**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification survey initiated on 6/24/2025 and completed on 7/2/2025, the facility did not ensure that all completed Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services within 14 days of the resident assessment completion date. This was identified for one (Resident #57) of one resident reviewed for the Resident Assessment task. Specifically, Resident #57's two quarterly and one Skilled Nursing Facility Prospective Payment System (PPS) discharge assessment was not transmitted within 14 days of the resident assessment completion date. The finding is: A facility policy and procedure titled Minimum Data Set Assessments, effective 5/1/2025, documented that each resident admitted to the facility will be assessed utilizing the Minimum Data Set tool as a means of improving resident care. The Minimum Data Set tool will be completed in accordance with the Minimum Data Set Resident Assessment Instrument Manual and regulatory directives. Information gathered on the minimum data set will be encoded and electronically transmitted to the State Survey Agency.Resident #57's Skilled Nursing Facility Prospective Payment System (PPS) discharge assessment dated [DATE], documented a Brief Interview for Mental Status of 13, indicating the resident had intact cognition. The assessment completion date was documented as 7/12/2024.A review of the Minimum Data Set Assessment 3.0 Nursing Home Validation report dated 6/26/2025 revealed that the Skilled Nursing Facility Prospective Payment System (PPS) discharge assessment Minimum Data Set Assessment with an Assessment Reference date of 6/26/2024 was completed on 7/12/2024 and transmitted to the Centers for Medicare and Medicaid Services on 8/6/2024. The Minimum Data Set was transmitted 9 days late.Resident #57's Quarterly Minimum Data Set Assessment, dated 8/9/2024, documented a Brief Interview for Mental Status of 13, indicating the resident was cognitively intact. The assessment completion date was documented as 8/23/2024. A review of the Minimum Data Set Assessment 3.0 Nursing Home Validation report dated 6/26/2025 revealed that the Quarterly Minimum Data Set assessment dated [DATE], completed on 8/23/2024, was transmitted to the Centers for Medicare and Medicaid Services on 9/19/2024. The Minimum Data Set was transmitted 14 days late. Resident #57's Quarterly Minimum Data Set Assessment, dated 2/9/2025, documented a Brief Interview for Mental Status of 6, indicating the resident had severely impaired cognition. The assessment completion date was documented as 6/5/2025. A review of the Minimum Data Set Assessment 3.0 Nursing Home Validation report dated 6/26/2025 revealed the Quarterly Minimum Data Set assessment dated [DATE], completed on 2/23/2025, and was transmitted to the Centers for Medicare and Medicaid Services on 6/5/2025. The Minimum Data Set was transmitted 88 days late.During an interview on 6/26/2025 at 2:49 PM, the Minimum Data Set Coordinator stated the facility generally submits the assessments on a weekly basis, and the late submissions were due to incomplete assessments by facility staff. During an interview on 6/26/2025 at 3:12 PM, the Director of Nursing Services stated they were not aware of delays in the transmission of the Minimum Data Set Assessments.During an interview on 6/26/2025 at 3:29 PM, the Administrator stated they were not aware that the Minimum Data Set assessments were being transmitted late to the Centers for Medicare and Medicaid Services. The Administrator further stated that the delay was probably due to the various departments not signing off on their sections as completed.10NYCRR 415.11

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey initiated on 6/24/2025 and completed on 7/2/2025, the facility did not ensure the accuracy of Minimum Data Set Assessments.This was identified for one (Resident #187) of four residents reviewed for Accidents. Specifically, based on the Resident #187's Comprehensive Care Plan and Fall Risk assessment, the resident utilized a chair alarm daily. The resident's Quarterly Minimum Data Set assessment, dated 4/11/2025, and a Significant Change Minimum Data Set assessment dated [DATE], did not indicate the use of the chair alarm.The finding is:A facility policy and procedure titled Minimum Data Set Assessments, effective 5/1/2025, documented that each resident admitted to the facility will be assessed utilizing the Minimum Data Set tool as a means of improving resident care. The Minimum Data Set tool will be completed in accordance with the Minimum Data Set Resident Assessment Instrument Manual and regulatory directives. The Minimum Data Set Assessment is a core set of screening and assessment elements, including common definitions and coding categories that form the foundation of the comprehensive assessment for each resident.A Comprehensive Care Plan titled Risk for Falls, initiated on 7/5/2023 and last reviewed on 4/25/2025, documented risk for falls related to the diagnosis of Huntington's Disease. The interventions included a chair alarm to recliner or wheelchair when out of bed.Resident #187 was admitted to the facility with a diagnosis of Huntington's Disease. A Significant Change in Status assessment dated [DATE] documented a Brief Interview for Mental Status score of 14, indicating the resident had intact cognition. The Minimum Data Set did not document the use of a chair alarm.Resident #187 was admitted to the facility with a diagnosis of Huntington's Disease. A Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 9, indicating the resident had moderately impaired cognition. The Minimum Data Set did not document the use of a chair alarm.During an interview on 7/1/2025 at 10:32 AM, Certified Nursing Assistant #1 stated that Resident #187 was at high risk for falls, and when the resident was out of bed in the recliner chair, a chair alarm was used for safety because of the resident's involuntary movements due to Huntington's Disease.During an observation and interview on 7/1/2025 at 10:41 AM, Licensed Practical Nurse #3 stated that Resident #187 had a chair alarm on their recliner chair. Licensed Practical Nurse #3 stated that the resident utilized a chair alarm for safety related to the resident's involuntary muscle movements as a result of Huntington's Disease. During the interview, Licensed Practical Nurse #3 showed the surveyor the chair alarm that was present on the resident's recliner chair.During an interview on 7/1/2025 at 1:14 PM, Minimum Data Set Coordinator #2 stated that the nursing sections of Resident #187's Minimum Data Set Assessments are completed by the Registered Nurse Manager. Minimum Data Set Coordinator #2 stated that the assessments should be reviewed for accuracy before submission by the Registered Nurse Manager.The Registered Nurse Manager was not available for an interview.During an interview on 7/2/2025 at 9:26 AM, the Director of Nursing Services stated that they were not aware that the Minimum Data Set Assessments were incorrect. They further stated that there is no system in place to double-check the accuracy of the assessments. The Director of Nursing Services stated that at this time, there is no one designated to review the accuracy of the Minimum Data Set Assessments.10 NYCRR 415.11 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 6/24/2025 and completed on 7/02/2025, the facility did not develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (Resident #51) of two residents reviewed for Abuse. Specifically, Resident #51 was diagnosed with Legal Blindness, and the facility did not develop a visual impairment care plan with person-centered interventions to address the resident's needs. The finding is: The facility policy entitled Comprehensive Care Plan, reviewed on 3/2025, documented the facility must develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and time frames to meet each resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The comprehensive person-centered care plan must be developed and completed within seven days after completion of the minimum data set comprehensive assessment. The comprehensive care plan must be prepared by the interdisciplinary team. Resident #51 was admitted with diagnoses including Legal Blindness, Congestive Heart Failure, Major Depressive Disorder, and Anxiety Disorder. The Minimum Data Set assessment dated [DATE] documented a Brief Interview of Mental Status score of 15, which indicated the resident had intact cognition. The Minimum Data Set assessment documented that the resident had impaired vision. The Patient Review Instrument (PRI), dated 4/23/2025, documented that the resident was legally blind. A review of the medical record revealed that no care plan for impaired vision was initiated until 6/27/2025, 63 days after the resident's admission. During an interview on 7/1/2025 at 9:20 AM, Licensed Practical Nurse #2 stated that the Registered Nurses were responsible for developing the comprehensive care plan. Licensed Practical Nurse #2 stated they did not know that Resident #51 had no care plan to address the resident's visual impairment needs until 6/27/2025. During an interview on 7/1/2025 at 11:41 AM, Registered Nurse #4 stated the resident was legally blind. All Registered Nurses were responsible for developing the care plans. Registered Nurse #4 stated they did not know that there was no comprehensive care plan to address the resident's visual impairment needs until 6/27/2025.During an interview on 7/2/2025 at 12:00 PM, Unit Manager Registered Nurse #3 stated they did not initiate the comprehensive care plan to address the resident's visual impairment needs; however, all staff members were aware the resident was legally blind. During an interview on 7/2/2025 at 2:11 PM, the Director of Nursing Services stated the resident's comprehensive care plan for vision should have been completed by 5/14/2025. 