) with an expiration date of 2/2021 and Laxative suppositories with an expiration date of 11/2020. - [DATE] at 1:30 PM, the Unit B2 medication room refrigerator contained Tylenol 650 mg suppositories with an expiration date of 7/2020. During an interview on [DATE] at 3:15 PM, Licensed Practical Nurse #8 stated the expiration dates on the medication should be checked every time it is opened, and the expired bottles should have been discarded. During an interview on [DATE] at 1:18 PM, LPN #9 and stated all nurses check for outdates. During an interview on [DATE] at 1:45 PM, LPN #11 stated, all nurses should be checking for outdates. During an interview on [DATE] at 2:28 PM, the Director of Nursing stated the nurse giving the medications should be checking for outdates. She was not aware of the outdates but there should not be any on the carts or in the medication room. 10NYCRR 415.18(e)(1-4)

Based on observation and interviews, during the Standard Survey which was attempted on 9/30/2020, the facility did not ensure the governing body, (County Executive and Commissioner of Social Services) established and implemented policies regarding the management and operation of the facility. Specifically, the governing body did not allow seven surveyors from the New York State Department of Health (NYS DOH) access to the facility to conduct Standard and Life Safety Surveys which certify and determine compliance with the requirements in 42 CFR Part 483, Subpart B and are required to receive payment under Medicare or Medicaid. The findings are: The State Operations Manual (SOM) Chapter 7 documented the following: -7200 -Emphasis, Components, and Applicability (Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) documents that skilled nursing facilities and nursing facilities must be in compliance with the requirements in 42 CFR Part 483, Subpart B to receive payment under Medicare or Medicaid. To certify a skilled nursing facility or nursing facility, complete at least: A life safety code survey; and A standard survey (Forms CMS-670, 671, 672, 677, 801 through 807, and Exhibits 85, 86, 88 to 95). -7207 - Unannounced Surveys -(Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) (Also see §2700 and Chapter 5 of this manual.) 7207.1 - Introduction (Rev. 63, Issued: 09-10-10, Effective: 09-10-10, Implementation: 09-10-10) This instruction implements §§1819(g)(2)(A) and 1919(g)(2)(A) of the Act, and 42 CFR 488.307. It also reiterates CMS policy that all nursing home surveys are to be unannounced, including standard surveys, complaint surveys and onsite revisit surveys. State Operations Manual Appendix PP, Guidance to Surveyors for Long Term Care Facilities, provides: Surveyors are considered representatives of the Secretary and/or the State. Facility staff cannot prohibit surveyors from talking to residents, family members, and resident representatives. NOTE: If facility staff attempt to interfere with the survey process and restrict a surveyor's ability to gather necessary information to determine compliance with requirements, surveyors should consult with the CMS Regional Office. New York Public Health Law section 2803(1)(a) provides: The commissioner [of the New York State Department of Health] shall have the power to inquire into the operation of hospitals and to conduct periodic inspections of facilities with respect to the fitness and adequacy of the premises, equipment, personnel, rules and by-laws, standards of medical care, hospital service, including health-related service, system of accounts, records, and the adequacy of financial resources and sources of future revenues. The QSO-20-14-NH dated March 13, 2020 (revised) documented the following: CMS and state survey agencies are constantly evaluating their surveyors to ensure they don't pose a transmission risk when entering a facility. For example, surveyors may have been in a facility with COVID-19 cases in the previous 14 days, but because they were wearing PPE effectively per CDC guidelines, they pose a low risk to transmission in the next facility, and must be allowed to enter. However, there are circumstances under which surveyors should still not enter, such as if they have a fever. On 9/30/2020 at 8:38 AM, the Administrator met the surveyors at the entrance of the facility. The Administrator was informed by the survey team that they were at the facility to conduct a Standard and Life Safety survey. The Administrator stated he would need to obtain approval from the County Executive prior to allowing the surveyors entrance into the facility to conduct the surveys. On 9/30/2020 at 8:44 AM, an overhead announcement, heard by the survey team in the front vestibule, was made inside the facility asking staff to welcome the Department of Health to the facility. On 9/30/2020 at 8:45 AM, a surveyor provided the Commissioner of Social Services for the County a letter dated 7/23/2020 from the Department of Health that documented, consistent with the Executive Order 202.30 signed on July 9, 2020 and as amended by the Executive Order 202.40 New York State nursing home surveillance staff were subject to the same provisions and standards of weekly testing as New York State nursing home staff. The Commissioner stated she would contact the County Executive to see if the surveyors could enter the building to conduct the survey. On 9/30/2020 at 8:51 AM, the Commissioner of Social Services stated the County Executive relayed the surveyors needed to provide negative COVID-19 test results within the past 7 days in order to be allowed entrance into the facility. The Commissioner of Social Services would not accept the Department of Health letter dated 7/23/2020. On 9/30/2020 at 9:03 AM, the Commissioner of Social Services stated the County Executive had a counteroffer. The surveyors were to allow copies of their ID's to be taken and provide signatures attesting to negative test results so the facility could cross reference the surveyors' personal information provided. The Commissioner of Social Services stated the purpose of cross-referencing surveyor information was to allow the County to access the DOH database to gain access to surveyor COVID-19 test results to prove the surveyors were negative. The survey team declined to grant access to their personal medical records protected by HIPAA (Health Insurance Portability and Accountability Act). The Commissioner of Social Services acknowledged that she understood the surveys were federal requirements. The Commissioner of Social Services stated the surveyors were not allowed access to the facility despite the Department of Health letter dated 07/23/2020. On 9/30/2020 at 9:10 AM, the Commissioner of Social Services stated she did not have an update on whether the surveyors were going to be allowed entrance into the facility by the County Executive to conduct the survey. On 9/30/2020 at 10:15 AM, the survey team left the facility property. 10 NYCRR 415.26(b)(1),(3),(9) 10 NYCRR 400.2