**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview during the abbreviated survey, (NY00340966), the facility did not ensure all allegations were thoroughly investigated for 1 of 4 residents. Specifically, Resident # 3 complained of pain in the shoulder and had x ray done on 4/26/2024 that showed a displaced right scapular fracture and osteopenia and was transferred to the hospital on 4/26/2024. The hospital history and physical report documented the resident reported that while in the facility when they were being repositioned, they heard a pop in their right shoulder. The facility did not provide any incident and accident report of the incident when requested by surveyors.The findings are: Resident #3 was re-admitted on [DATE] with diagnosis that include but not limited to Parkinson's Disease, Functional Quadriplegia, and Acute Kidney Failure.A quarterly Minimum Data Set, dated [DATE] documented a Brief Interview of Mental Status Score a 15; indicating the resident was cognitively intact with no behaviors. Resident had upper and lower extremity impairment on one side and uses a wheelchair for locomotion. Resident required supervision with eating and was dependent with bed mobility and transfers. Always incontinent of urine and frequently incontinent of bowel.The facility did not provide anu incident/accident report when requested.Review of the Radiology Report dated 4/26/2024 documented there was an x ray of the right shoulder. The Impression documented a Displaced scapular fracture and Osteopenia.A review of the Hospital Transfer Sheet dated 4/26/2024 documented under clinical information that the x ray showed a fracture of the right shoulder. Resident complained of right shoulder pain and received Tylenol around the clock.Review of the Hospital History and Physical Report dated 4/26/2024 documented under chief complaint that Resident #3 stated nurses were helping her reposition in bed yesterday and they heard a pop in their right shoulder. In house x-ray showed scapular fracture.On 6/09/2025 surveyor requested all incident reports on file for the Resident from 3/2024 to 4/2024. The Administrator informed surveyor that there were no incident reports for the resident from 3/2024 through 4/2024.A review of a nursing progress note written by Registered Nurse Supervisor dated 4/26/2024 documented Resident #3's x ray report of the right shoulder showed a Displaced scapular fracture and osteopenia. Xray results reported Assistant Director of Nursing, Family and Nurse Practitioner. Resident #3 to be sent to [NAME] for further evaluation. During an interview 6/11/2025 at 9:24am with Administrator stated that they know they spoke with the resident regarding the allegation that nurses pulled on them when repositioning them. They did not think it was a fracture. The old director of nursing may have a soft file where they started an investigation, but they need to find the file to see if they can locate the file. They did not think there was an official investigation completed for the incident because the facility questioned the aides, and they reported they were not rough with the resident. They completed the first X ray in house that looked like a fracture. However, the resident was at their baseline and had their regular range of motion, and did not seem to be in any more pain than usual. Out of an abundance of precaution they sent the resident to the hospital for follow- up where the hospital did the full trauma workup. They requested for the hospital to complete the trauma workup on the resident. Eventually the hospital completed the workup on the resident, and it revealed that the resident did not have a fracture.During an interview on 6/11/2025 at 10:17am with Resident #3's family representative they stated Resident # 3 had multiple incidents in the facility that were centered around care. For example, there was an incident where they fell, and it was not clear what happened. Resident # 3's family representative stated that while in the facility the staff was trying to help them out of bed, but they slipped and fell. This incident that occurred on 4/26/2025 when they were hospitalized it was reported that they were pulled on during cares. Resident # 3's Family Representative heard this and reported it to the Director of Nursing in the facility. They were told by the Director of Nursing that they would complete an internal investigation. Resident #3's family Representative reported they never filed a formal complaint with any one about the incident, but they did report it to the Director of Nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (NY00373412, NY00374723), the facility did not ensure residents were free from abuse for 3 out of 3 residents (Resident #1, Resident # 2, Resident # 6) reviewed for abuse. Specifically, 1) On 2/26/2025 Resident #1 who had a known history of wandering, wandered into Resident # 2's room and Resident # 2 became agitated and put their hands on Resident # 1. Resident # 1 fell to the floor and kicked Resident # 2 in the leg. Resident #1 had no behavior care plan initiated before the incident. 2) On 3/11/2025 Resident # 1 was observed by staff in the doorway of their room holding their roommate(Resident # 6) by the collar. There was no documented behavior care plan was not initiated for Resident # 1 who had a known previous history of resident to resident altercation.The findings are:A review of the facility's Abuse investigation protocol/ Resident to Resident abuse policy last reviewed 5/2/2024 documented it is the policy of the facility to conduct a thorough investigation of all accusations/or reports of resident abuse to determine if a crime has been committed. Nursing Administration / Nurse administrator on call is responsible for reviewing information provided and advises if any further interventions are needed to ensure the safety of the resident. Considers room or floor change to prevent reoccurrence. Care plans for both residents must be updated to reflect risk for victimization, behaviors, aggressive behaviors, etc.Resident # 1 was admitted to the facility on [DATE] with a diagnosis that include but not limited to dementia with mood disturbances, Pre-glaucoma, and depression.A Minimum Data Set, dated [DATE] documented the Resident had a Brief Interview Mental Status score of 01/15 indicating the resident is not cognitively intact with no documented behaviors. No impairments to upper or lower extremities. Resident uses a wheelchair and walker for locomotion. Independent with eating and supervision with bed mobility and transfers. Resident is occasionally incontinent of urine and always continent of bowel.Review of an elopement/wander risk assessment dated [DATE] documented Resident #1 score was a 20 indicating the resident was a high risk for elopement/wandering.A review of all Resident # 1's care plans revealed no behavior care plan was in place.A review of Resident # 1's skin assessment dated [DATE] documented scratches to the right arm. Resident # 2 was admitted to the facility on [DATE] with diagnosis that include but not limited to Diabetes type 2, Muscle weakness, and End Stage Renal Disease.A Minimum Data Set, dated [DATE] that documented the resident had a brief interview of mental status score a 14/15 indicating the resident is cognitively intact with no behaviors present. Resident # 2 uses a wheelchair and walker for locomotion. Resident has an impairment on one side of the upper extremity. Requires set up with eating, independent with bed mobility, and supervision with transfers. Resident is occasionally incontinent of urine and always continent of bowel.A review of the facility's internal investigation conclusions / findings dated 2/26/2025 documented that on 2/26/2025 at 4:15pm, Resident # 2 grabbed Resident # 1's arm, pulled Resident # 1 out of their room and onto the ground. Resident # 1 landed on their buttocks. Resident # 1 kicked Resident # 2 in the leg in attempt to get Resident # 2 to let go of their arm. Staff intervened immediately. 911 was called immediately after assessing the resident's safety. Resident # 1 was assisted off the floor and into a wheelchair. Resident # 1 was assisted back to bed, body assessment completed by a Registered Nurse, then the resident was seen by the in-house Nurse Practitioner. Ambulance arrived with a police escort. Resident # 2 was discharged to Mid-[NAME] Regional Hospital for psychological evaluation. Resident # 2 has not returned to the facility.A review of the police case report 2025-0394 dated 02/26/2025 documented caller from the facility reports a psychiatric emergency with a patient who had been physical with another patient, and they would like to have them removed. Patient was willingly transported to Mid- [NAME] Regional for evaluation by Empress.During an interview on 5/9/2025 at 12:30pm, Certified Nursing Aide # 1 stated they worked in the facility for a while but cannot remember the date. They are usually assigned to the south side, but it depends on the needs. They are familiar with Resident # 1. Resident # 1 needs supervision and has dementia. Resident # 1 will wander into other resident's room, and they will redirect them. The resident can get agitated. Resident # 1 will become physically aggressive if you don't back off of them, but if you back off and give them space, they will calm down. Certified Nursing Assistant # 1 had not seen them initiate physical aggression toward other residents, but Resident #1 will protect themself. Certified Nursing Assistant # 1 can recall an incident between Resident # 1 and Resident # 6 where they were sitting at the table together and Resident #6 became aggressive toward Resident #1. They were separated from each other. Resident # 2 was in the facility and was on dialysis, but they are no longer in the facility. Resident # 2 would not hurt anyone because they had a good mind. If Resident # 2 became upset with someone it would be verbal, but they would not hit someone.During an interview with Licensed Practical Nurse #1 on 5/9/2025 at 1:10pm, they stated they are aware of the incident that took place between Resident # 1 and Resident # 2 on 2/26/2025. Licensed Practical Nurse #1 was at the nurses' station on the north side talking to Resident #2 and Resident # 1 was wandering the hallway. When resident #2 seen resident # 1 attempting to enter their room Resident # 2 then threatened to hit Resident # 1. Resident # 2 threw Resident # 1 on the ground. The aide came over to assist. Social worker and Director of Nursing came down to the north side unit. Resident # 1 kicked and hit Resident #2, and it escalated the situation more. 911 was called, but Licensed Practical Nurse #1 cannot remember who called them. Licensed Practical Nurse #1 usually work on the north side, so they are not familiar with all the intervention in place for Resident # 1. The facility sent Resident# 2 out to Mid-[NAME] Regional Hospital for a psychiatric evaluation and the facility did not accept the resident back. The facility did not take the resident back because they were a threat. The facility called the family to find out if they wanted to pursue charges, but they did not.During an interview with the Director of Nursing on 5/12/2025 at 10:30am they stated they started working in the facility as the Director of Nursing since 12/16/ 2024. They were notified of the incident on 2/26/2025 with resident #1 and #2 right after it happened. They went downstairs because they were still in the building. Resident # 2 was very aggressive and angry, and they were there interacting with social worker. Resident # 2 was aggressive and telling social worker to leave them alone. One of the nurses called 911, but they cannot remember which one called. The Director of Nursing waited and assisted Resident #1 back to their room. Resident # 1 had a assessment completed, but the resident did not remember the details of the incident. The Nurse Practitioner came to assess Resident # 1 and there were no noted injuries after incident. Director of Nursing stated they explained the situation to officers and Resident # 2 went to hospital for a psychological evaluation. It is the facility's Protocol that any resident-to-resident interaction is followed up by psychology/psychiatry. Resident # 1' was not's family was notified and the family did not want Resident # 2 near Resident # 1, and they wanted to press charges. The facility provided Resident # 1's family information for family to press charges. Then they collected statements and started Incident/Accident Form and reporting process. Incident occurred on 2/26/2025 and it was reported on 2/26/2025. Resident # 2 was discharged home from the hospital. The Supervisor called Mid-[NAME] for follow up on Resident # 2 and nurse at the hospital stated that Resident # 2 was discharged home on 2/26/2025. Interventions that were added after the incident was the facility put a stop sign on Resident # 2's door. there was follow up with the social worker, Nurse Practitioner, and frequent rounding. Frequent rounding is done every 2 hours so there would be no documentation in Visual (EMR system) Documentation is only signed if hourly rounding is completed. Since the incident on 2/26/2025 Resident # 1 has been good, and they wander around.During interview with Resident # 2 on 5/16/2025 at 11:00am, they stated they were in the hallway during the day of the incident, and they saw that Resident # 1 was in the doorway of their room. Resident #2 stated they grabbed Resident # 1, and they fell to the floor. Then Resident #1 while on the floor kicked them in the left leg. This all occurred in the hallway. They do not watch people well in that place. That was not the first time that Resident #1 had wandered into their room. Resident #2's roommate reported to them that Resident # 1 had laid in their bed, but Resident # 2 was not there when this occurred because they were out of the facility at the time. When they found out that Resident # 1 laid in their bed, they requested their sheets be changed. Resident # 2 stated they know that Resident # 1 has dementia but that is no excuse for them to wander in people's rooms. Resident # 1 should be watched, but the facility does not have enough help. Physical therapy was working with Resident # 2 and that was helping them. Resident #2 stated there were a few people present at the time of the incident and the police also came to the facility. Resident # 2 was sent to Mid-[NAME] Regional Hospital for a psychiatric evaluation, and they did not return to the facility. Resident # 2 was told by the facility that they that they could not return and Resident # 1's family was pressing charges on them because of the incident. Resident # 2 stated they had nowhere to go when they were discharged from the hospital.Resident # 6 was admitted to the facility on [DATE] and last re admitted to the facility on [DATE] with diagnosis that include but not limited to psychotic disorder with delusions, dementia with behavioral disturbances, and muscle weakness.A Quarterly Minimum Data Set, dated [DATE] documented Resident #6 had a Brief Interview for Mental Status score of 3/15; indicating the resident is not cognitively intact with no behaviors present. Resident had no impairment to upper or lower extremities and uses a wheelchair for locomotion. Resident is a moderate assist with eating, and maximum assist with bed mobility. Resident is frequently incontinent of urine and bowel.Review of a potential for abuse care plan for Resident #6 initiated on 9/24/2024 documented Resident is at risk for potential abuse due to immobility with an update on 3/11/2025 of Resident-to-Resident altercation. Interventions dated 9/24/2024 include encourage resident to verbalize any concerns fearsA review of the facility's internal investigation documented at approximately 1:30pm on 3/11/2025 Activity Aide # 1 was walking past room [ROOM NUMBER] and in the doorway, Resident #6 was sitting and had blood on their face. Resident #1 approached Resident # 6, Activity Aide # 1 witnessed Resident #1 pointing their finger on Resident # 6's face stating, Do you know who I am? while holding Resident # 6 by the collar. Activity Aide # 1 attempted to separate both resident but was unable to do this alone and went for assistance. Resident # 6 sustained scratches to the left side of their face and under the left eye and side of left neck. Resident # 1 had scratches to the right arm.A review of Resident # 6's skin assessment dated [DATE] documented scratches to left side of their face and above their left eye.A review of Nursing Progress notes for Resident # 6 had no documented notes about the incident that occurred 3/11/2025 between Resident # 6 and Resident # 1.A review of the facility's 5-day report submitted on 3/19/2025 documented a conclusion that the abuse was verified. Corrective Actions taken because of the verified abuse included Resident # 1 and Resident # 6 were seen by in house provider, social worker and psychiatry. 10 NYCRR 415.4(b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (NY00360874), the facility did not ensure 1 out of 3 (Resident # 7) residents were free from significant medication errors. Specifically, Resident # 7 did not receive their physician ordered medication Enoxaparin Sodium (a medication to prevent blood clots) from 11/6/2024-11/12/2024. There were omissions on the Medication Administration Record with no documented nursing notes as to why the medications were not administered. 2) Resident #7 did not receive their medication Diazepam (a central nervous system depressant) from 11/6/2024-11/12/2024 as ordered by the physician. There was no documentation that the physician was notified or reasons why the medications were not administered. Resident #7 was transferred to the hospital on [DATE] for change in mental status. The findings are:The facility Medication Administration Policy and Procedure dated 9/1/2024 documented it is the policy of the facility to ensure that Medication Administration and documentation occurs in a timely and accurate manner.Resident # 7 was admitted to the facility on [DATE] and had diagnoses that include but not limited to trauma subdural hematoma without loss of consciousness, alcohol abuse, and major depressive disorder.A discharge Minimum Data Set, dated [DATE] documented the resident had no behaviors present. Resident required set up with eating and moderate assistance with toileting, moderate assistance with bed mobility and maximum assistance with transfers. Resident occasionally incontinent of urine and always continent of bowel.Review of the physician order dated 11/6/2024, documented the physician prescribed Enoxaparin Sodium Subcutaneous solution 30 milligrams/0.3 milliliters, give 30 milligrams subcutaneously every 12 hours, at 9 am and 9 pm for a diagnosis of personal history of traumatic brain injury.Review of the Medication Administration Record revealed Resident # 7 did not receive their medication (Enoxaparin Sodium, to prevent clotting) on 11/07/2024-11/09/2024 at 9am and 9pm and 11/10/2024 at 9am as ordered.Nurse progress notes from 11/6/2024-11/12/2024 was reviewed. There were no documented reasons as to why the doses were not administered on 11/7/2024-11/09/2024 at 9am and 9pm and 11/10/2024 at 9am.The physician order dated 11/6/2024 documented a physician order to give Diazepam (a central nervous system depressant) oral tablet 10 milligrams 1 tablet by mouth three times a daily for 180 days at 9 am, 1pm, and 5pm for a diagnosis of Anxiety.Review of the Medication Administration Record revealed omissions on for Diazepam on 11/6/2024 at 9am, 1pm, and 5pm, on 11/7/2024 and 11/08/2024 at 9am, 1pm and 5pm. The reason documented not done.Nurse progress notes from 11/6/2024-11/12/2024 were reviewed. There was no documented evidence as to why the doses of Diazepam were not administered on 11/6/2024-11/08/2024 at 9am, 1pm, 5pm as ordered.A review of a nursing progress note dated 11/13/2024 documented the resident was admitted to the hospital with a diagnosis of Altered Mental Status.A review of a nursing progress note dated 11/12/2024 at 10:43 am documented resident family member met with writer with concerns of resident's medical condition. Writer reported to resident bedside to assess the resident. Resident noted to be laying in bed in fetal position facing the wall. Writer approached the resident and attempted to get the resident's attention. Resident failed to engage with writer. Resident's pupils noted to be dilated and resident staring straight forward. Resident unable to answer basic question when asked. Responses seemed mumbled. This is a noticeable change from residents' baseline upon admission. Resident noted to have emesis on several occasions in the past few days.During an interview with Nurse Practitioner on 6/17/2025 at 11:48 am they stated usually during an omission of medications the nurses will note why the medication was not administered in a nursing progress note. Nurse Practitioner reviewed the medication administration record for Resident # 7 and stated it was 9 months ago, so they do not remember what happened with this resident's medication. It was ordered and there is no documentation why it was not administered. The Nurse Practitioner stated the diazepam was ordered for anxiety and they would have held the medication if there was no indication of anxiety. If a medication is ordered and it is out of stock, the nurses will inform the physician. The Nurse Practitioner stated they could not remember if they were informed or not. They were made aware that the resident was vomiting, and the resident was assessed. The nurses need to inform the physicians that the resident is refusing their meds and that is the facility protocol. They were not notified in this instance and there are no notes to indicate why the resident did not receive the diazepam or lovenox. Residents have the right to refuse medication, but there should be a note if the resident refuses a medication.During an interview on 6/17/2025 at 12:12pm, the Director of Nursing stated Narcotics needed for specific med pass are placed in the medication carts after the nurses complete their narcotic count at the beginning of each shift. If it requires blood pressure they will take vitals beforehand. Verify three times that it is the right medication for the right patient. If a resident refuses medication, then you would try to encourage and explain risk of not taking medication. Not, after the first refusal would you call the provider. This refusal would be put on report so that it can be monitored and passed on to the other nurses. If it continues then you notify the provider. If it is a significant medication, then you need to notify the provider. The medication nurse should notify the manager or supervisor, so they are aware of the refusal. The medication nurse can notify the provider of the resident's refusal. Nurses should document the refusal in the medication administration record and write a nursing progress note about the medication refusal. Surveyor requested for Director of Nursing to review Resident # 7's Medication Administration Record from 11/2024. Director of Nursing reviewed the medication administration record and stated they do not know what happen in this situation because they were not the director of the nursing at the time this occurred. Director of Nursing stated that if they were the Director of Nursing when this occurred, they would follow up with the nursing staff to find out what happened and if the resident refused the medication. If this was a medication error then they would also conduct a house wide in-service on medication administration, refusal and what to do in a situation where a resident refuses medication. Director of Nursing stated if after following up with the nursing staff these are true omissions; then they would write the responsible nurse up for a medication error and call the provider. However, they would need to follow up with the nurse and find out why the medication was not administered.Attempts to contact Licensed Practical Nurse # 2 on 6/16/2025 at 11:42 am was unsuccessful.Surveyor attempted to contact Licensed Practical Nurse # 3 on 6/17/2025 at 12:31 pm regarding medication omissions on the medication administration record. Calls were not returnedFormer DON did not return calls 10 NYCRR 415.12(m)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (NY00342534) the facility did not ensure residents right to be free from abuse for 1 out of 3 residents (Resident #1) reviewed for abuse. Specifically, on 8/5/2024 Resident #2 who was known to be physically/verbally abusive wandered into Resident #1's room, threw their items on the floor, tried to take away their walker and punched them with a closed fist on their arm. Resident #1 reported they were punched on the right arm by Resident #2. Resident #1 was assessed with no injuries and Resident #2 was discharged to the hospital for further evaluation. Findings include: The facility abuse, neglect and exploitation of resident's policy dated 7/12/2018 and last reviewed/revised 4/2020 documented it is the policy of the facility that acts of physical, verbal, and mental abuse directed against residents are absolutely prohibited. Each resident has the right to be free from verbal, sexual, physical, and mental abuse. Residents will not be subjected to abuse by anyone, including but not limited to, staff and other residents. Comprehensive policies and procedures have been developed to aid the facility in the prevention of abuse, neglect, exploitation, mistreatment, or misappropriation of property of the residents. 1)Resident #1 was readmitted to the facility on [DATE] with diagnosis including but not limited to malignant neoplasm of endometrium, Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity. An annual Minimum Data Set, dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 15/15, associated with intact cognition. No behaviors noted. The Resident was independent for eating, bed mobility and transfers, required moderate assistance for toileting and used a wheelchair or a walker for locomotion. Resident #1 was occasionally incontinent of urine and continent of bowels. Review of a behavior care plan dated 8/7/2024 documented the resident was a victim of a resident-to-resident altercation and had unsolicited physical contact by another resident. The goal was the resident will be separated from the aggressor and would not be victimized by other resident, will suffer no emotional effects. Interventions included to assess for injury, keep the resident separated from other aggressor residents, provide emotional support, assess for feelings of fear or lack of safety, and provide social work counseling. Review of an accident/incident investigative form statement dated 8/7/2024 at 6:20 PM written by the Director of Nursing documented Resident #1 was sitting on their bed when another resident wandered into their room and hit them with a closed fist around the shoulder area. Review of the 5-day investigative conclusion submitted by the facility documented the findings were verified and Resident #2 was transferred to the hospital for increase agitation and later returned to the facility. The care plans for Resident #1 and Resident #2 were updated with instructions to keep the residents apart. Resident #2 to be redirected when wandering into resident's rooms and frequent visual checks to be initiated. 2) Resident #2 admitted to the facility on [DATE] diagnosis including but not limited to Neurocognitive disorder with Lewy bodies, Dementia and Personal History of Traumatic Brain Injury. A 5-day Minimum Data Set, dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 99 associated with severe cognition impairment with making daily decisions. The resident exhibited verbal and physical behaviors directed towards others. Resident #2 required partial assistance with ambulation, eating and bed mobility, was dependent for toileting and required supervision for transfers. A cognitive impairment care plan dated 7/29/2024 documented Resident #2 experienced severe cognitive deficits, recent decline in cognitive status, Lewy body dementia, impaired decision-making ability, poor insight/reasoning and poor impulse control. The goal was to promote/improve alertness and awareness with interventions to anticipate the resident's needs, provide orientation and cueing as needed, provide calming environment reduce stimulus and psychiatry and psychology consult and treatment as indicated. A behaviors care plan dated 8/7/2024 documented Resident #2 exhibited combativeness, confusion, wandering, physically abusive and aggressive behaviors. The goal was episodes of aggression would be decreased by redirection. Interventions listed included educate staff, resident/representative on behavioral interventions and consequences as indicated, observe and document behaviors every shift and psychiatric evaluations as indicated. A resident-to-resident altercation (aggressor) care plan dated 8/7/2024 documented Resident #2 was physically aggressive and made unwanted physical contact with another resident. The goal was Resident #2 would be kept apart from Resident #1 and would not display any further physical aggression toward other residents. Interventions listed included keep resident apart from other residents, provide 1:1 supervision until calm, psychiatric consult as ordered, remove resident from situation utilizing calm approach and send to hospital for evaluation of increased agitation and aggressive behaviors. Review of an accident/incident investigative form dated 8/5/2024 documented at 6:20 PM Resident #2 was visiting with their wife and wandered into Resident #1's room. Resident #2 struck Resident #1 with a closed fist around their shoulder area. During an interview on 8/26/2024 at 10:35 AM Resident #1 stated on 8/5/2024 they were in the bathroom in their room, and they heard things being thrown to the floor. They exited the bathroom and found Resident #2 in their room, and they asked Resident #2 to stop and get out of their room. Resident #2 instead, tried to grab their walker and punched them in the arm. Resident #1 stated Resident #2's wife came and removed Resident #2 from the room. Resident #1 stated Resident #2 terrorized them and other residents for days, but after this incident the facility sent the resident out for evaluation. Resident #2 returned to the facility after a few hours, but the resident is no longer in the facility. Stated the Velcro stop sign was at the entry of their room, but Resident #2 just pulled it down and came in that day on 8/5/2024. Resident #1 pointed to a fading brownish bruised area on their right upper arm and showed a picture in their cellphone of a deep purple ecchymosis area to the right upper arm, and stated this was from the incident and is now going away. Resident #1 stated the Director of Nursing was in the building when the incident occurred on 8/5/2024 and they had Resident #2 immediately removed from the building. During an interview on 8/26/2024 at 3:45 PM the Director of Nursing stated they were in the building on 8/5/2024 when the incident occurred between Resident #1 and Resident #2. They were called by Licensed Practical Nurse #1 stating that Resident #2 went into Resident #1's room and struck them. They assessed Resident #1 and had Resident #2 sent out for evaluation. The Director of Nursing stated Resident #1 was a little shaken up after the incident, but they were not injured. The Director of Nursing stated Resident #1 did express concern with Resident #2's behaviors. Resident #2 was transferred out to another facility on 8/9/2024. The Director of Nursing stated they observed Resident #1 and there was no injury noted to Resident #1. The Director of Nursing stated on 8/5/2024 the day of the incident with Resident #1, Resident #2 was with their wife and wandered away from them and went into Resident #1's room. 10 NYCRR 415.4(b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey 4/8/24-4/17/24, the facility did not ensure residents had the right to a dignified existence for 8 of 8 residents reviewed for dining (Residents #54, #40, #39, #19, #25, #49, #56 and #28). Specifically, 1)clothing protectors were applied to Resident # 54, #40, #39, #19, #25, and #49 without first obtaining the residents permission; and 2) staff were observed standing over Resident #56 and #28 while feeding the residents their lunch. Findings include: The facility policy titled Resident Rights dated 2/27/18 documented all residents will be treated with kindness, respect, and dignity. The facility policy titled Preparing Resident for Meal dated 8/30/18 documented to inquire if the resident would like to wear a clothing protector in order to prevent spills of food items from staining clothes. 1. Resident #54 had diagnoses of atrial fibrillation, cerebrovascular accident, and dysphagia (difficulty swallowing). The Minimum Data Set (assessment tool) dated 2/25/24 documented the resident had moderate cognitive impairment -Resident #40 had diagnoses of Type II Diabetes Mellitus, dementia, and hypertension. The Minimum Data Set, dated [DATE] documented the resident had severe cognitive impairment and fed themselves. -Resident #39 had diagnoses of hypertension, dementia, and Type II Diabetes Mellitus. The Minimum Data Set, dated [DATE] documented the resident had moderate cognitive impairment and fed themselves. An observation was made on 4/11/24 at 12:18 PM of Staff #14 (Certified Nurse Aide) placing a clothing protector over the head of Residents #54, #40, and #39 without asking permission. Staff #14 stated they put the clothing protectors on every resident daily. Staff #14 stated they did not ask the residents prior to placing the clothing protector because all residents get them. During an interview on 4/17/24 at 09:10 AM, Resident #54 stated they were bothered by it and would like to be told and asked before the clothing protector was applied. 2. Resident #56 had diagnoses of quadriplegia, neurogenic bladder, and alcohol abuse. The admission Minimum Data Set, dated [DATE] documented the resident was cognitively intact and was dependent on staff for eating. During an observation on 4/9/24 at 12:38 PM, Resident #56 was in their room being fed by Staff #13 (Certified Nurse Aide) and on 4/11/24 at 01:05 PM Resident #56 was in the hallway being fed by Staff #13. During both observations Staff #13 stood over Resident #56. During an interview on 4/9/24 at 12:40 PM and 4/11/24 at 1:05 PM, Staff #13 stated they were aware they should sit while feeding residents but they preferred to stand. During an interview on 4/12/24 at 9:15 AM, Resident #56 stated they would like to see the person who was feeding them, but were unable to raise their head due to a prior neck surgery and use of a neck collar. -Resident #28 has diagnoses of major depressive disorder and obstructive uropathy. The Minimum Data Set, dated [DATE] documented the resident had moderate cognitive impairment and needed assistance from staff with activities of daily living. During an observation on 4/11/24 at 01:02 PM Staff #8 (Certified Nurse Aide) was standing over Resident #28 while feeding them their lunch. During an interview on 04/11/24 01:10PM, Staff #8 stated they were standing while feeding residents because there were so many residents that required assistance. Staff #8 stated they should sit while assisting but choose to stand. During an interview on 04/17/24 at 09:24 AM, Staff #7 (Licensed Practical Nurse Unit Manager) stated the certified nurse aides had been trained to ask for permission prior to applying the clothing protectors. Staff #7 stated staff should be seated while assisting residents with their meals, but stated sometimes there were no chairs. 10 NYCRR 415.3