10 NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 6/24/2025 and completed on 07/02/2025, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and residents' choices. This was identified for one (Resident #40) of five Residents reviewed for Bladder and Bowel Incontinence. Specifically, Resident #40 had a history of diarrhea and constipation, and the staff were administering Imodium (used to treat diarrhea) and Senna (a stimulant laxative to treat constipation) daily to the resident. The finding is:The facility's policy titled Bowel Protocol, last reviewed 4/30/2025, documented that nursing staff will monitor and document the daily bowel function of the residents. The evacuation sheet is to be checked by nurses daily. If no bowel movement in two days, Milk of Magnesia 30 milligrams will be administered at bedtime. If no bowel movement in three days or no result from Milk of Magnesia by 7:00 AM, one Dulcolax suppository will be administered. If no result from Dulcolax by 8:00 PM, administer a Fleet enema. If no bowel movement by 7:00 AM, the Physician will be called. Resident #40 was admitted with diagnoses that included Dementia, Constipation, and Diarrhea. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 14, indicating the resident was cognitively intact. The Quarterly Minimum Data Set documented that Resident #40 was frequently incontinent with bowel movements, was not on a toileting program, and required partial to moderate assistance with toileting. A Comprehensive Care Plan titled at risk for Constipation related to decreased mobility dated 1/21/2025, last reviewed and revised 4/18/2025, documented interventions that included monitoring bowel movements each shift, following bowel protocol as needed, giving medications as ordered, and notifying the Physician if the current regimen was not effective. There was no Comprehensive Care Plan developed for Diarrhea. A physician's order dated 1/14/2025 and discontinued on 5/12/2025 documented Imodium AD (Loperamide), give one 2 milligram tablet daily at 9:00 AM.A physician's order dated 12/27/2024 and discontinued 5/17/2025 documented Senna, give one 8.6 milligram tablet daily at 9:00 PM.A physician's order dated 05/18/2025 and discontinued 07/01/2025 documented Senna, give one 8.6 milligram tablet daily at 9:00 PM. The resident had a physician's orders for Dulcolax suppository and Colace (stool softeners) as needed; however, there were no parameters added. There was no documented evidence of the Physician's order for Resident #40 to implement bowel protocol as per the facility's policy. Review of the Medication Administration Record for March 2025 documented Imodium A-D (Loperamide) 2 milligrams given 1 tablet daily at 9:00 AM; all doses were documented given, but one dose was held on 3/16/2025. There was no documented rationale to hold the medication administration on 3/16/2025.Review of the Medication Administration Record for March 2025 documented Senna 8.6 milligrams given 1 tablet daily at 9:00 PM, all doses given. Review of the Medication Administration Record for April 2025 documented Imodium A-D (Loperamide) 2 milligrams given 1 tablet daily at 9:00 AM; all doses given. Review of the Medication Administration Record for April 2025 documented Senna 8.6 milligrams given 1 tablet daily at 9:00 PM, all doses given. Review of the Medication Administration Record for May 2025 documented Imodium A-D (Loperamide) 2 milligrams given 1 tablet daily at 9:00 AM; all doses given. Medication discontinued 5/12/2025.Review of the Medication Administration Record for May 2025 documented Senna 8.6 milligrams given 1 tablet daily at 9:00 PM, all doses given.Review of the Medication Administration Record for May 2025 documented Dulcolax (Bisacodyl), give one suppository 10 milligrams as needed for no bowel movement in 3 days or if no result from Milk of Magnesia. No doses were administered. The Bowel Report for May 2025 documented the following: The resident had a large bowel movement on 5/01/2025. The resident had no bowel movement from 5/2/2025 to 5/4/2025. There was no documented evidence that the bowel protocol was implemented for the resident.The resident had a medium bowel movement on 5/8/2025, 5/9/2025, and 5/12/2025. The resident did not have a bowel movement on 5/10/2025 and 5/11/2025.The Nursing progress note dated 5/12/2025 documented the resident had a large, hard stool with loose stool coming out around the sides. The resident was having a hard time getting all the stool to pass. The Physician's note dated 5/12/2025 documented to transfer the resident to the emergency room. The resident had a history of Diarrhea with actual Fecalith (a hardened mass of feces made of compacted stool) in the rectum and loose stool passing around the blockage. The abdomen was soft and tender to palpation. The emergency room Physician exam note dated 5/12/2025 documented abdomen was tender to light palpation, and bowel sounds were active in all four quadrants. A large volume of stool, gray in color and clay-like consistency, was noted. Soft stool was seen in the brief. A Large Fecalith was noted on rectal examination. Disimpaction was performed with a large amount of Fecalith removed without complication. A Computed Tomography scan (CT scan) dated 5/12/2025 documented a large amount of fecal material present in the colon. During an interview on 06/26/2025 at 11:11 AM, Licensed Practical Nurse #4 stated Resident #40 had an as-needed physician's order for a suppository, and they did not administer any of the as-needed medications ordered for constipation. Licensed Practical Nurse #4 stated they were the medication nurse for Resident #40 on 5/2/2025 and 5/4/2025, and they did not recall notifying the physician regarding the resident not having a bowel movement from 5/2/2025 to 5/4/2025. Licensed Practical Nurse #4 stated they should have checked the bowel report at the start of each shift to ensure that a resident is having regular bowel movements and should have notified the charge nurse and or the Physician that the resident was receiving Imodium in the morning and Senna at night. During an interview on June 26, 2025, at 11:59 AM, Registered Nurse Unit Manager #6 stated that the nurses should have adhered to the bowel protocol when Resident #40 did not have a bowel movement for three days on 5/02/2025, 5/03/2025, and 5/04/2025. According to the facility policy, the bowel protocol should be initiated after three consecutive days of no bowel movement. The nurse should have notified the Physician and started the bowel protocol as necessary. Registered Nurse Unit Manager #6 stated that they were not aware the resident was receiving Imodium in the morning and Senna at night. The medication nurses should have reviewed the medications and identified that the resident was receiving the stool softener and the anti-diarrhea medication daily. During an interview on 06/27/25 at 09:00 AM, the Director of Nursing Services stated that at the start of each shift, unit nurses should generate a bowel report from the Electronic Medical Record. The nurses should follow the facility's bowel protocol and notify the Physician. During an interview on 6/27/2025 at 12:30 PM, Primary Physician #1 stated the nurse should have notified them and obtained an order for Milk of Magnesia when Resident #40 did not have a bowel movement on 5/2/2025, 5/3/2025, and 5/4/2025. Primary Physician #1 did not recall if they were notified of the resident not having a bowel movement for three days. Primary Physician #1 stated the nurse could have given a suppository on day three; there was an order for a suppository as needed. Resident #40 went to the hospital and was diagnosed with a Fecalith, not an impaction. Resident #40 was anemic on admission. Primary Physician #1 stated the resident complained of loose stool, abdominal pain, and discomfort, and was chronically anemic. Primary Physician #1 stated they thought the resident had a gastrointestinal bleed, and a gastrointestinal workup was completed. Primary Physician #1 stated, It doesn't make sense that this resident was on Senna and Imodium; this is not a correct regimen. The resident should not have received both medications daily, and they (Primary Physician #1) must have missed that during their monthly review of the physician's orders. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 6/24/2025 and completed on 7/2/2025, the facility did not ensure that the resident maintained, to the extent possible, acceptable parameters of nutritional and hydration states. This was identified for one (Resident #10) of one resident reviewed for Nutrition. Specifically, Resident #10 had a 5.3% significant weight loss in one month, from January 2025 to February 2025. The Registered Dietitian documented the resident's significant weight loss on 2/10/2025. On 2/19/2025, a 3-Day Calorie Count was completed and revealed the resident was not meeting their estimated calorie and protein needs; however, the Registered Dietitian did not put any new nutritional interventions into place to prevent the resident from losing further weight.The finding is: The facility's policy titled, Weight Changes, last reviewed in September 2024, documented it is the responsibility of the Dietitian, Medical Services, and Nursing Services that any new specific (significant) weight change (gain or loss) of greater than or equal to 10% in 6 months; greater than or equal to 7.5% in 3 months; or greater than or equal to 5% in one month will be addressed with a possible explanation and recommendation for intervention and documented in the Electronic Medical Record (EMR). It is the responsibility of the Interdisciplinary Care Team to recommend interventions for unplanned weight changes when appropriate and may include, but are not limited to: Food Intake Study (Calorie Count); Re-evaluation of food/fluid preferences; Weekly weight monitoring; Supplements/Nourishments; Liberalization of therapeutic diet or change in diet order; Swallow evaluation; Psychological services; Labs (blood work), review of medications, further medical work-up to determine any underlying etiology of weight change. The facility's policy titled Nutrient Intake Analysis (Calorie Count), last reviewed in September 2024, documented that upon completion of the Calorie Count, the Dietitian will record a summary of the calorie count analysis (indicating calorie and protein intake). This will be documented in the Electronic Medical Record (EMR) under Progress Notes. The Dietitian will make recommendations in the Electronic Medical Record (EMR) and communicate these to the medical practitioner and nursing staff if findings indicate a need for further assessment