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated survey (NY00315011) conducted from 4/08/24 to 4/17/24, the facility did not ensure that the written description of the facility policy to implement advance directives was followed for one of one residents (Resident #0) of reviewed for Advance Directives. Specifically, cardiopulmonary resuscitation was administered and the resident was not sent to the hospital as per request for Resident #0 with orders for Do Not Resuscitate and orders to send to the hospital if necessary. The finding are: The facility policy titled Advanced Directives dated 5/4/18, documented the facility will honor the wishes of the resident/representative regarding medical concern, by honoring the existing advanced directives of the resident as well as offering the resident/representative the opportunity to make changes to existing advanced directives. Resident #0 was admitted with diagnoses including acute sepsis, acute hyperkalemia, and altered mental status. The admission Minimum Data Set, dated [DATE] documented the resident had severely impaired cognition. The care plan titled Advanced Directives dated 4/4/23, documented do not resuscitate/do not intubate. Interventions included review advanced directives, choices, and options with the resident/representative. The medical orders for life sustaining treatment (MOLST) for Resident #0 was signed by the designated representative, two witnesses, and the medical provider on 4/5/23 and documented Do Not Resuscitate and send to the hospital if necessary. The physician orders dated 4/5/23 documented Do Not Resuscitate. The social worker progress note dated 4/5/23 documented Do Not Resuscitate and Do Not Intubate. The physician progress note dated 4/6/23 documented Medical Orders for Life Sustaining Treatment, Do Not Resuscitate and Do Not Intubate. The nursing progress note dated 4/14/23 documented the resident had increased anxiety, was yelling out for help, and was frequently asking staff to stay with them because they were scared. The nursing progress note dated 4/17/23 documented the resident was unresponsive in bed in the morning, 911 was called and cardiopulmonary resuscitation was started. Resident was evaluated by registered nurse and found to be without pulse and respiration. During an interview on 04/09/24 01:30 PM, Resident #31 stated that on multiple days prior to Resident #0 expiring, they observed Resident #0 yelling out for staff and requesting to go to the hospital due to complaints of not feeling well, and that the wishes were ignored. Resident #31 stated that on 04/17/24, they observed staff in Resident #0 room resuscitating Resident #0, and that it was an traumatizing experience for them. Resident #31 stated that they asked the previous Administrator why staff did not send Resident #0 to the hospital as per their request and were told by the Administrator that Resident #0 had a Do Not Resuscitate order and therefore, staff were unable to send them to the hospital. During an interview on 04/15/24 at 01:55 PM, the Director of Nursing stated that if a resident had Do Not Resuscitate order, staff should not have perform cardiopulmonary resuscitation and that staff determined the advanced directives by the red dot on the outside of the resident room door and their bracelet . Additionally, the Director of Nursing confirmed that the Medical Orders for Life Sustaining Treatment for Resident #0 documented to send to the hospital if necessary and that Resident #0 should have been sent to the hospital if they requested. During an interview on 04/15/24 at 02:51 PM, Staff # 3 (Licensed Practical Nurse) stated if the progress note documented that they performed cardiopulmonary resuscitation on Resident #0, that was what occurred. Staff # 3 (Licensed Practical Nurse) stated that the Medical Orders for Life Sustaining Treatment document if a resident had Do Not Resuscitate instructions and that if Resident #0 had requested to go to the hospital, their wishes should have been honored. During an interview on 04/16/24 at 10:48 AM, Nurse Practitioner #1 stated that cardiopulmonary resuscitation should not have been initiated on a resident that had a Do Not Resuscitate order. Nurse Practitioner #1 stated that they were informed that the nurse had initiated cardiopulmonary resuscitation prior to the chart being reviewed, and then after the chart was reviewed, they realized that Resident #0 had a Do Not Resuscitate order. 10 NYCRR 415.3(e)(1)(ii)

Based on observation, interview, and record review conducted during the recertification survey from 4/08/24 to 4/17/24, it was determined for 1 of 1 resident (Resident # 11) reviewed for personal property, the facility did not ensure grievances were resolved in a timely manner. Specifically, the facility lacked documentation that a thorough investigation was completed or that there was timely resolution after Resident #11's report of missing clothing. The findings are: The facility Policy and Procedure titled Investigation of Grievance/concerns reviewed 11/20/23 documented that the facility would complete a prompt, thorough investigation of all grievances. Resident #11 was admitted with diagnoses of chronic obstructive pulmonary disease, bipolar disorder, and atrial fibrillation. The Quarterly Minimum Data Set (MDS an assessment tool) dated 3/5/2024 documented the resident was cognitively intact and had continuous behaviors. The social work progress note dated 3/27/2024 documented they would look into the resident's missing clothes. There was no documented evidence that a grievance was completed during March 2024. During an interview on 04/8/2024 at 10:00 AM Resident #11 stated their clothing was missing and they told the social worker, but had not heard anything back. During an interview on 4/11/24 at 11:31 AM Staff #6 (Social Worker) stated missing clothes were documented on a missing personal and misappropriation of property form, not a grievance form. Staff #6 stated they had only 1 report of missing property for the current year and were unaware of any other missing property. When asked about Resident #11's clothing Staff #6 stated they were unaware of Resident 11's missing clothing. When the progress note from 3/27/2024 was reviewed, Staff #6 could not say why a grievance or missing property form was not completed or why when asked initially they said no missing property had been reported. During an interview on 4/11/24 at 11:45 AM the Administrator stated if the facility was not able to locate the missing property quickly, they would fill out a form to ensure an investigation was done. The Administrator stated if after an investigation they were unable to locate the property, they would replace the items or reimburse the resident . The Administrator stated an investigation should have been documented and either a missing property or a grievance form completed. 10 NYCRR 415.3(c)(1)(i)