and/or interventions. Resident #10 had diagnoses that include Hypothyroidism and Hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severely impaired cognitive skills for daily decision making. The resident required supervision or touching assistance of one person for eating. The resident's height was 75 inches, and they weighed 213 pounds. The Physician's Order initiated on 4/5/2024 and last renewed on 6/4/2025, documented for the resident to receive Ensure Plus (a liquid nutritional supplement) 4 ounces by mouth four times daily. The Physician's Order dated 1/16/2025 documented the resident's diet as No Added Salt (NAS). There were no alterations to the diet consistency, and thickened liquids were not indicated. Special instructions: Allow for extra gravy/sauce when available. This Physician's Order was discontinued on 5/8/2025. The resident's Weight Record documented on 1/7/2025 the resident weighed 211.9 pounds, and on 2/4/2025 the resident weighed 200.6 pounds, which indicated an 11.3-pound or a 5.3% significant weight loss in 30 days or 1 (one) month. The Dietary Progress Note dated 2/10/2025, written by Registered Dietitian #1, documented that the resident's usual body weight in the past 6 months fluctuated between 211-218 pounds, and therefore 200.6 pounds was very low and was also a significant 5.3% (11.3 pounds) weight loss in the past month. New weight to be taken in the next few days. If further weight loss occurred, Registered Dietitian #1 would recommend a 3-Day Calorie Count for the resident. The resident's Weight Record dated 2/11/2025 documented that the resident weighed 199 pounds. The Dietary Progress Note dated 2/11/2025, written by Registered Dietitian #1, documented that the resident was reweighed on 2/11/2025 and weighed 199 pounds, confirming weight loss. A 3-Day Calorie Count was recommended to begin tomorrow (2/12/2025). The Physician's Order dated 2/11/2025 documented a Calorie Count for 3 days, to be initiated on 2/12/2025 and completed on 2/14/2025. The Dietary Progress Note dated 2/19/2025, written by Registered Dietitian #1, documented the results of the resident's 3-Day Calorie Count, which revealed the resident was not meeting their daily estimated calorie and protein needs. The resident's Weight Record dated 3/4/2025 documented the resident weighed 192.5 pounds, reflecting an additional 8.1 pounds or 4% weight loss in 30 days or 1 (one) month. Review of the resident's Electronic Medical Record (EMR) on 7/1/2025 at approximately 10:30 AM revealed no documented evidence that Registered Dietitian #1 recommended or implemented any further dietary interventions after acknowledging the resident's significant weight loss from January 2025 to February 2025 and also after the completion of the resident's 3 Day Calorie count to address the resident was not meeting their daily estimated calorie and protein needs. During an interview on 7/1/2025 at 11:20 AM, Registered Dietitian #1 stated they did not implement any nutritional changes to the resident's diet after the significant weight loss and after the 3 Day Calorie Count showed that the resident was not meeting their estimated daily calorie and protein needs because the resident's weight loss was due to a cognitive decline. Registered Dietitian #1 stated that when a resident has a significant weight loss, they would usually update the resident's food preferences and offer other supplements. If the resident was accepting of the supplement, they would increase how often the resident was provided with the supplement. Registered Dietitian #1 stated that Resident #10 did not always accept their Ensure Plus supplement; however, they (Registered Dietitian #1) never offered the resident another supplement, and should have. During an interview on 7/1/2025 at 1:55 PM, Chief Clinical Dietitian #1 stated that when a resident has a significant weight loss, they would review the resident's food preferences with the resident to see if there was something in particular that they have a liking for and offer that food to them in a double portion. Chief Clinical Dietitian #1 stated that there was also an opportunity to increase a resident's caloric intake by offering nourishments between meals, such as half a sandwich. Chief Clinical Dietitian #1 stated Registered Dietitian #1 should have offered Resident #10 a different food item because something needed to change to create an opportunity for the resident to gain weight. 10 NYCRR 415.12(i)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey, initiated on 6/24/2025 and completed on 7/2/2025, the facility did not ensure that pain management was provided to each resident who requires such services, consistent with professional standards of practice, and the comprehensive person-centered care plan. This was identified for one (Resident #110) of one resident reviewed for Pain management. Specifically, Resident #110 did not receive their pain medication in a timely manner on 6/25/2025.The finding is:The facility's policy titled Pain Management, dated 9/2024, documented the facility will review the resident's level of pain on a daily basis and promote each resident's level of comfort through pharmacological and non-pharmacological interventions.The facility's policy titled Administration of Medications, dated 10/2024, documented to Adhere to the 6 Rights of Medication Administration: Right patient/resident, Right dose, Right route, Right medication, Right form, and Right time. Administer medications in a timely manner according to orders.Resident # 110 had diagnoses that included Chronic Obstructive Pulmonary Disease, Unspecified abnormalities of gait and mobility, Pain disorder exclusively related to psychological factors, and Pain in the left hip. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15, indicating the resident had intact cognition. The resident's pain level using the Numeric Rating Scale (00-10) was a 6 out of 10. The Pain Frequency was occasional.A Comprehensive Care Plan titled pain/discomfort, effective 6/4/2025, documented that pain will be managed and maintained to the resident's comfort level of 2 out of 10 on the pain scale (10 being the highest level of pain the resident can have). The interventions included to assess/monitor for pain or change in condition with potential for pain, anticipate the resident's need for pain intervention, monitor the effectiveness of the plan. Pharmacological interventions as ordered.A Comprehensive Care Plan titled Torn meniscus (cartilage injury) of the Left Knee, effective 6/04/2025 documented to assess and monitor for pain.The current physician's order documented to administer two (2) tablets of Acetaminophen Tablet 325 milligrams by mouth every six (6) hours for Pain.During an observation of the medication administration, performed by Licensed Practical Nurse #1 on 6/25/2025 at 11:47 AM, Resident # 110 stated that they were waiting for their pain medication, Acetaminophen 650 milligrams, since 9:00 AM, and they are supposed to receive the medication at 9:00 AM. Resident # 110 stated their pain level in their knee was a six (6) out of 10. The resident stated that the Acetaminophen 650 milligram has not been effective in relieving the pain in their knee. The resident stated they have been asking to see a Physician to increase the Acetaminophen to 1000 milligrams instead of 650 milligrams, and the facility was not being responsive to their request.Licensed Practical Nurse #1 was immediately interviewed after the observation and stated they were behind in their work and were not able to give the resident's medication at 9:00 AM. Licensed Practical Nurse #1 did not assess Resident # 110's pain level prior to giving the pain medication. Licensed Practical Nurse #1 stated that they were not aware of the resident's request for increased pain medication.The June 2025 Medication Administration Record documented that a pain observation will be conducted each shift using the [NAME] pain scale (score of 1-10, where 1 is the least amount of pain and 10 is the highest amount of pain). The June 2025 Medication Administration Record indicated the resident had no pain on 6/25/2025 at 12:00 PM.The June 2025 Medication Administration Record documented that Resident # 110 received Acetaminophen 650 milligrams on 6/25/2025 at 11:47 AM. The resident was scheduled to receive Acetaminophen 650 milligrams twice daily, at 9:00 AM and 9:00 PM.During an interview on 6/25/2025 at 12:15 PM, Registered Nurse # 1 stated that Licensed Practical Nurse #1 should have administered Resident #110's medications within one hour before or after the scheduled time, and if they were late in administering the medications, they should have reported to Registered Nurse # 1. Registered Nurse # 1 stated the resident's pain level should have been assessed when the resident reported that their pain medications (Acetaminophen 325 milligrams) were not working. Registered Nurse # 1 stated that if the resident's pain is not managed, the nurses should notify the Physician. During an interview on 7/2/2025 at 1:29 PM, the Director of Nursing Services stated the medication nurse has an hour before and an hour after the scheduled administration time to provide the medications to the residents. The Director of Nursing Services stated Licensed Practical Nurse #1 should have administered the 9:00 AM medications no later than 10:00 AM. The Director of Nursing Services stated that if Licensed Practical Nurse #1 was running late, they should have notified the Charge Nurse. The Charge Nurse could have intervened to ensure the residents received their medications on time. During an interview on 7/2/2025 at 2:34 PM, the Attending physician #1 stated that if Resident #110 does not receive their pain medications on time, the resident may experience uncontrolled pain. The Physician stated they were never made aware of the resident requiring stronger pain medication before 6/25/2025 (last week). 