Based on staff interviews and record review during the recertification survey conducted from 4/8/2024-4/17/2024 the facility did not ensure that required documentation was sent to the receiving provider at the time of a hospital transfer for 1 of 2 residents (Resident #54) reviewed for hospitalization. Specifically, there was no documented evidence that a transfer summary was completed/sent when Resident #54 was transferred to the hospital. The findings are: Policy and Procedure dated 11/1/2017 titled Admission/Discharge/Transfer documented: when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. Resident #54 was admitted with diagnoses which include history of cerebral vascular accident, dysphagia, and seizures. The 5 Day Minimum Data Set (an assessment tool) dated 2/25/2024 documented the resident had moderately impaired cognition. The nursing progress note dated 2/17/2024 documented the family requested that the resident be transferred to the hospital. There was no documented evidence that a transfer summary was completed. There was no evidence that documentation including the contact information of the practitioner/resident representative, advance directive information, special instructions/precautions/medications, comprehensive care plan goals, and other necessary information was sent with the resident. During an interview on 4/16/24 at 11:55 AM after reviewing the electronic medical record the Assistant Director of Nursing stated that they were unable to locate the transfer to the hospital documentation. 10 NY CRR 413.3(h)(1)(ii)(a-c)

Based on record review and interview during a recertification survey conducted from 4/8/2024-4/17/2024 the facility did not ensure that they provided written notice of the facility's Bed Hold policy upon transfer to all residents or residents' representative(s) for 1 of 2 residents (Resident #54) reviewed for hospitalization. Specifically, Resident #54 and/or their representatives were not provided written notice of the bed hold upon discharge to the hospital. The findings are: The Policy and Procedure dated 11/12/2019 and titled Bed Hold documented: The facility will notify the designated representative and / or the resident of the facility's bed reservation policies, in writing, at the time of admission and at the time of transfer. Resident #54 had Diagnosis's of cerebral vascular accident, dysphagia, and seizures. The 5 Day Minimum Data Set (an assessment tool) dated 2/25/2024 documented the resident had moderately impaired cognition. The nursing progress note dated 2/17/2024 documented the family requested that the resident be sent to the hospital. The nursing progress note dated 2/23/2024 documented that the resident returned from the hospital. There was no documented evidence that Resident #54 and/or their representative was given written notice of the bed hold policy. During an interview on 4/16/24 at 1:39 PM Staff #6 (Social Worker) stated they did not send notice of bed hold to any resident unless they were private pay. During an interview on 4/16/24 at 1:43 PM the Administrator stated the facility should give residents and/or resident representatives the notice of bed hold when a resident was discharged to the hospital. 10 NYCRR 415.3(h)(4)(i)(a)

Based on observation, record review and interview conducted during a recertification 4/8/24-4/17/24, the facility did not ensure that necessary assistance and care were provided to carry out activities of daily living for 1 of 3 residents reviewed for activities of daily living (Resident #52). Specifically, Resident #52 was not toileted timely after calling for assistance. The findings are: Resident #52 was admitted on with diagnoses including Type II Diabetes Mellitus, and Major Depressive Disorder. The Annual Minimum Data Set (a resident assessment and screening tool) dated 1/14/24 documented the resident was cognitively intact and required moderate staff assistance for walking and toilet use and was always continent of bowel and occasionally incontinent of urine. The care plan for Activities of Daily Living initiated on 1/7/24 had interventions that included toilet every 2-4 hours and as needed. The care plan for incontinent care dated 1/7/24 documented the resident would be free from skin breaks, free from psycho social complications including withdrawal, embarrassment, humiliation, isolation and resignation. Interventions included educate resident on toileting plan, encourage resident to use call bell and toilet every 2-4 hours as needed. The nurse note dated 4/2/24 at 12:02 AM documented the resident was using the call bell complaining of diarrhea. The resident did not allow the certified nursing assistant working on the unit to care for them, so the resident was told they had to wait a few minutes until the certified nursing assistant from the other unit was free to change them. The resident stated, I don't care I am going to keep ringing until someone changes me. The nurse documented they went to the room four times and asked the resident to stop because someone would be there shortly. The resident refused and kept arguing with the nurse. Approximately 5 minutes later the certified nursing assistant from the other unit came to take care of the resident. During an interview on 4/12/24 02:52 PM with Resident #52, they stated there was a problem with not enough staff and described the instance in the nurses note. The resident stated they have bowel troubles and sometimes just couldn't wait. Staff come into their room to turn the call bell off then leave without taking care of the problem. The resident stated they felt humiliated they had a bowel movement in bed. During an interview 4/16/24 at 10:56 AM Staff #7, (Licensed Practical Nurse Unit Manager) stated they were shocked the nurse did not help the resident. Staff #7 stated that a lot of residents used the call bell but this resident had a real concern. Staff #7 stated if there was only one certified nursing assistant on the unit and the resident did not want that certified nursing assistant, then the nurse should have provided the care. During an interview on 4/16/24 at 12:36 PM the Director of Nursing stated in this case the nurse would be responsible to care for the resident and they did not know why that did not happen. 10 NYCRR 415.12(a)(3)

Based on observation, record review and interview during the recertification survey conducted 4/8/2024-4/17/2024, the facility did not ensure all residents were provided an ongoing program to support residents in their choice of activities and designed to meet their individual needs based on the comprehensive assessment and care plan and the preferences of each resident for 1 of 1 resident (Resident #50) reviewed for activities. Specifically, Resident #50 did not have an admission activity assessment completed to assess for and provide meaningful activities. Findings include: A review of the policy and procedure titled Activities dated 2/4/2019 documented the activities programs are staffed with personnel who have appropriate training and experience to meet the needs and interests of each resident. Resident #50 was admitted with diagnoses including diabetes, end stage renal disease, and anxiety disorder. The activities care plan dated 12/7/2023 documented the resident was on contact isolation for clostridium difficile (C. diff, bacterial infection of bowel) and required in room activities. The Quarterly Minimum Data Set (an assessment tool) dated 3/12/2024 documented the resident's cognition was severely impaired. During an observations on 04/09/24 at 01:33 PM and 04/11/24 at 01:34 PM, the resident was sitting in their room alone. There was no documented evidence in the electronic medical record that an activities admission assessment had been completed. There was no documented evidence in the he electronic medical record that a March quarterly activities assessment had been completed. The activities attendance sheets documented the resident was seen 1 time in March 2024 for a 1:1 visit and had not attended any other activities. During an interview on 04/11/24 01:38 PM the Activity Director stated they should have assessed the resident for activities on admission but could not find the assessment. The care plan was developed when the resident was on precautions, and should have updated when the resident came off precautions. The care plan and assessment should have been updated in March with the quarterly Minimum Data Set. The Activity Director stated they should have identified this, and if the original assessment had been done it would have triggered the review. 10NYCRR 415.5(f)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #43 with diagnosis of type 2 diabetes, schizophrenia, and dysphagia following unspecified cerebral vascular disease. The Quarterly Minimum Data Set (an assessment tool) dated 1/3/2024 documented the resident had intact cognition, and no behaviors. The pain management care plan dated 1/2024 documented an intervention for monitoring and document the reaction to pain medication. The March 2024 physicians orders documented Tylenol 650 every 6 hours for pain. Review of the April 2024 Medication Administration Record documented the resident received Tylenol every 6 hours, however there was no documentation regarding an assessment of pain. During an interview and observation on 04/10/24 at 11:39 AM, Resident #43 was sitting in a wheel chair and stated they had pain that affected their sleep and had been reported to the staff. Resident #43 stated staff only gave them Tylenol. During an interview on 4/12/24 at 1:56 PM the Assistant Director of Nursing stated the staff were not documenting the residents pain scale in the medical record as it was not included in the order. The Assistant Director of Nursing stated staff should document a pain scale for residents who receive pain medications so they would know if the intervention was effective. During an interview on 4/12/24 at 4:00PM Staff #12 (Registered Nurse) stated Resident #43 did not have an order to document pain level. 10 NYCRR 415.12 Based on observation, record review and interview conducted during the recertification survey from 4/8/24-4/17/24, the facility did not ensure that pain management was consistently provided for 2 of 2 residents reviewed for pain (Resident #56 and #43). Specifically, 1) Resident #56 did not receive Lidocaine patches as ordered and was not provided monitoring of their pain level to determine the need for an alternate treatment; and 2) Resident #43's pain level was not monitored. The findings are: A review of the policy and procedure titled Pain dated 5/25/2018, documented the staff will reassess the individuals pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain. 1) Resident #56 was admitted with diagnoses including quadriplegia after fall with a neck fracture, neurogenic bladder, and subluxation (partial dislocation) of the shoulder. The Minimum Data Set, dated [DATE] documented the resident was cognitively intact and had impairment of bilateral upper and lower extremities. The hospital Discharge summary dated [DATE] documented the resident had pain most likely from subluxation of left shoulder versus neuropathic pain and to continue Lidocaine patches to this area. The physician order dated 2/23/24 documented Lidocaine External Patch apply 1 patch daily at 9:00 AM; remove at 09:00 PM. Tylenol oral tablet 325 milligrams, 2 tabs every 4 hours as needed. The nursing care plan for Pain Management initiated 2/23/24 documented the resident would maintain adequate level of comfort. Interventions included administering medications as ordered, monitoring for/observing verbal pain indicators and documenting using 0-10 pain scale every shift and as needed. The pain assessment dated [DATE] documented the resident had guarding and moaned during cares, received Tylenol with relief and had daily pain in the left shoulder with intermittent duration. The Medication Administration Records dated 2/23/2024- 04/17/2024 documented the Lidocaine patches were not administered and not available on 2/27,2/28, 2/29, 3/4, 3/5, 3/6, 3/8,3/9,/3/11,3/12, 3/13, 4/4,4/5, 4/6, 4/7, 4/8, 4/9, 4/11, 4/12, and 4/13/24. Tylenol 325 mg tablet 2 tablets every 4 hours as needed was administered once daily on the following days: 3/5, 3/15, 3/18, 3/22, 3/26, 3/27, 3/28, 3/29, and 3/31/24. Further review of the medication administration record and treatment administration record revealed no documented evidence of a pain scale or pain monitoring. During an interview on 4/9/24 at 12:36 PM, Resident #56 they stated they received pain medications but not all the time because the facility told them they ran out of medications. Resident #56 stated their pain was mostly in the left shoulder and sometimes in their back. During an interview on 4/12/24 at 11:48 PM, Staff#10 (Licensed Practical Nurse) stated they gave medications to the resident regularly and patches were not always available in the resident's supply box. Staff #10 stated they did not offer an alternate to the resident or notify the nurse practitioner or medical doctor about the problem. They further stated they did not do pain scales. During an interview on 4/12/24 at 12:11 PM, Staff #7 (Licensed Practical Nurse Unit Manager) stated they were aware of a supply problem when the resident first came but was not aware it was on going. Staff #7 stated they told Staff#1 (Staffing Coordinator) that the patches needed to be reordered since it was a stock item. Staff #7 reviewed the Medication Administration Record and stated they were not aware the resident had missed so many of the patches. They stated the physician should have been notified. During an interview on 4/15/24 at 12:34 PM, Staff #1 stated they got requests from nurses about low stock meds and reordered them from pharmacy. The patches were requested and they were not aware there was a problem. During an interview on 4/15/24 at 4:26 PM, the Nurse Practitioner they stated they reviewed the resident's medications on a visit and when they saw the red X on the Medication Administration record they assumed it was because the resident refused the drug. They stated they were unaware the resident was not getting the patches due to unavailability and would have offered an alternative pain option if they knew.

Based on record review and interviews conducted during the recertification survey conducted from 4/08/24 to 4/17/24, the facility did not ensure that they consistently posted the daily nurse staffing information (daily resident census, total number/ actual hours worked by licensed nurses and certified nurse aides, and specific units) to be readily accessible to residents and visitors. Specifically, the daily nursing staff information was posted in the lobby area of the building on the other side of a coded door that the residents were unable to unlock unless accompanied by staff. Furthermore, the daily nursing staff information was not updated to reflect any staffing changes throughout the day and the specific units were not reflected on the posting. The findings are: On 04/09/24 at 9:20 AM, upon entering the lobby of the building the daily nurse staffing information was posted and not easily accessible to residents due to needing a code to unlock the door that led to the lobby area. Additionally, the specific units were not reflected on the posting. On 04/11/24 at 5:08 PM, the daily posted nurse staffing information, posted in the lobby, documented there were 2 registered nurses directly responsible for resident care working on the day shift. The staffing sheet documented that there were no registered nurses directly responsible for residents working on 4/11/24 day shift. On 04/12/24 at 9:38 AM, the daily posted nurse staffing information documented there were 3 registered nurses directly responsible for resident care working on the day shift. The staffing sheet documented there were no registered nurses working on 4/12/24 day shift. Additionally, the daily posted nurse staffing information documented there was 1 evening shift registered nurse directly responsible for resident care. The staffing sheet documented that there were 2 registered nurses directly responsible for residents working 4/12/24 evening shift. On 04/15/24 at 9:02 AM, the daily posted nurse staffing information documented there were 3 registered nurses directly responsible for resident care working on the day shift. The staffing sheet documented there were no registered nurses directly responsible for resident care working on 4/15/24 day shift. On 04/15/24 at 10:40 AM, the daily posted nurse staffing information for both 4/13/24 and 4/14/24 was received incomplete by Staff #1 (Staffing Coordinator). On both days for evening and night shift the current resident census, the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift were blank. On 04/16/24 at 9:29 AM, the daily posted nurse staffing information documented there were 3 registered nurses directly responsible for resident care working on the day shift. The staffing sheet documented that there were no registered nurses directly responsible for resident care working on 4/16/24 day shift. On 04/17/24 at 9:22 AM, the daily posted nurse staffing information documented there were 3 registered nurses directly responsible for resident care working on the day shift, The staffing sheet documented that there were no registered nurses directly responsible for resident care working on 4/16/24 day shift. During an interview on 04/12/24 at 11:47 AM, Staff #5 (Receptionist) stated they were told that they were responsible for posting daily nurse staffing/resident census information and had not seen a supervisor or nurse update the sheet. Staff #5 stated the daily staffing sheets were not accurate and the resident census at the receptionist desk was days old at times at times. During an interview on 04/15/24 at 4:10 PM, Staff #1 (Staffing Coordinator) stated they used to be the receptionist and they were not trained on the daily posted nurse staffing/resident census information. They stated they were told to fill in the day shift and the Nursing Supervisor would fill out all the other shifts. Staff #1 stated Nursing Supervisor did not fill out the sheet. During an interview on 04/15/24 at 4:22 PM, the Director of Nursing stated the Nursing Supervisors were responsible for completing the daily posted nurse staffing/resident census information. They stated the receptionist should not completing the posted staffing as they were not aware of updates on staffing. Additionally, the Director of Nursing stated that the daily posted nurse staffing/resident census information should not be posted in the lobby because the residents did not have easy access to the lobby due to needing a code to get out. 10NYCRR 415.13

Based on record review and interview conducted during the recertification survey from 4/08/24 to 4/17/24, the facility did not ensure that the Facility Assessment was reviewed, accurate and updated as necessary. Specifically, the education, training, and competencies required for the certified nurse aides on the Facility Assessment were out of their scope of practice. The findings are: The Facility Profile dated 2/21/24 and last reviewed with the Quality Assurance Agency/Quality Assurance and Performance Improvement committee on 3/20/24 documented the certified nurse aides had training and competencies in glucometers, medication administration, gastronomy tube placement, ventilation/tracheostomy, aseptic dressings, electrocardiograms, and Pleural catheters. During an interview on 04/12/24 at 12:15 PM, the Administrator stated the Facility Assessment was accurate and it was reviewed recently with the Quality Assurance Agency/Quality Assurance and Performance Improvement committee. During an interview on 04/12/24 at 12:20 PM, the Director of Nursing stated that the Facility Assessment was not accurate and that certified nurse aides were not able to perform those duties as indicated on the facility assessment. During an interview on 04/12/24 at 01:05 PM, the Administrator stated that they reviewed the Facility Assessment realizing that the certified nurse aide and registered nurse/licensed practical nurse duties were inaccurate and stated that they did not know how that was not observed by the Quality Assurance Agency/Quality Assurance and Performance Improvement committee on 3/20/24. 10NYCRR 483.70(e)(1)-(3)

Based on record review, and interview conducted during a recertification survey from 4/8/2024-4/17/2024, the facility did not implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, the facility was unable to provide a February or March 2024 infection/antibiotic tracking report. The findings are: There was no documented evidence for an infection and antibiotic tracking report for February and March 2024. During an interview on 4/15/24 at 12:00 PM the Infection Control Practitioner stated the facility was a little behind in reviewing, the tracking and antibiotic stewardship. They stated the last one reviewed was in January 2024. During an interview on 4/15/24 at 12:16 PM the Administrator stated that the infection control nurse was responsible for the antibiotic stewardship. The Administrator stated they were unaware that the facility was behind in infection control tracking and antibiotic stewardship. 10 NYCRR 415.19 (a)(1,3)

Based on observation and interview conducted during the recertification survey from 4/8/24-4/17/24, the facility did not ensure that residents were provided a safe, sanitary, and comfortable home-like environment. Specifically, 1. there was a strong urine odor in Resident #33 and 36's shared room and 2. the window curtain in Resident #25's room was hanging off the rod. The findings including: The facility policy entitled: Cleaning and Disinfecting Rooms Revised 11/12/2019. The facility policy stated environment surfaces will be disinfected on a regular basis, three times per week and when surfaces are visibly soiled. Clean curtains, window blinds, and walls when they are visibly soiled or dusty. Conduct monthly spot checks to ensure that all curtains and window treatments are cleaned and orderly. During an interview on 4/8/24 at 10:35 AM, Resident #33 stated everything was broken in the facility. At that time there was a strong urine odor inside the room. During an observation on 4/9/24 at 12:47 PM, and 4/10/24 at 9:35 AM Resident #25's window curtain was ripped, hanging down and not attached to the curtain rod. During an observation on 04/11/24 at 12:37 PM, Resident #33 and Resident #36's shared room continued to have a strong urine odor. During an interview on 4/12/24 at 9:51 AM, Resident #33 stated they were not sure if the facility was doing anything about the strong urine odor. During an interview on 4/12/24 at 9:51 AM Resident #36 stated that they told the staff a long time ago about the strong urine odor in the room. During an interview on 4/12/24 at 10:12 AM, Staff # 7( Licensed Practical Nurse Manager ) stated Resident #33's mattress had a strong urine odor. Staff #7 stated Resident #33 has gotten better with changing their clothes and not wearing the same pair of shorts several times. During an interview on 4/15/2024 at 10:15 AM, Staff #8 (Certified Nurse Aide) stated Resident #33 washed and hung their clothing in their room, but the mattress had a urine odor because Resident #33 was incontinent and was non-complaint with cares. During an interview on 4/15/24 at 10:28 AM, the Director of Housekeeping/Laundry stated that Resident #33 was not sending all their dirty clothing to the laundry. The Director of Housekeeping stated the resident's mattress was wiped down daily, but the resident may need a new mattress. During an interview on 4/15/24 at 10:38 AM Staff #12 (Maintenance Worker) stated the curtains in Resident #25's room were the only ones the facility had; the facility had been trying to get rid of curtains and change to blinds. 10 NYCRR 415.29