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 6/24/2025 and completed on 7/2/2025, the facility did not ensure that the medical care of each resident was supervised by the Physician, including monitoring changes in the resident's medical status. This was identified for one (Resident #10) of one resident reviewed for Nutrition. Specifically, Resident #10 had a 5.3% significant weight loss in 30 days, from January 2025 to February 2025, which was not addressed by their Physician. The finding is: The facility's policy titled, Weight Changes, last reviewed in September 2024, documented it is the responsibility of the Dietitian, Medical Services, and Nursing Services that any new specific (significant) weight change (gain or loss) of greater than or equal to 10% in 6 months; greater than or equal to 7.5% in 3 months; or greater than or equal to 5% in one month will be addressed with a possible explanation and recommendation for intervention and documented in the Electronic Medical Record (EMR). It is the responsibility of the Interdisciplinary Care Team to recommend interventions for unplanned weight changes when appropriate and may include, but are not limited to: Food Intake Study (Calorie Count); Re-evaluation of food/fluid preferences; Weekly weight monitoring; Supplements/Nourishments; Liberalization of therapeutic diet or change in diet order; Swallow evaluation; Psychological services; Labs (blood work), review of medications, further medical work-up to determine any underlying etiology of weight change. The facility's policy titled, Nutrient Intake Analysis (Calorie Count), last reviewed in September 2024, documented upon completion of the Calorie Count, the Dietitian will record a summary of the calorie count analysis (indicating calorie and protein intake). This will be documented in the Electronic Medical Record (EMR) under Progress Notes. The Dietitian will make recommendations in the Electronic Medical Record (EMR) and communicate these to the medical practitioner and nursing staff if findings indicate a need for further assessment and/or interventions. The facility's policy titled, Attending Physician Role and Responsibilities, dated March 2020, documented the Attending Physician must take an active role in supervising the care of each resident assigned to their care. Supervising the Care of Residents includes, but is not limited to: Monitoring changes in resident's medical status and providing consultation or treatment when called by the facility. Resident #10 has diagnoses that include Hypothyroidism and Hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severely impaired cognitive skills for daily decision making. The resident required supervision or touching assistance of one person for eating. The resident's height was 75 inches, and they weighed 213 pounds. The Physician's Order initiated on 4/5/2024 and last renewed on 6/4/2025, documented for the resident to receive Ensure Plus (a liquid nutritional supplement) 4 ounces by mouth four times daily. The Physician's Order dated 1/16/2025 documented the resident's diet as No Added Salt (NAS). There were no alterations to the diet consistency, and thickened liquids were not indicated. Special instructions: Allow for extra gravy/sauce when available. This Physician's Order was discontinued on 5/8/2025. The resident's Weight Record documented on 1/7/2025 the resident weighed 211.9 pounds, and on 2/4/2025 the resident weighed 200.6 pounds, which indicated an 11.3-pound or a 5.3% significant weight loss in 30 days or 1 (one) month. The Dietary Progress Note dated 2/10/2025, written by Registered Dietitian #1, documented that the resident's usual body weight in the past 6 months fluctuated between 211-218 pounds and therefore 200.6 pounds was very low and was also a significant 5.3% (11.3 pound) weight loss in the past month. New weight to be taken in the next few days. If further weight loss occurred, Registered Dietitian #1 would recommend a 3 Day Calorie Count for the resident. The Dietary Progress Note dated 2/10/2025, written by Registered Dietitian #1, documented that the resident's usual body weight in the past 6 months fluctuated between 211-218 pounds, and therefore 200.6 pounds was very low and was also a significant 5.3% (11.3 pounds) weight loss in the past month. New weight to be taken in the next few days. If further weight loss occurred, Registered Dietitian #1 would recommend a 3-Day Calorie Count for the resident. The resident's Weight Record dated 2/11/2025 documented that the resident weighed 199 pounds. The Dietary Progress Note dated 2/11/2025, written by Registered Dietitian #1, documented that the resident was reweighed on 2/11/2025 and weighed 199 pounds, confirming weight loss. A 3-Day Calorie Count was recommended to begin tomorrow (2/12/2025). The Physician's Order dated 2/11/2025 documented a Calorie Count for 3 days, to be initiated on 2/12/2025 and completed on 2/14/2025. The Dietary Progress Note dated 2/19/2025, written by Registered Dietitian #1, documented the results of the resident's 3-Day Calorie Count, which revealed the resident was not meeting their daily estimated calorie and protein needs. The email written on 2/19/2025 by Registered Dietitian #1 to Primary Physician #1 and other facility staff documented that the resident's 3 Day Calorie Count revealed the resident was not meeting their daily estimated calorie and protein needs. The resident's Weight Record dated 3/4/2025 documented the resident weighed 192.5 pounds, reflecting an additional 8.1 pounds or 4% weight loss in 30 days or 1 (one) month. Review of the resident's Electronic Medical Record (EMR) on 7/1/2025 at approximately 10:45 AM revealed no documented evidence that Primary Physician #1 acknowledged the resident's significant weight loss from January 2025 to February 2025 including the resident's 3 Day Calorie count result that indicated the resident was not meeting their daily estimated calorie and protein needs. During an interview on 7/1/2025 at 11:20 AM, Registered Dietitian #1 stated when a resident has a significant weight loss, they make the resident's Primary Physician aware by sending them an email. During an interview on 7/01/2025 at 12:50 PM, Primary Physician #1 stated that they are either verbally informed or will receive a memo from Registered Dietitian #1 informing them when a resident has a significant weight loss or when Registered Dietitian #1 gives them the result of a 3-Day Calorie Count. Primary Physician #1 stated that they were unsure if they had read the email sent to them by Registered Dietitian #1 on 2/19/2025. Primary Physician #1 stated they were unaware of the criteria for a significant weight loss, and they were not aware that they were supposed to document when a resident had a significant weight loss. During an interview on 7/2/2025 at 10:45 AM, the Medical Director stated they were unaware of the criteria which defines a significant weight loss and depended on professional ancillary staff, such as the Registered Dietitian, to inform them when a resident has had a significant weight loss. The Medical Director stated it is the Primary Physician's responsibility to document when a resident has a significant weight loss, examine the resident, and have a discussion with the Registered Dietitian of what could be done to prevent further weight loss such as increasing the resident's food portions. 10 NYCRR 415.15(b)(1)(i)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey initiated on 6/24/2025 and completed on 7/2/2025, the facility did not ensure that the irregularities identified by the Pharmacist were reviewed by the medical provider and documented that the action had been taken to address the irregularities. This was identified for one (Resident #126) of two residents reviewed for Mood and Behavior. Specifically, a Medication Regimen Review form dated 4/8/2025 by the Consultant Pharmacist documented that the co-administration of Seroquel (antipsychotic medication) and Remeron (antidepressant medication) may increase the risk for abnormal electrocardiogram and Serotonin syndrome. The Pharmacist recommended assessing the continued co-administration of Seroquel and Remeron. The Nurse Practitioner agreed with the recommendations; however, there was no documented evidence in the medical record of an assessment for the combined use of Seroquel and Remeron. The finding is: The facility's Medication Regimen Review policy and procedure, last reviewed 2/2025, documented that, drug regimen of each resident must be reviewed at least once a month by a Licensed Pharmacist and report any irregularities to the attending Physician, Medical Director, and the Director of Nursing. These reports must be acted upon in a timely manner. The Physician must review the recommendation and document a response to the Pharmacist's comments in the area provided on the report within a month.Resident #126 was admitted with diagnoses that included Dementia and Depression. An Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 4, which indicated the resident had severely impaired cognition. The resident had no symptoms of Depression and was receiving antipsychotic, antianxiety, and antidepressant medications. The resident exhibited verbal, physical, and other behaviors for 1-3 days in the assessment look-back period. A Physician's order dated 7/21/2023 and reviewed on 6/12/2025 documented Remeron 15 milligrams, give 1/2-tab (7.5 milligrams) orally at bedtime for Major Depressive Disorder. A Physician's order dated 3/25/2025 documented Seroquel 25 milligrams, give one tablet orally every 12 hours for Delusional (false belief) disorders. A Medication Regiment Review Form dated 4/8/2025 documented that the resident was currently receiving Seroquel and Remeron. Please note that co-administration may increase the risk for [abnormal electrocardiogram] and Serotonin syndrome. Consider to assess and document the risk versus benefit of continued combined use in your progress notes. The Medication Regiment Review Form was signed by Nurse Practitioner #2, and they agreed with the recommendation.A Review of the medical record revealed there was no documented evidence from Nurse Practitioner #2 regarding an assessment of the risk versus the benefit for the continued combined use of Seroquel and Remeron. A Comprehensive Care Plan for Psychosocial Well Being, dated 3/25/2025 and reviewed on 4/10/2025, documented the resident was receiving Seroquel 25 milligram every 12 hours, for behavioral management related to physical/aggressive behavioral symptoms, and the resident was a potential danger to themself or others. During an interview on 7/2/2025 at 10:45 AM, Nurse Practitioner #2 stated they reviewed and signed the Medication Regimen Review Form on 4/9/2025; however, they did not document their response regarding the risk versus the benefit for the continued combined use of Seroquel and Remeron in their note on 4/9/2025, and that they should have. During an interview on 7/2/2025 at 12:17 PM, the Medical Director stated the Medication Regimen Review Form was a part of the medical record and that they educated the medical staff to document their response to recommendations on the Review Form. The Medical Director stated that Nurse Practitioner #2 should have addressed the recommendation in the resident's medical record. During an interview on 7/2/2025 at 12:49 PM, the Director of Nursing Services stated the Nurse Practitioner/Physician should document the responses to the recommendations provided by the Pharmacist in the medical record. The Director of Nursing Services further stated Nurse Practitioner #2 should have addressed the risk and benefit for the continued combined use of Seroquel and Remeron. 