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews during a recertification survey 4/8/24-4/17/24, the facility did not ensure residents received treatment and care in accordance with professional standards of quality for 4 of 6 residents (Residents #14, #27, #54 and #56) reviewed for quality of care. Specifically, 1) Resident #14 vascular wound dressing was not changed daily as ordered and was observed on 4/12/24 with a date of 4/9/24 on the dressing. 2) Resident #54 did not have post hospitalization appointments scheduled for follow up care. 3) Resident #56's order for compression stockings was not carried out and a follow up urology appointment was not scheduled. 4) Resident #27 did not receive daily wound care as ordered on 8 of 19 days from 3/29/24 to 4/16/24. Findings include: 1) Resident #14 was admitted with diagnoses including adult failure to thrive, venous insufficiency, and hypothyroidism. Resident #14's Minimum Data Set (an assessment tool) dated 3/23/24 documented the resident had moderate cognitive impairment and was dependent on staff for assistance with hygiene and toileting, and required cueing for eating. The Physician's orders dated 3/08/24 document to cleanse the vascular wound to left lower extremity with normal saline or wound cleanser, apply Silver Alginate, cover with a gauze pad, and wrap with Kling. Change the dressing daily and as needed. The nursing care plan for vascular wound initiated 7/22/22 documented to provide treatments as ordered. During a Resident Council meeting on 4/9/24 at 10:24 AM, the resident stated they had a wound dressing on their leg that went days without being changed. On a second interview with the resident 4/10/24 at 10:13 AM they stated they had a wound on their left foot that was not always changed and sometimes it could be a few days without changing. The Treatment Administration Record from 3/8/24-3/31/24 documented no evidence the treatment was completed on 3/8,3/9,3/10,3/11, 3/13,3/14,3/19,3/20. The April 2024 Treatment Administration Record documented no evidence the treatment was completed on 4/1,4/2,4/3, 4/6,4/7,4/11/24. During a wound dressing change observation on 4/12/24 at 9:42 AM with the Staff #15 (wound care nurse) the old dressing on the left lower leg was wet with brown color on outside of the Kling which was loosely in place. The silk tape over the Kling had date of 4/9/24 written on it. When interviewed during the dressing change, Staff #15 stated they saw the resident on Monday, Wednesday and Friday and was not sure why it had not been changed since 4/9/24. During an interview on 4/12/24 at 12:17 PM, Staff #11 (Licensed Practical Nurse) stated the leg dressing change should have been done everyday and they did not know why it was not done. Staff #7 (Licensed Practical Nurse Unit Manager) stated they were not aware the dressing changes were not being done. Staff #7 stated that the expectation would be that if the dressing change was not done on the day shift it would be done on the evening shift. 2) Resident #54 was admitted from the hospital with diagnoses that include respiratory failure, atrial fibrillation, dysphagia, septicemia. The Minimum Data Set (an assessment tool) dated 2/25/24 documented the resident had moderate cognitive impairment, with impairment on upper extremity, and a percutaneous endoscopic gastrostomy tube (feeding tube) in place. During an interview with Resident #54 on 4/17/24 at 9:06 AM they stated they did not know why they still had the feeding tube as it was not being used. They stated they had not been to see the gastroenterologist or the cardiologist and was told it had to wait until they were discharged . Review of the resident discharge instructions from the hospital on 1/30/24 documented the resident had a gastrostomy tube in place after a cerebrovascular accident. The discharge instructions documented a follow up appointment was made by the hospital for the resident for July 1, 2024 at 11:30 with the cardiologist. Additional instructions included to schedule appointments with the gastroenterologist and the neurologist to be seen in 1-2 weeks. Review of the resident's recorded revealed no documented evidence the appointments with the gastroenterologist and the neurologist were made. On 2/17/24 the resident was hospitalized and returned to the facility on 2/23/24 with discharge instructions to schedule an appointment with the maxillofacial surgeon within 2 weeks. Further review of the resident's recorded revealed no documented evidence the appointment with the maxillofacial surgeon was made. During an interview on 4/17/24 at 9:35 AM, Staff#7 (Licensed Practical Nurse Unit Manager) stated they reviewed the discharge instructions and stated the follow up appointments were not needed and were listed on the discharge instructions for billing purposes. During an interview on 4/17/24 at 1:02 PM, the Assistant Director of Nursing stated the Staff #7 was new to the role and needed more training. 3) Resident #56 was admitted [DATE] with diagnoses including quadriplegia after fall with fractured cervical (neck) vertebrae, neurogenic bladder, subluxation of right shoulder. The Minimum Data Set, dated [DATE] documented the resident was cognitively intact and had impairment of bilateral upper and lower extremities. The resident was totally dependent on staff for all activities of daily living, wore an Aspen collar and required a mechanical lift to transfer out of bed. The resident had a Foley catheter. Urology consult: The hospital discharge instructions dated 2/23/24 documented the resident had a Foley catheter and to follow up with urology for urodynamic testing. Review of the resident's record revealed no documented evidence that urology was contacted. The resident care plan for Foley(Urinary Incontinence) initiated 2/27/24 had interventions that included urology consult as indicated. During an interview on 4/11/24 at 12:55 PM, Staff #7 stated they were not aware of a visit to the urologist and stated the resident had not left the building since their admission in February. The Staff #7 stated the discharge instructions were reviewed on admission and the urology order was missed. Compression stockings: The Physician orders dated 2/23/24 documents TED anti-embolic stocking to extremities before getting out of bed daily. The Treatment Administration Record was reviewed from 2/23/24-4/17/24 and documented the stockings were not in place 38 of 55 days. The Certified Nurses Assistant Care Guide listed the anti-embolic stockings. Observations were made on 4 /11/24 at 1:00 PM , 4/12/24 at 8:59 AM, and 4/16/24 at 10:15 AM, the resident was in their wheelchair and the anti-embolic stockings were not worn. During an interview with Resident #56 on 4/16/24 at 10:15 AM, they stated they had the anti-embolic stockings before coming to the facility but did not get them at this facility and did not know why. During an interview on 4/11/24 at 01:00 PM, Staff#8 (Certified Nurse Aide) stated the resident did not have the stockings and did not know why they were on their Care Guide. During an interview on 4/12/24 at 11:31 AM, Staff #11 (Licensed Practical Nurse) stated they did the medications first in the morning then moved on to the treatments. Staff #11 stated they signed off on treatments including stockings. Staff #11 stated they had not seen a pair of stockings for the resident but would put in an order. Order placed 4/14/24. As of 4/17/24 the resident had not received the stockings. During an interview on 4/16/24 at 10:39 AM, Staff # 7 (Licensed Practical Nurse Unit Manager) they stated they did not know what happened to the stockings. Staff #7 then went into the Resident #56 and asked the resident if they liked the stockings and Resident #57 stated the stockings made their legs feel good. During an interview on 4/15/24 04:26 PM, the Nurse Practitioner they stated they were not aware the resident was not provided the stockings. 10NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification and Abbreviated surveys (NY0322448, NY00308142 and NY00320376) from 4/08/24 to 4/17/24, the facility did not ensure that there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, upon review of the staffing schedule for multiple days and on all three shifts of staffing for each unit, the facility did not provide adequate staffing to meet the needs of the residents. The findings are: Review of the facility policy titled Staffing, Sufficient and Competent Nursing dated 11/2/18 documented that out facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Review of the Facility-Wide assessment dated [DATE], and reviewed by the Quality Assurance Agency/Quality Assurance and Performance Improvement committee on 3/20/24, did not provide a staff to resident ratio for comparison and did not provide the number of staff required to work on each of the two units. Facility-Wide Assessment for Nursing Staff documented: - Certified nurse aides: minimum number needed per day was 7. - Licensed practical nurse/Registered nurse: minimum number needed per day was 4. - Total number of facility nursing staff: minimum number needed per day was 11 and the maximum number needed per day was 34. - Total number of Agency nursing staff: minimum number needed per day was 0 and the maximum number needed per day was 0. During an interview on 04/09/24 at 1:30 PM, Resident #31 stated that during the whole month of February 2024 and some of March 2024, they did not get a shower because the facility was so short staffed. Resident #31 stated that on the weekends there was sometimes only one certified nurse aide working in the whole building, residents did not get out of bed, and resident were screaming requesting assistance with cares. During an interview on 04/11/24 at 1:35 PM, the Director of Nursing stated that the nursing staffing scheduling was not being done correctly prior to 3/15/24 when the previous scheduler was employed at the facility. The Director of Nursing stated that the previous scheduler was doing the nursing staffing scheduling on a day to day basis and not on a month by month basis as it should have been done. The Director of Nursing stated the nursing staffing schedule was supposed to be printed a month in advance and the scheduler was responsible for filling in the empty slots with per diems and agency staff, and making sure the facility was staff efficiently. During an interview on 04/11/24 at 01:40 PM, Staff #1 (staffing coordinator) stated they started the staffing coordinator position on 3/18/24 and that they did not receive any documentation or old schedules and the nursing staffing scheduling book was blank. During an interview on 04/11/24 at 02:45 PM, Staff #1 (staffing coordinator) stated they could not provide a staffing plan and was unaware if one was available. During an interview on 04/11/24 at 03:18 PM, Staff #19 (Human Resource Director) stated the facility did not have a staffing plan in place as there was a staffing conflict with the previous staffing coordinator. They stated with the new staffing coordinator the facility plans to repair the staffing issues. During an interview on 04/12/24 at 11:00 AM, Staff #2 (certified nurse aide) stated at times there was only one certified nurse aide in the whole building to cover both units during the night shift. During an interview on 04/12/24 at 11:47 AM, Staff #5 (receptionist) stated: - at times the facility had only 2 certified nurse aides working. This happened on the weekends and occasionally on the weekdays when someone had time off. - sometimes there was not a registered nurse in the building. - residents had called the receptionist desk when their call lights were on and staff were not answering, and staff complained about the call lights. - residents called the receptionist desk to ask for assistant with care such as toileting. During an interview on 04/16/24 at 02:29 PM, Staff #10 (certified nurse aide) stated that they were employed by an agency and that they have been working alone since 2 PM due to another certified nurse aide going home at 2 PM. Staff #10 stated that they were always working alone and there was a huge problem with staffing in the facility. During an interview on 04/17/24 at 09:57 AM, the Director of Nursing stated that on both units the minimum nursing staffing needed on day shift was two certified nurse aides and one licensed practical nurse. The minimum staffing needed on evening shift was two certified nurse aides and one licensed practical nurse per unit, and the minimum nursing needed on night shift was one certified nurse aide and one licensed practical nurse. The Director of Nursing stated that they and the Assistant Director of Nursing were in the building Monday-Friday on the day shift and the facility tried to have one registered nurse supervisor in the building on the evening shift but was not always able. The Director of Nursing stated that they did employ agency nursing staff and was not sure why the Facility-Wide Assessment did not indicate the agency staff was a part of the staffing. 415.13(a)(1)(i-iii)

Based on record review and interview conducted during the recertification survey conducted from 4/08/24 to 4/17/24, the facility did not ensure certified nurse aide performance reviews were completed at least once every 12 months for 5 of 5 (Staff #'s 8, 9, 16, 17, and 18) certified nurse aides reviewed. The findings are: There was no documented evidence that Staff #8, 9, 16, 17, and 18 had performance reviews completed at least once every 12 months. During an interview on 04/11/24 at 03:35 PM, the Assistant Director of Nursing stated that they became employed by the facility on 2/28/23 and became the staff educator in September 2023. The Assistant Director of Nursing stated certified nurse aide performance reviews had not been done prior to and since they became employed at the facility; and staff competencies should be done every 12 months and as needed. During an interview on 04/11/24 at 03:40 PM, the Director of Nursing stated that certified nurse aide performance reviews had not been done and should have been done. The Director of Nursing stated that staff performance was not being monitored and there had been complaints from residents and visitors about the staff. During an interview on 04/16/24 at 02:43 PM, Staff #8 (Certified Nurse Aide) stated that they had been working at the facility for over 28 years and had never received a performance review. 10NYCRR 415.26 (c)(2)(iii)

Based on observation, record review and interview conducted during the recertification survey from 4/8/2024-4/17/2024, the facility did not ensure that sanitary conditions were being maintained in the main kitchen area. Specifically, 1) undated and unlabeled food were in the freezer; 2) the dishwasher was not reaching the appropriate temperature; 3) staff were storing personal food in the refrigerator used for the residents' meals; 4) the exhaust wall fan was covered with dust and grease debris; 5) staff were not wearing beard cover while serving the residents their meals; and 6) tuna fish in a stainless steel container and lettuce were on the same shelf in the refrigerator. The findings include: The facility policy entitled Food Receiving And Storage Issued 6/26/2018 stated food services, or other designed staff, will always maintain clean food storage areas. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Uncooked and raw animal products and fish will be stored separately in drip proof containers and below fruits, vegetables and other ready to eat foods. On 4/8/24 at 9:57 AM, during the initial tour of the kitchen, the following was observed: - a sealed plastic bag with sausage patties undated and unlabeled in the freezer been stored on the top shelf. - a low temperature dishwasher not reaching the appropriate final rinse water temperature at 120 degrees, but has a final water rinse temperature at 110 degrees. (A low temperature dishwashing machine final rinse water temperature ranges from 120-150 degrees.) - staff stored their personal food in refrigerator 1 and refrigerator 2, the same refrigerators used for facility food storage and for the residents' meals. - the exhaust fan on the wall was soiled with dust and grease debris blowing on a rack where clean dishes were stored. - the dietary aide was not wearing a beard cover/restraint while serving the residents their meals in the dining room. - tuna fish was prepared and left in a stainless steel bowl was covered with a plastic wrap next to and on the same shelf with a container of lettuce. During an interview on 4/8/24 at 09:59 AM the Food Service Director stated the unlabeled and undated sausages patties were used within the week and were left over. The Food Service Director stated if the dish washing machine did not work, they would contact the vendor and would use disposable plates and utensils until the dish washer was repaired. During an observation on 4/8/24 at 1:05 PM the Dietary Aide was not wearing a beard cover while serving the resident's their lunch trays. At that time the Food Service Director stated the staff did not know they should be wearing a beard cover. During an observation on 4/12/24 at 11:18 AM during a follow-up of the kitchen area the Food Service Director was not wearing a beard cover. At that time the Food Service Director stated they ordered the beard covers and were waiting for them to be delivered. During an observation on 4/12/24 at 11:20 AM during a follow-up of the kitchen area, staff's personal food was noted in 2 refrigerators which were used to store residents' food. The Food Service Director stated that staff's food should be stored in the staff refrigerator. 10 NYCRR 415.14 (h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during a recertification survey from 4/8/24-4/17/24, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infections for 5 of 5 residents (#22, #8, #14, #56, and #18) reviewed for infection control. Specifically, 1) staff did not change gloves after touching a resident and/or assistive device and before handing out Resident #8's food tray and staff were observed using the same hand while feeding Resident #22 and Resident #8; 2) staff did not wear a gown during a dressing change for Resident #14 on Enhanced Barrier Precautions; 3) staff did not wear a gown during a treatment for Resident #56 on Enhanced Barrier Precautions and 4) there was no documentation that oxygen tubing was changed weekly and as needed for Resident #18. The findings are: The facility policy for Infection Prevention and Control Program dated 3/21/24 documented the program was a facility wide effort involving all disciplines and individuals and was an integral part of the quality assurance and performance improvement program. The undated facility policy for Enhanced Barrier Precautions documented precautions were used as an infection prevention and control intervention to reduce the spread of multi drug resistant organisms to residents. 1. Resident #22 had diagnoses of dementia, seizure, and Alzheimer's disease. Resident #22's Minimum Data Set (a resident assessment and screening tool) dated 3/4/24 documented the resident had severe cognitive impairment and was dependent on staff for eating. Resident #8 had diagnoses of dementia, alzheimer's disease, and dysphagia (difficulty swallowing). Resident #8's Minimum Data Set, dated [DATE] documented the resident had severe cognitive impairment and needed assistance from staff for eating. During a meal observation on 4/9/24 at 12:45 PM Staff #8 (Certified Nurse Assistant) was wearing gloves and touched Resident #28's wheelchair, touched the brake adjusted the chair, touched the brake, parked the chair, then walked over to the food truck, opened the door and removed a tray. Staff #8 placed Resident #8's tray, touched Resident #8 on the shoulder/hand and removed their gloves. Staff #8 applied a new pair of gloves without performing hand hygiene and proceeded to feed Resident #22 and Resident #8 using the same right hand. Staff #8 was then observed holding Resident #22's spoon, putting it down and picking up Resident #8's spoon to feed the resident. During an interview on 4/17/24 at 9:26 AM Staff# 7 (Licensed Practical Nurse Unit Manager) stated they monitored and watched staff in the dining room to make sure infection control practices were maintained. During an interview on 4/17/24 at 1:22 PM Staff #8 stated they were right-handed and had a slip up and further stated you caught me. When asked about wearing the gloves Staff #8 stated it was something new and they were confused about when to wear the gloves. 2. Resident #14 had diagnoses of hypothyroidism, anxiety disorder and venous insufficiency. The Minimum Data Set, dated [DATE] documented the resident had impaired cognition and had a foley catheter. The physician orders dated 4/1/24 documented Enhanced Barrier Precautions for lower leg extremity wound every shift. During a wound dressing observation on 4/12/24 at 9:42 AM, Staff #15 (wound care nurse) without the use of a gown, applied gloves and after removing the old dressing leaned over to inspect the wound causing their identification badge to come in contact with the wound drape and the residents leg before resting on Staff #15's shirt. During an interview on 4/12/24 at 9:45 AM Staff #15 stated they should have been wearing a gown the whole time when doing the wound treatment but forgot. Staff #15 stated they did not noticed their identification badge coming in contact with the resident and wound drape but if they had a gown on that would not have happened. 3. Resident #56 was admitted [DATE] with diagnoses including quadriplegia after fall with avulsion fracture of C7, neurogenic bladder, and subluxation of right shoulder. The Minimum Data Set, dated [DATE] documented the resident was cognitively intact and had impairment of bilateral upper and lower extremities and had a foley catheter. There was no documented evidence in the physician orders to indicate the resident was on Enhanced Barrier Precautions. During a treatment observation on 4/16/24 at 10:27 AM Staff #7 gathered supplies and explained the procedure to the resident. Staff#7 washed hands, donned gloves and performed the treatment. The Staff #7 was not wearing a gown at the time they performed the treatment. The resident#56 had signage on the door for Enhanced Barrier Precautions. During an interview with Staff #7 4/16/24 at 10:27 AM they stated they were supposed to wear the gown even if it is just skin prep and stated they usually do but at the time was nervous and was still getting used to the new precautions. During an interview on 4/17/24 at 9:26 AM Staff# 7 (Licensed Practical Nurse Unit Manager) stated the Enhanced Barrier Precautions came out in March and the staff were in serviced. 10 NYCRR 415.19(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the recent recertification survey, the facility did not ensure that the interdisciplinary team (IDT) determine if a significant change assessment was warranted in the required 14-day period after a decline was identified for a resident who decline in functional status. Specifically, 1 of 1 resident (Resident # 9) reviewed for Activities of Daily Living (ADLs) had a functional decline in 2 or more areas based on 2 comparative Minimum Data Set (MDS, an assessment instrument); 2 a significant change MDS was not done within the required 14-day period after the decline was identified in order to determine appropriate plan of care and treatment. The findings are: Resident # 9 has diagnoses and conditions not limited to Diabetes Mellitus, Major Depression, and Dementia. According to the 3/20/19 Annual MDS, the resident had severe impaired cognition, and required extensive assistance of one person with bed mobility, transfer, dressing, personal/oral hygiene, extensive assistance of 2 people with toileting, and was independent with eating. Subsequent Quarterly MDS dated [DATE] coded the resident as severely impaired cognition and required total dependence of one person with bed mobility, dressing, toileting, personal/oral hygiene, extensive assistance of 1 person with transfer, and independent with eating. The 8/29/19 and 11/2/19 Quarterly MDS documented the resident had moderate impaired cognition and required total staff dependence of 1 person with bed mobility, transfer, dressing, toileting, personal hygiene, and independent with eating. Based on the comparative 3/20/19 Annual and 6/1/19 Quarterly MDS as indicated above, the resident showed a decline in more than 2 areas of her ADL function. The facility did not provide any documented evidence that the IDT conducted assessment for functional decline to determine if a significant change MDS should have been done in the required 14-day period after the decline was identified in order to determine appropriate plan of care and treatment. The MDS Coordinator (MDSC) was interviewed on 1/17/20 at 12:43 PM and stated that the resident did have a decline in more than 2 areas of her ADLs function based on the 3/20/19 and 6/1/19 Quarterly MDS, and a significant change MDS should have been done by the previous MDS Coordinator, who no longer works at the facility. The MDSC stated a significant change was not done. The MDSC stated that the resident's 8/29/19 and 11/2/19 Quarterly MDS were coded the same as total dependence of 1 person in ADL function bed mobility, transfer, dressing, toileting, bathing, and personal/oral hygiene, independent with eating after setting up. The MDSC further stated that all the MDS were done by the previous MDS Coordinator. 415.11(a)(3)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #61 was admitted [DATE] with diagnosis of Compression Fracture of the Lumbar-Sacral Spine, Hypertention and Type II Diabetes. The resident is cognitively intact and requires the assistance of 2 people for transfer, and dressing based on admission MDS 1/7/2020. The physician's orders dated 12/31/2019 included a pain monitoring tool used to assess a resident's pain level before and after receiving pain medication every shift. The order also indicated Tylenol 325 mg be provided every 6 hours as needed for pain. Review of the monitoring tool revealed documentation on two shifts that the resident complained of pain, requested and was given Tylenol per MD order. There was no documentation of the effectiveness of the Tylenol and was no comprehensive standard pain assessment on record. An interview was conducted with the resident on 1/14/20 10:50AM who stated he is in pain and does not want Tylenol because it does not work for him. Review of the nursing care plans in place, reflected care plans to address Nutrition, Psycho-Social Well-Being, Discharge Planning, Advance Directives and Therapeutic Recreation. There was no plan in place to address the resident's pain management, including assessing level of pain prior to receiving pain medication, assessing the effectiveness of the medication and non-pharmacological interventions for pain The unit LPN (LPN#1) was interviewed on 1/16/2020 and she did not know why a plan was not in place and stated there should be a pain management care plan. Based on observation, interview and record review conducted during the recent recertification survey, the facility did not ensure that care plans with measurable goals, time frames and interventions were developed to address each resident's medical care needs. Specifically, care plans had not been developed to address issues related to: (1) multiple medical diagnoses with prescribed medications (Resident #53), (2) pain management for a resident with a spinal fracture (Resident #46), and ( 3) medical diagnoses of cirrhosis of the liver and hypothyroidism (Resident #37). The findings are: 1. Resident #53 was admitted with diagnoses including Dementia, Hypertension, and Depression. The 1/2/20 Significant Change MDS (Minimum Data Set: an assessment tool) revealed that resident #53 received 7 days of antidepressant and anticoagulant medicatoin and 1 day of antibiotic therapy. The January 2020 Physician's orders included but were not limited to the following medications: Namenda 5mg daily, Lexapro 10mg daily, Omeprazole 10mg daily, Pradaxa 150mg twice daily, Requip 0.25mg twice daily, and Flomax 0.4 at bedtime Review of the care plans revealed the facility did not develop care plans to address the following diagnoses Atrial Fibrillation and prescribed medication(Pradaxa), Dementia and prescribed medication (Namenda), Depression and prescribed medication (Lexapro), Benign Prostatic Hyperplasia and prescribed medication (Flomax), Restless Leg Syndrome and prescribed medication (Requip), and Gastroesophageal Reflux and prescribed medication (Omeprazole). An interview was conducted on 1/16/20 at 3:25PM with the Registered Nurse Supervisor (RN #1). She stated the nurse that was responsible for developing the care plans no longer worked at the facility. She further stated she would now have the responsibility for the development of the care plans. 3. Resident #37 was admitted to the facility on [DATE] with diagnoses including Chronic Hepatitis C, Cirrhosis of the liver, and Hypothyroidism. The physician's orders included Lactulose 30 mg 4 times daily for high ammonia level (associated with Cirrhosis of the liver) and Levothyroxine 75 mcg daily for hypothyroidism. A nursing progress note date 9/4/19 stated that the resident was observed to have altered mental status and was refusing to have laboratory work done to rule out hypoxia versus elevated ammonia level and excess opioids. On 10/30/19 a laboratory report showed ammonia level to be 174 (18-72). The resident's plan of care did not include measureable goals and interventions to address cirrhosis of the liver and hypothyroidism. During an interview with the current Unit Manager/Registered Nurse on 1/17/20 at 2:36 PM she stated that the nurse responsible for the developement of the care plan was no lonnger at the facility and she just recently took over responsiblility for care planning on the unit. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recent recertification survey, the facility did not ensure care plans were reviewed and revised to address issues related to smoking and anxiety. Specifically, no interventions were initiated to address non-compliance with the facility's no smoking policy (Resident #2). and the plan of care addressing anxiety was not evaluated to address the continued use of 3 psychoactive medications (Resident #23). The findings are: 1. Resident #2 was admitted to the facility with diagnosis including Chronic Renal Failure and Type II Diabetes. The physician's orders indicated the resident receives hemodialysis three times weekly off site. Based on admission MDS The resident is cognitively intact, can make needs known and self-propels in a wheelchair. An Accident/Incident report from 1/6/20 7:30 pm, the resident was observed on the second floor unit in a back bathroom rolling his wheelchair and smoking cigarettes. On 1/7/20 morning the resident was once again found on the second floor unit smoking in a back bathroom. The unit LPN #1 was interviewed on 1/16/20 3:41PM and stated the resident was not harmed and was redirected back down to the first-floor unit. She stated the social worker was in attendance and had a lengthy discussion with the resident about the facility's non smoking policy. The physician was notified and a nicotine patch was offered, but the resident declined. The nursing care plan was reviewed for non-compliance which was initiated on 1/7/20. The care plan did not include goals or interventions addressing the resident's non-compliance to the no smoking policy. An interview with the unit LPN was conducted on 1/17/20 3:41PM who stated that the current non-compliance care plan did not have interventions to address smoking and stated there should be resident centered interventions in place. An interview was conducted with the RN supervisor on 1/17/20 4:05PM who was able to verbalize interventions to address the resident's non compliance but she was unable to produce a written document. 2. Resident #23 was admitted to the facility on [DATE] with the diagnoses of Diabetes Mellitus, Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Insomnia, and Anxiety Disorder. According to the admission Minimum Data Set (MDS) (a tool to address resident care needs) dated 6/5/19, the resident had moderate cognitive impairment, exhibited no behavioral symptoms, displayed no signs and symptoms of a mood disorder, and was on an antianxiety medication. There was no care plan directly addressing anxiety disorder. The psychosocial care plan dated 7/3/19 noted that the goals for the resident were to adjust to placement as evidenced by positive expression; remain positive and and motivated to rehab goals; maintain ties with family and friends; acclimate to facility routine; not exhibit signs and symptoms of depression, anxiety, hopelessness, anger, social isolation or mood disturbances. The interventions to achieve this goal included: encourage family and friends to visit; express feelings about admission and placement; invite to resident council; 1:1 interactions and refer for psychological services. A review of nursing and medical progress notes revealed the following information regarding the resident's behavior (Notes are by nursing unless otherwise indicated): 7/30/19 - (medical note): asked to see resident for fear and anxiety during rehab. Anxiety disorder, fear of falling. Add Buspar 5 mg twice daily (increased to 5 mg three times daily on 8/26/19 for reasons not noted in the resident's clinical record). 10/7/19 - resident moved from 20-1 to 28-1; resident screams and yells all night. Keeps roommate up all night. Her husband comes to visit at night and turns the TV up loud. Was in hallway cursing residents saying they are bad and they want to kill her; constant redirecting needed. New order to start Trazadone 100 mg at bedtime. 10/7/19 - (medical note): increased anxiety when standing in physical therapy and continues to yell out at night. Admits to not being able to sleep. Assessment/Plan- anxiety interfering with rehab/COPD . Will try Ativan prior to Rehab and see effect. Increase Trazodone to 100 mg at hour of sleep. 10/8/19 - episodes of screaming and yelling at night. Ativan (Lorazepam) given with good effect. 10/9/19 - yelling at beginning of shift; able to redirect and calm down to sleep; later yelling at other residents, making threatening remarks. Positive for UTI (urinary tract infection). The resident's current medication regimen included three medications daily for anxiety: Buspar 5 mg three times daily, Lorazepam 0.5 mg daily (initiated on 10/18/19 0.5 mg twice daily and decreased on 11/20/19 to current dose), and Trazadone 100 mg daily, which was an increase from 50 mg daily on 10/7/19, 2 days before the resident tested positive for a UTI on 10/9/19 ). The most recent quarterly MDS dated [DATE] showed that the resident was severely cognitively impaired, had signs and symptoms of a mood problem (problems with sleeping, tiredness and concentration) and rejected cares 1-3 days weekly. There was no documented evidence that the resident's Psychosocial plan of care mentioned above had been evaluated prior to or after the completion of the above quarterly MDS assessment to address the ongoing use of three psychoactive medications and the effectiveness of planned interventions. This is in light of the fact that Trazadone was increased to 100 mg and Lorazepam was ordered to be given daily at a time when the resident was positive for a UTI. These changes were not reevaluated to determine if they should remain in effect. The Nurse Manager/Registered Nurse was interviewed on 1/17/20 at 2:36 PM regarding the development and evaluation of the resident's care plan. She stated that the Registered Nurse responsible for this was no longer working at the facility and she (the new manager) recently assumed responsibility for the unit. 415.11(c)(2)(i-iii)