10 NYCRR415.18(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review during the Recertification Survey, the facility did not ensure a comfortable environment for residents, staff, and visitors. This was identified on one ([NAME] Unit) of seven units observed during the Environmental Task. Specifically, during an initial tour on 6/25/2025 between 12:45 PM and 1:00 PM of the [NAME] Unit, elevated environmental temperatures between 81 degrees Fahrenheit (F) to 87 degrees Fahrenheit were noted in resident rooms, hallways, and dining areas. The [NAME] Side corridor of the [NAME] Unit Heating Ventilation Air Conditioning Unit (HVAC) and the Package Terminal Air Conditioners (PTAKS) units in multiple resident rooms and the general use area were not functioning as intended. The finding is:The New York State Department of Health health alert for extreme heat event issued for the period of June 23, 2025 - June 25, 2025, indicated temperatures in the upper 90s with feels-like temperatures to 105 - 110 degrees Fahrenheit for the area where the facility is located.Federal Regulations S483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990, must maintain a temperature range of 71 to 81 degrees Fahrenheit. The facility's Policy and Procedure titled: Management of Extreme Heat with an effective date of 10/29/2020, documented to maintain an awareness of internal and external temperatures throughout the season and monitor residents for any signs and symptoms that may occur during periods of extreme heat. It further included the following procedures, including but not limited to:Regularly inspect and maintain the Heating Ventilation Air Conditioning Unit (HVAC) system.Maintain cooling supplies: Portable fans, temporary cooling devices, and non-perishable foods and fluids.Develop procedures to monitor the physical environmentTemperature, humidity, ventilation, and the screening process.Develop relocation procedures within the facility to areas with cooler temperatures or with functioning air conditioning.Educate staff on the risks of extreme heat, including heat cramps, heat exhaustion, heat stroke, sunburn, and Dehydration.Develop a resident assessment protocol including vital sign checks, focusing on core temperature, comfort checks, and resident Dehydration.During an observation of the [NAME] Unit on June 25, 2025, between 12:45 PM and 12:52 PM, a resident occupied room [ROOM NUMBER], was noted with an ambient temperature of 87 degrees Fahrenheit; the unit's [NAME] Side corridor space ambient temperature ranged from 84 -85 degrees Fahrenheit; and the [NAME] Side Dining room ambient temperature was noted to be 81 degrees Fahrenheit.During an interview on 6/25/2025, at 12:48 PM, the Director of Plant Operations stated that the [NAME] unit [NAME] Side corridor Heating Ventilation Air Conditioning Unit (HVAC) system had shut down in the morning on 06/25/2025 due to the excessive heat wave and that the Heating Ventilation Air Conditioning Unit (HVAC) technician was in the process of fixing the Heating Ventilation Air Conditioning Unit (HVAC) system and that they were relying on the resident room Package Terminal Air Conditioners to help keep the rooms cool. The Director of Plant Operations further stated that select occupied resident room Package Terminal Air Conditioners (PTAKS) units were not providing enough cool air to the resident rooms and the dining room. They further stated that the facility was in the process of repairing and replacing some of the Package Terminal Air Conditioners (PTAKS) units. They further stated that fans were provided to some resident rooms; however, the fans were not able to keep the rooms cool during the heat wave. During the subsequent observation on 6/25/2025, between 2:22 PM to 2:50 PM, the [NAME] Unit had 12 resident rooms with the following room air temperatures: room [ROOM NUMBER] - 84.5 degrees Fahrenheitroom [ROOM NUMBER] - 83 degrees Fahrenheitroom [ROOM NUMBER] - 82 degrees Fahrenheitroom [ROOM NUMBER] - 84 degrees Fahrenheitroom [ROOM NUMBER] - 88 degrees Fahrenheitroom [ROOM NUMBER] - 85 degrees Fahrenheitroom [ROOM NUMBER] - 84 degrees Fahrenheitroom [ROOM NUMBER] - 83 degrees Fahrenheitroom [ROOM NUMBER] - 82 degrees Fahrenheitroom [ROOM NUMBER] - 82 degrees Fahrenheitroom [ROOM NUMBER] - 84 degrees Fahrenheitroom [ROOM NUMBER] - 88 degrees Fahrenheit During an observation on 6/25/2025 at 4:00 PM, the Director of Plant Operations stated the corridor's Heating Ventilation Air Conditioning Unit (HVAC) system was working and was cooling down the Unit. They took additional environmental temperatures of the [NAME] unit and identified nine resident rooms with elevated environmental temperatures. They provided temperature readings for the nine rooms that were recorded to be between 83 degrees Fahrenheit to 86 degrees Fahrenheit. They identified 14 residents in the affected rooms who would be moved to an empty unit ([NAME]). The empty rooms on the [NAME] unit would be checked for a comfortable environmental temperature before relocating the residents. They also provided a list of the residents scheduled to be relocated. The Director of Plant Operations further stated they had put in a request for new Package Terminal Air Conditioners (PTAKS) units a while ago and that corporate had not approved the request in time due to having all new finance staff. The Director of Plan Operations further provided vendor quotes dated 6/24/2024 and 06/26/2024 for the replacement of 20 Package Terminal Air Conditioners (PTAKS) units. They further stated that they would try to expedite the replacement of Package Terminal Air Conditioners (PTAKS), and once received, it would take approximately three weeks to get the units installed.During an interview on 6/25/2025 05:59 PM, the Director of Plant Operations stated that nursing staff had notified them about heat this morning (6/25/2025) on the [NAME] unit, and they (the Director of Plant Operation) sent their staff to check the Heating Ventilation Air Conditioning Unit (HVAC) system and it was identified that the high sensor switch allowing the unit to cool was adjusted and then the system went back into cooling mode. During an interview on 6/26/2025 at 2:00 PM, the Director of Plant Operations stated that they did not normally take environmental temperatures in the facility and that they would implement and record temperature measurements on a daily basis.10NYCRR 415.5(h)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review during the Recertification Survey and Abbreviated Survey (Complaint # NY00359206 ) initiated on 6/24/2025 and completed on 7/2/2025 the facility did not ensure sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. This was identified on four ([NAME], [NAME], Deporres and [NAME]) of eight nursing units. Specifically, on the 3:00 PM to 11:00 PM shift, the [NAME] Unit, the [NAME] Unit, the Deporres Unit, and the [NAME] Unit were not staffed according to the levels specified in the Facility Assessment on 6/27/2025 to 6/29/2025 (Friday, Saturday, and Sunday).The findings are: The facility Departmental Staffing policy and procedure, last reviewed 4/2025, documented all departments will schedule their staff at par levels outlined in the Facility Assessment for all shifts, daily. Staffing may be adjusted per unit based on the unit and acuity to maintain staff to resident ratio. A Review of the Facility Assessment 4/30/25 documented the par levels for the following units:-[NAME] Unit: 3:00 PM - 11:00 PM shift should have five (5) Certified Nursing Assistants with a Certified Nursing Assistant to Resident bed ratio (1:11).-[NAME] Unit: 3:00 PM - 11:00 PM shift should have four (4) Certified Nursing Assistants to Resident bed ratio (1:10).-Deporres Unit: 3:00 - 11:00 PM shift should have four (4) Certified Nursing Assistant to Resident bed ratio (1:10).-[NAME] Unit: 3:00 PM - 11:00 PM shift should have four (4) Certified Nursing Assistants to Resident bed ratio(1:10). A review of the daily actual nursing staffing schedule from 6/24/2025 to 7/2/2025 revealed the following:-The [NAME] Unit had a census of 37/40 residents on 6/27/2025. There were three (3) Certified Nursing Assistants assigned to the unit during the 3:00 PM-11:00 PM shift. The unit should have had five (5) Certified Nursing Assistants according to the Facility Assessment.-The [NAME] Unit had a census of 39/40 residents on 6/27/45 and 6/29/2025. There were three (3) Certified Nursing Assistants assigned to the facility during the 3:00 PM-11:00 PM shift. The unit should have had four (4) Certified Nursing Assistants according to the Facility Assessment.-The Deporres unit had a census of 37/40 residents on 6/28/2025. There were three (3) Certified Nursing Assistants assigned to the facility during the 3:00 PM-11:00 PM shift. The unit should have had four (4) Certified Nursing Assistants according to the Facility Assessment.