Based on observation, interview and record review conducted during a recent recertification survey, the facility did not provide the necessary care and devices needed maintain or prevent further contracture for 1 resident (Resident # 41) reviewed for limited range of motion. The findings are: Resident #41 has current diagnoses and conditions including but not limited to Generalized Muscle Weakness, Spasm, and Contracture of Upper and Lower Extremity. According to the 12/5/19 Quarterly Minimum Data Set (MDS; an assessment instrument), the resident had severe impaired cognition, and was totally dependent on staff for Activities of Daily Living (ADLs) (e.g. bathing, dressing, grooming etc.) A Splint/Cast/Brace/Immobilizer Care Plan initiated 9/19/19 and in effect at the time of the review documented the resident uses splints to both hands for contracture. The current physician orders in effect at the time of the review had orders for bilateral hand splints daily, to be applied in the AM, and taken off at hours of sleep. The resident was observed lying in bed on 1/14/20 at 10:33 AM without devices to his right and left hand that are required to maintain or prevent further contracture of his upper extremities. Multiple follow up observations were conducted in the morning on 1/14/20. The resident remained without devices to both hands. The resident was unable to provide information due to severe cognitive impairment. A follow up observation was conducted on 1/16/20 at 3:47PM. The resident was out of bed in his reclining chair without the bilateral hand splints. The day shift Licensed Practical Nurse (LPN # 2) was interviewed on 1/16/20 at 3:49 PM and stated that the resident should have hand splints on. She further stated she was not sure why they were not in place. LPN #2 stated that the assigned Certified Nursing Assistant (CNA # 3) who cared for the resident had left for the day. CNA #2 was interviewed on 1/16/20 at 3:59 PM about the lack of splints that he should have been wearing. CNA #2 stated she was not sure why they were not on. The 7A-3PM CNA # 3 who took care of the resident on 1/16/20 was interviewed on 1/17/20 at 10:29 AM and stated that he forgot to apply the resident's hand roll on 1/16/20. 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the most recent re-certification survey, the facility did not ensure that 1 of 1 resident reviewed for respiratory care was provided appropriate care consistent with standards of practice and in accordance with a written plan of care. Specifically, the resident was being administered 3 liters of oxygen not in accordance with the physician's orders or written plan of care. The findings are. Resident #23 was admitted to the facility on [DATE] with the diagnoses of Diabetes Mellitus, Hypertension, Chronic Obstructive Pulmonary Disease (COPD), and Anxiety Disorder. On 1/14/20 at 8:45 AM the resident was observed receiving oxygen at about 2.5 Liters via a nasal cannula. The resident was observed receiving 3 liters of oxygen at other times when out of bed to include: 1/14/20 at 11:20 AM, 1/16/20 at 11:13 AM and 1/16/20 at 12:38 PM . However, according to the physician's order, the resident was to be administered 3 liters of oxygen via a BiPAP machine (a type of breathing apparatus, delivering pressurized air through a facial or nasal mask to one's airways) from 1:00 PM to 4:00 PM and 9:00 PM to 6:00 AM daily. The resident's current Respiratory care plan did not reflect the use of oxygen. The day shift Licensed Practical Nurse (LPN #1) on the unit was interviewed on 1/17/20 at 3:11 PM. She stated that in the past the resident had had an order for 3 liters of oxygen continuously, which was not carried over in the orders for past several month. 415.12(k)(6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the most recent recertification survey, the facility did not ensure that each resident's drug regimen was free of unnecessary medications used for pain management and the treatment of hypertension. This was evident for 2 of 5 resident's reviewed for unnecessary medications (Residents #37 and #23) and 1 of 2 resident's reviewed for pain management (Resident #49). Specifically, there was inadequate pain monitoring for the use of opioids for Residents #37 and #49) and inadequate monitoring of vital signs for the use of an antihypertensive medication (Resident #23). The findings are: 1. Resident #37 was admitted to the facility with diagnoses including Chronic Hepatitis C, Cancer, Cirrhosis of the liver, Depression and Hypothyroidism. The resident was also admitted with the history of psychoactive substance abuse. The significant change Minimum Data Set (MDS, an assessment instrument) dated 12/12/19 revealed that the resident had no cognitive impairment, and experienced frequent pain with an intensity of 10 (on a pain scale of 1-10). The current physician's orders included Morphine Sulfate 15 mg every 12 hours (since 1/7/20) and Oxycodone 5 mg every 4 hours as needed for pain with an intensity of 5-10. On 1/15/19 a new physician's order was received for another pain medication, Ultram 50 mg twice daily as needed for pain with an intensity of less than 5. A review of the Medication Administration Record (MAR) for the months of December 2019 and January 2020 (1/1/20 to 1/16/20) showed that Oxycodone was administered as follows: December 2019 - given on 16 days 1 to 2 times January 2020 - given on 13 days (of 16 days) There was no documented evidence that the intensity of the resident's pain was determined prior to the administration of Oxycodone. This was brought to the attention of a Licensed Practical Nurse (LPN #1) on the unit on 1/19/20 in the afternoon. She provided no evidence that the intensity of the resident's pain was being determined prior to the administration of Oxycodone. 2. Resident #49 was admitted to the facility on [DATE] with diagnoses including Depression. The admission MDS dated [DATE] indicated that the resident had no cognitive impairment, was assessed to be depressed, and to have severe pain. The current physician's orders included Hydromorphone HCL 6 mg every 6 hours as needed for pain with an intensity of 5-10. A review of the MAR for December 2019 showed that Hydromorphone HCL was administered 14 times with no documented evidence that the intensity of the resident's pain was determined prior to administration. The surveyor interviewed LPN #1 on 1/16/20 at 3:15 PM to determine why the intensity of the resident's pain was not being monitored. She stated that the resident's pain was usually above 5. She provided no documentation to support this claim. 3. Resident #23 was admitted to the facility with diagnoses including Hyperlipidemia, Anxiety, Heart Failure, Hypertension and Diabetes Mellitus. The current physician's orders included an order for Metoprolol (antihypertensive medication) 50 mg twice daily (hold for systolic blood pressure less than 100 and Heart Rate less than 60) The MAR showed that HR was not being monitored. Instead the MAR showed that Metoprolol not to be given if the diastolic blood pressure was less than 60. LPN #1 was interviewed on 1/16/20 at 11:26 AM. She stated that the information on the MAR regarding the diastolic blood pressure was entered incorrectly by the unit manager who was not working at the present time. The MAR should have made reference to the resident's heart rate and not diastolic blood pressure. 415.12(l)(1)

Based on observation, interview, and record review conducted during the recent recertification survey, the facility did not ensure that facility staff followed proper hand hygiene to prevent cross contamination and the spread of infection for 1 of 3 residents (Resident #59) reviewed for pressure ulcer. The findings are: Resident #59 has diagnoses and conditions not limited to Acute Kidney Issues, Diabetes Mellitus, Stage 3 left heel Pressure Ulcer (PU), and Unstageable Deep Tissue Injury (DTI) PU to Right Heel. According to the 1/7/2020 5-Day Minimum Data Set (MDS; an assessment tool), the resident had a Brief Interview Mental Status (BIMS) score of 7 out of 15, which indicated moderately impaired cognition. The MDS also noted that Resident #59 required extensive staff assistance with Activities of Daily Living (ADLs). Physician's orders dated 1/7/20 had a directive to clean Resident #59's right and left heel with Normal Saline, apply Skin Prep, and leave open to air. During a wound observation conducted on 1/16/20 at 11:26AM on the South side unit, the Licensed Practical Nurse (LPN #2) donned a pair of gloves then removed the resident's right and left leg pressure relief boots and socks. Without removing her gloves and sanitizing her hands, LPN #2 used the same soiled gloves to open several packages of 4x4 gauze and a small bottle of Normal Saline (NS). With the same soiled gloves, LPN #2 then saturated the 4x4 gauzes with the NS and cleansed the resident's left heel wound site which was observed with blackish tissue. With the same soiled gloves, LPN #2 then applied the ordered Skin Prep to the site. Without removing her soiled gloves, LPN #2 proceeded to cleanse the resident's right heel wound site with the saturated NS gauze, then applied the ordered Skin Prep. Without removing her soiled gloves, LPN #2 then reapplied the resident's leg boots and socks. LPN #2 used one pair of gloves to perform the entire wound care procedure, as well as removing and reapplying the resident's leg boots and socks. LPN #2 was interviewed on 1/16/20 at 11:58AM following the wound care procedure and stated that she was not sure why she did not change her gloves and washed her hands after removing the resident's leg boots and socks. LPN #2 stated that she did not remove a dressing from both wound sites and was not thinking about anything. 415.19 (a) (1-3)