-The [NAME] Unit had a census of 37/40 residents on 6/28/2025. There were (3) Certified Nursing Assistants assigned to the facility during the 3:00 PM-11:00 PM shift. The unit should have had four (4) Certified Nursing Assistants according to the Facility Assessment.During an interview on 7/2/2025 at 11:22 AM, the Staffing Coordinator stated that staffing on the weekend of 6/27/2025 to 6/29/2025 was a challenge and that there were a couple of units that worked below the par levels. The Staffing Coordinator stated that when the census on the unit falls below 35, they adjust the par level for that unit. The Staffing Coordinator stated on the weekend of 6/27/2025 to 6/29/2025, there were call-ins and the facility was unable to get staff to cover the call-ins. The Staffing Coordinator stated they did not frequently have staffing concerns; however, during graduation season, staff usually call in sick. During an interview on 7/2/2025 at 12:55 PM, the Director of Nursing Services stated they were responsible for determining the unit par levels; however, the par levels are reviewed with the facility Administrator. The Director of Nursing Services stated they adjust the par levels based on the unit census and acuity. On the 40-bed unit, the staffing is adjusted if the resident census falls to 32 residents or below. The Director of Nursing Services stated that weekend staffing can be challenging; the facility was understaffed on the weekend of 6/27/2025 to 6/29/2025, not because the facility did not have the staff, but because of the staff call-outs. During an interview on 7/2/2025 at 3:01 PM, the Administrator stated they call the facility on the weekends to check on staffing. The Administrator stated when they adjust the par levels, the unit's acuity and census is taken into consideration. The Administrator stated there are times when they have excess nurses, that the nurses would agree to work as a Certified Nursing Assistant when they are down Certified Nursing Assistant. Was that the case on the identified weekend?? The Administrator stated the nurses are expected to help when the unit is short of Certified Nursing Assistants. The Administrator stated their expectation is for the units to be at the par level outlined in the Facility Assessment. 10 NYCRR 415.13(a)(1)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 6/24/2025 and completed on 7/2/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety. This was evident during the Dining Observation task for one ([NAME] Unit) of seven units. Specifically, during the dining observation on the [NAME] Unit, the temperature of cold food items (tuna sandwich, turkey sandwich, and milk) was above acceptable standards for safe serving temperatures. In addition, there was no system in place to monitor the temperature of cold food items.The finding is:A facility policy and procedure titled Food Temperatures, reviewed 2/2025, documented that the Culinary Department will review and manage food temperatures to ensure the safety of food being served to residents. Any discrepancies in food temperatures will be managed to ensure compliance with regulatory directives. The Culinary Ambassador takes the temperatures often to monitor for safe temperature ranges of at or below 40 degrees Fahrenheit. If the Ambassador has a temperature out of range on their unit, they are to call the kitchen and speak to the Chef or Supervisor for corrective action. During the Dining Observation Task on 6/25/2025 at 12:13 PM on the [NAME] unit, Culinary Ambassador #1 was recording the temperature of the hot food items to be served at the lunch meal. The lunch meal trays were set up with milk, soda, juice, and pudding. There was one meal tray with a turkey sandwich, and another tray had a tuna sandwich. During an interview on 6/25/2025 at 12:16 PM, Culinary Ambassador #1 stated that they were responsible for monitoring the temperature of the foods being served. Culinary Ambassador #1 stated they monitor the temperature of the unit refrigerators where the food is stored; however, they do not take the temperature of the cold food items, such as milk or sandwiches served during meals. During an observation on 6/25/2025 at 12:33 PM, a main entree was served on a meal tray that was preset with a turkey sandwich and other condiments. Registered Nurse #2 delivered the tray to the resident in their room. Before the tray was served, the temperature of the turkey sandwich was taken and registered at 70 degrees Fahrenheit. During an observation on 6/25/2025 at 12:35 PM, the tuna sandwich temperature was measured at 72 degrees Fahrenheit, and an eight-ounce container of milk temperature was measured at 55 degrees Fahrenheit. During an observation on 6/25/2025 at 12:35 PM, a main entree was served on a meal tray that was preset with a tuna sandwich, an eight-ounce container of milk, and other condiments. After the main entree was plated, Registered Nurse #2 was going to serve the tray to the resident. Prior to the tray being served, the temperature of the tuna sandwich was taken and registered at 72 degrees, and an eight-ounce container of milk temperature measured at 55 degrees Fahrenheit. During an interview on 6/25/2025 at 12:38 PM, Registered Nurse #2 stated that the nursing staff set up the room trays at 12:00 PM. Registered Nurse #2 observed the temperatures of the turkey and tuna sandwiches and acknowledged that the turkey and tuna sandwich temperatures were not at appropriate serving temperatures and should not be served. During an interview on 6/25/2025 at 12:42 PM, the Director of Culinary Services stated that the Culinary Ambassadors were responsible for monitoring the food temperatures for both hot and cold food items and recording temperatures on the temperature log form. Any concerns should be reported to the Dietary Supervisor. The Director of Culinary Services stated they were not aware that the temperature log form did not include the cold food items, such as milk, sandwiches, or desserts. During an interview on 6/27/2025 at 9:07 AM, the Director of Nursing Services stated that the Certified Nursing Assistants were responsible for setting up the meal trays with the beverages and desserts. The Director of Nursing Services stated that the food items should not be placed on the trays in advance because of the risk of food getting spoiled. Additionally, holding food in the danger zone temperatures may cause a potential foodborne illness. 10 NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the recertification survey, initiated on 6/24/2025 and completed on 7/02/2025, the facility did not maintain the cooling system in proper working conditions to provide a healthy, functional, and comfortable environment for residents, personnel, and the public. This was identified on one ([NAME] Unit) of seven units observed during the Environmental Task. The [NAME] Side corridor of the [NAME] Unit Heating Ventilation Air Conditioning Unit (HVAC) and the Package Terminal Air Conditioners (PTAKS) units in multiple resident rooms and the general use area were not functioning as intended. The finding is: The New York State Department of Health health alert for extreme heat event issued for the period of June 23, 2025 - June 25, 2025, indicated temperatures in the upper 90s with feels-like temperatures to 105 - 110 degrees Fahrenheit for the area where the facility is located. Federal Regulations S483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990, must maintain a temperature range of 71 to 81 degrees Fahrenheit. The facility's Policy and Procedure titled: Management of Extreme Heat with an effective date of 10/29/2020, documented to maintain an awareness of internal and external temperatures throughout the season and monitor residents for any signs and symptoms that may occur during periods of extreme heat. It further included the following procedures, including but not limited to:Regularly inspect and maintain the Heating Ventilation Air Conditioning Unit (HVAC) system.Maintain cooling supplies: Portable fans, temporary cooling devices, and non-perishable foods and fluids.Develop procedures to monitor the physical environmentTemperature, humidity, ventilation, and the screening process.Develop relocation procedures within the facility to areas with cooler temperatures or with functioning air conditioning.Educate staff on the risks of extreme heat, including heat cramps, heat exhaustion, heat stroke, sunburn, and Dehydration.Develop a resident assessment protocol including vital sign checks, focusing on core temperature, comfort checks, and resident Dehydration.During an observation of the [NAME] Unit on June 25, 2025, between 12:45 PM and 12:52 PM, a resident occupied room [ROOM NUMBER], was noted with an ambient temperature of 87 degrees Fahrenheit; the unit's [NAME] Side corridor space ambient temperature ranged from 84 -85 degrees Fahrenheit; and the [NAME] Side Dining room ambient temperature was noted to be 81 degrees Fahrenheit.During an interview on 6/25/2025, at 12:48 PM, the Director of Plant Operations stated that the [NAME] unit [NAME] Side corridor Heating Ventilation Air Conditioning Unit (HVAC) system had shut down in the morning on 06/25/2025 due to the excessive heat wave and that the Heating Ventilation Air Conditioning Unit (HVAC) technician was in the process of fixing the Heating Ventilation Air Conditioning Unit (HVAC) system and that they were relying on the resident room Package Terminal Air Conditioners to help keep the rooms cool. The Director of Plant Operations further stated that select occupied resident room Package Terminal Air Conditioners (PTAKS) units were not providing enough cool air to the resident rooms and the dining room. They further stated that the facility was in the process of repairing and replacing some of the Package Terminal Air Conditioners (PTAKS) units. They further stated that fans were provided to some resident rooms; however, the fans were not able to keep the rooms cool during the heat wave. During the subsequent observation on 6/25/2025, between 2:22 PM to 2:50 PM, the [NAME] Unit had 12 resident rooms with the following room air temperatures: room [ROOM NUMBER] - 84.5 degrees Fahrenheitroom [ROOM NUMBER] - 83 degrees Fahrenheitroom [ROOM NUMBER] - 82 degrees Fahrenheitroom [ROOM NUMBER] - 84 degrees Fahrenheitroom [ROOM NUMBER] - 88 degrees Fahrenheitroom [ROOM NUMBER] - 85 degrees Fahrenheitroom [ROOM NUMBER] - 84 degrees Fahrenheitroom [ROOM NUMBER] - 83 degrees Fahrenheitroom [ROOM NUMBER] - 82 degrees Fahrenheitroom [ROOM NUMBER] - 82 degrees Fahrenheitroom [ROOM NUMBER] - 84 degrees Fahrenheitroom [ROOM NUMBER] - 88 degrees FahrenheitDuring an observation on 6/25/2025 at 4:00 PM, the Director of Plant Operations stated the corridor's Heating Ventilation Air Conditioning Unit (HVAC) system was working and was cooling down the Unit. They took additional environmental temperatures of the [NAME] unit and identified nine resident rooms with elevated environmental temperatures. They provided temperature readings for the nine rooms that were recorded to be between 83 degrees Fahrenheit to 86 degrees Fahrenheit. They identified 14 residents in the affected rooms who would be moved to an empty unit ([NAME]). The empty rooms on the [NAME] unit would be checked for a comfortable environmental temperature before relocating the residents. They also provided a list of the residents scheduled to be relocated. The Director of Plant Operations further stated they had put in a request for new Package Terminal Air Conditioners (PTAKS) units a while ago and that corporate had not approved the request in time due to having all new finance staff. The Director of Plan Operations further provided vendor quotes dated 6/24/2024 and 06/26/2024 for the replacement of 20 Package Terminal Air Conditioners (PTAKS) units. They further stated that they would try to expedite the replacement of Package Terminal Air Conditioners (PTAKS), and once received, it would take approximately three weeks to get the units installed.During an interview on 6/25/2025 05:59 PM, the Director of Plant Operations stated that nursing staff had notified them about heat this morning (6/25/2025) on the [NAME] unit, and they (the Director of Plant Operation) sent their staff to check the Heating Ventilation Air Conditioning Unit (HVAC) system and it was identified that the high sensor switch allowing the unit to cool was adjusted and then the system went back into cooling mode. During an interview on 6/26/2025 at 2:00 PM, the Director of Plant Operations stated that they did not normally take environmental temperatures in the facility and that they would implement and record temperature measurements on a daily basis.10 NYCRR:415.29

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 4/7/2024 and completed on 4/12/2024 the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life. This was identified for one (Resident #77) of two residents reviewed for dignity. Specifically, during a lunch meal observation on 4/7/2024 Certified Nursing Assistant #1 was observed standing over Resident #77 while they assisted Resident #77 with their lunch meal. The finding is: The facility's policy titled, Feeding a Resident, documented to ensure that all residents receive the assistance required to complete a meal in a comfortable, pleasant, and supportive environment to enhance the experience as well as the resident's overall intake. Residents may require different levels of assistance, from set-up to encouragement, to full feeding. The procedure outlined nursing staff should have a chair available to ensure staff are sitting at eye level and staff should not stand while feeding a resident. Resident #77 was admitted with diagnoses that included Parkinson's Disease, Type 2 Diabetes, and Chronic Obstructive Pulmonary Disease. The Quarterly Minimum Data Set assessment dated [DATE] documented the Brief Interview for Mental Status score was 3, which indicated severe cognitive impairment. The resident required substantial/maximal assistance for meals. During a tour of the Assisi Unit during the lunch meal on 4/7/2024 at 12:52 PM, Certified Nursing Assistant #1 was observed assisting Resident #77 with their meal while standing next to the resident's bed. Resident #77's Comprehensive Care Plan for Nutritional Status initiated on 4/4/2023 and last reviewed on 2/20/2024 documented that as of 4/4/2023 Resident #77 was fed by staff. Certified Nursing Assistant #1 was interviewed on 4/7/2024 at 1:15 PM and stated Resident #77 was not able to grip utensils and needed total assistance with meals. Certified Nursing Assistant #1 stated they regularly assisted Resident #77 with their lunch meal, and they normally stood by Resident #77's bed while they assisted the resident with lunch because they (Certified Nursing Assistant #1) do not like to sit. Certified Nursing Assistant #1 stated they were aware they should sit next to a resident while they assisted with meals because if they stood over a resident, it does not ensure the resident's dignity. Licensed Practical Nurse #1, the unit's Charge Nurse, was interviewed on 4/7/2024 at 2:20 PM and stated when a staff member assisted a resident with eating the staff member should not be towering over the resident and should be seated next to the resident. Licensed Practical Nurse #1 stated the staff member should be at eye level with the resident and should be interacting with the resident during meal assistance. Licensed Practical Nurse #1 stated being seated next to the resident preserves the resident's dignity. Resident #77 was interviewed on 4/10/2024 at 1:42 PM and stated they would like to feed themselves, but they were not able to hold utensils. Resident #77 stated they did not like when a staff person stood over them while providing meal assistance. The [NAME] President of Clinical Service (Director of Nursing Services) was interviewed on 4/12/2024 at 9:06 AM and stated if a staff member assisted a resident with feeding, the staff member should be seated next to the resident so they could make eye contact, interact with the resident, and preserve the resident's dignity. 10 NYCRR 415.3(d)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 4/07/2024 and completed on 4/12/2024 the facility did not ensure that a resident who is fed by enteral means receives the appropriate treatment, care, and services to prevent complications of enteral feeding. This was identified for one (Resident #199) of one resident reviewed for Tube Feeding. Specifically, on 4/07/2024 at 10:40 AM and again on 4/07/2024 at 12:40 PM Resident # 199's tube feeding, and hydration bottles were not labeled including the resident's name, flow rate, date, and time the feeding was initiated. The finding is: The facility's policy titled, Gastrostomy Tube Feeding via Enteral Feeding Pump dated 4/2023 documented the feeding product container is labeled with the date, time, rate of flow, and the nurse's initials. Resident #199 was admitted with diagnoses of Epilepsy, Diabetes Mellitus, and Hypertension. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #199 had a Brief Interview for Mental Status score of 99, indicating the resident had severely impaired cognition. Resident #199 has a feeding tube and receives more than 51 percent of their total calories and 501 cubic centimeters or more fluid through tube feeding per day. The physician's orders dated 2/29/2024 documented to administer Jevity 1.5 (tube feeding formula) at 60 milliliters per hour over 17 hours via the feeding tube with a water flush of 40 milliliters every hour during feeding. The amount of fluid to be administered in 24 hours (formula and the water flush) is 1680 milliliters. The Comprehensive Care Plan titled, Tube Feeding dated 11/27/2023 documented that Resident #199 was at risk for altered nutritional status because the resident was not able to eat or drink by mouth (nothing by mouth-NPO) and required tube feeding. Resident #199 required tube feeding as the primary and only source of nourishment and hydration. Interventions included monitoring for mechanical complications related to tube feeding and providing adequate nutrients and fluids via a feeding tube to meet assessed needs. During an observation on 4/07/2024 at 10:40 AM Resident #199 was observed in bed. The tube feeding and hydration bottles were observed hanging on a feeding pole and the tube feeding was being administered to the resident via a feeding pump. The feeding and hydration bottles did not have a label, including the resident's name, flow rate, time, and date. During an observation on 4/07/2024 at 12:10 PM, Resident #199 was observed in bed. The tube feeding and hydration bottles were observed hanging on a feeding pole and the tube feeding pump was turned off. The feeding and hydration bottles did not have a label, including the resident's name, flow rate, time, and date. Nurse Manager #1 was interviewed on 4/10/2024 at 11:01 AM and stated the tube feeding bottle should have been labeled with the resident's name, the time the tube feeding bottle was hung, the date, and the flow rate. The label should have been initialed by the nurse who hung the tube feeding bottle. Registered Nurse #2 was interviewed on 4/12/2024 at 8:58 AM and stated they were the float nurse and were assigned to Resident #199's unit on Saturday 4/06/2023 and were familiar with the resident. Registered Nurse #2 stated they were training a new nurse who was not familiar with this facility. While showing the new nurse how to hang the feeding bottle for Resident #199, they forgot to label the tube feeding and the hydration bottles. Registered Nurse #2 stated they should have labeled the bottles with the resident's name, room number, date and time the bottle was hung, and the rate. The [NAME] President of Clinical Services (Director of Nursing Services) was interviewed on 4/12/2024 at 11:05 AM and stated the nursing staff should have labeled the tube feeding bottle. The nursing staff should verify the feeding bottle with the physician's orders, then label the bottle with the resident's name, flow rate, time, date hung, and the nurse's initials. When a tube feeding is already in progress the staff should verify that the bottle label matches the physician's order to ensure accuracy. 10 NYCRR 415.12(g)(1-7)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the Recertification Survey initiated on 4/07/2024 and completed on 4/12/2024 the facility did not ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for one (Resident #608) of three residents reviewed for Respiratory Care. Specifically, Resident #608 had a physician's order to administer 3 liters of oxygen via a nasal cannula as needed (PRN); however, on 4/07/2024 at 10:13 AM, the resident was observed receiving 4 liters of oxygen instead of the prescribed 3 liters. Additionally, there was no documented evidence in the medical record that the resident was being administered oxygen therapy as ordered by the physician. The findings are: The facility policy titled, Oxygen Therapy dated 12/2023 documented to check the physician's orders for oxygen therapy and the liter flow rate; Check that the liters ordered are accurate on the oxygen supply source gauge; Sign the Medication Administration Record that oxygen was applied. Resident #608 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, and Chronic Kidney Disease. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 14, indicating the resident had intact cognition. The Comprehensive Care Plan for Chronic Obstructive Pulmonary Disease dated 2/16/2024 documented interventions that included to administer oxygen therapy as ordered. A physician's order dated 2/14/2024 documented to administer 3 liters of oxygen per minute via a nasal cannula as needed for shortness of breath. During an observation on 4/7/2024 at 10:13 AM Resident #608 was observed sitting in their bed and was receiving 4 liters of oxygen per minute via a nasal cannula. Resident #608 was interviewed on 4/7/2024 at 10:13 AM and stated they had been at the facility for approximately one and a half months and frequently use oxygen to help them breathe better. During a second observation on 4/9/2024 at 12:39 PM Resident #608 was observed sleeping in their bed. The resident was receiving 3 liters of oxygen per minute via a nasal cannula. During a subsequent observation on 4/10/2024 at 1:50 PM Resident #608 was observed sitting in their bed. The resident was receiving 3 liters of oxygen per minute via a nasal cannula. Resident #608 was re-interviewed on 4/10/2024 at 1:50 PM and stated they always use supplemental oxygen because it helps them breathe better. The Medication Administration Record from 4/1/2024 to 4/10/2024 lacked documented evidence that Resident #608 was receiving oxygen therapy. The Treatment Administration Record for April 2024 was reviewed and revealed no documentation for oxygen therapy administration for Resident #608. Registered Nurse #4 was interviewed on 4/10/2024 at 1:58 PM and stated they were not sure where they were supposed to document that the resident was receiving supplemental oxygen therapy. They believed the oxygen administration should be documented in the electronic medical record progress notes, the Medication Administration Record, or the Treatment Administration Record. Registered Nurse #1, the Nurse Manager, was interviewed on 4/10/2024 at 2:04 PM and stated Resident #608 has a physician's order for oxygen use as needed. The resident utilizes supplemental oxygen therapy every day. The nursing staff should be signing for the oxygen administration on the resident's Medication Administration Record including the amount being administered. Registered Nurse #1 stated there is no documentation in Resident # 608's medical record that the resident was receiving oxygen therapy. Registered Nurse #1 stated when a resident uses oxygen, the nurses must document the oxygen administration in the resident's medical record. The [NAME] President of Clinical Services (DNS) was interviewed on 4/12/2024 at 11:03 AM and stated the nursing staff should document oxygen administration including the amount administered in the resident's medical record. 10 NYCRR 415.12(k)(6)

Based on observations, record review, and interviews conducted during a Recertification Survey initiated on 4/7/2024 and completed on 4/12/2024, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen observation conducted on 4/7/2024. Specifically, the walk-in refrigerator for dairy was observed with multiple trays including eight trays of coconut custard pie and two trays of diet vanilla pudding, the items were not labeled and dated. The walk-in refrigerator adjacent to the freezer was observed with one carton of liquid eggs that was opened and dated 4/18/2024. There was no indication when the egg carton was first opened. The walk-in freezer was observed with one pan of frozen leftover entrée, cornflake chicken, labeled and dated 1/23/2024. The facility staff did not know when to discard leftover perishable foods. The finding is: The facility's policy titled, Food Services: Storage Guidelines dated 2/2024 documented the executive chef and chefs are responsible for proper storage of meat and frozen foods, groceries, rotation, and sanitation of milk, produce, and dairy products. The policy did not address the storage of food after preparation or storage of leftovers. The facility's policy titled, Food Services Product Labeling and Dating dated 2/2024 documented all products shall be labeled, dated, and discarded in accordance with the Product Labeling, Dating, and Discard Chart. All opened/altered items shall be labeled with description, prep date, and discard date. The policy documented discard date of ready-to-eat items was three days from the prepared date. The policy documented discard date of liquid eggs was three days from the opening date if opened. The policy did not address labeling, dating, or tracking of leftover perishable foods. A tour of the kitchen was conducted on 4/7/2024. A walk-in refrigerator that was designated for dairy products was inspected at 9:52 AM with the Director of Culinary Services present. A sheet pan rack was observed holding eight trays of coconut custard pies and two trays of diet vanilla pudding. The diet vanilla puddings were stored in clear plastic cups. There were approximately 30 pies and 40 cups of diet vanilla pudding on the rack. Both items were unlabeled and undated. The Director of Culinary Services was interviewed immediately after the observation on 4/7/2024 and stated the items were prepared this morning and would find out which staff was assigned the task. The Culinary Ambassador was interviewed on 4/7/2024 at 10:00 AM. The Culinary Ambassador stated they prepared the desserts in the morning but forgot to date and label them before storing the rack away. The Culinary Ambassador stated they should have labeled and dated the food items after preparation. The Culinary Ambassador stated the desserts were prepared for tomorrow's (4/8/2024) lunch. The Director of Culinary Services was re-interviewed on 4/7/2024 at 10:03 AM and stated that the Culinary Ambassador should have dated and labeled the desserts after they (Culinary Ambassador) prepared them. The label should indicate when the food was prepared and what meal they are prepped for. The walk-in refrigerator adjacent to the freezer was inspected at 10:06 AM. One carton of liquid eggs was observed opened, plastic-wrapped, and dated 4/18/2024. The kitchen supervisor was immediately interviewed who was unable to indicate when the carton was first opened and what the 4/18/2024 date referred to. The kitchen supervisor stated that the carton should be labeled and dated when it is opened and they would discard the carton that was dated 4/18/2024. The walk-in freezer was inspected on 4/7/2024 at 10:11 AM with the Kitchen Supervisor and the Director of Culinary Services. One pan of food labeled cornflake chicken dated 1/23/2024 was observed. The kitchen supervisor stated that the date indicated when the leftover cornflake chicken was frozen. The kitchen supervisor stated the leftover foods could be reused when the residents' menu cycled and the item was repeated after three weeks. The kitchen supervisor was unable to explain why the observed entrée (cornflake chicken) had been kept in the freezer for more than two months. The kitchen supervisor stated they did not know when to discard the item if it remained unused. The Director of Culinary Services was interviewed again on 4/7/2024 at 10:16 AM and stated they were new at the facility and were not familiar with the facility's policy regarding tracking the leftover foods and when to discard the leftovers. The Director of Culinary Services further stated when labeling the food items the facility staff should clearly document if the date was for the day the food was prepared or for the day the food should be discarded. 10 NYCRR 415.14(h)

Based on record review and interviews conducted during a Recertification Survey initiated on 4/7/2024 and completed on 4/12/2024, the facility did not ensure that their policy regarding the use and storage of foods brought to residents by family and other visitors included to ensure facility staff assists the resident in accessing and consuming the food if the resident is not able to do so on their own. Specifically, the facility did not provide accommodations for heating and storage of food brought to residents from outside the facility. Additionally, the facility Administrator and the Director of Culinary Services stated that residents who were unable to eat on their own would be provided feeding assistance by facility staff only when facility prepared food was consumed. The finding is: The facility provided an additional policy titled Resident who Order Food from an Outside Venue dated 8/21/2022 which documented that residents may order food from an outside venue. When the food is delivered it will be immediately delivered to the resident and the staff will assist the resident as needed to complete the meal. The policy did not include how food would be stored safely and in a way that is separate or easily distinguishable from the facility food. The facility's policy titled Food Safety Requirements - Use and Storage of Food and Beverages Brought in for Residents by Family, Visitors dated January 2024 and last revised in April 2024 documented that although the facility does not discourage resident representatives, family or other visitors from bringing in food or beverages for the resident, the facility does not reheat or store food items that are not prepared by the facility. Guidelines regarding food brought in from outside the facility include but are not limited to hot food/beverages that may be brought in from the outside already heated to a temperature of 165 degrees Fahrenheit and transported in a thermal container to maintain the temperature and safety of the food. It should be immediately provided to the resident to ensure temperature safety. The designated representative or family member takes full responsibility for the food brought in from outside. The facility does not take any responsibility for food brought in from the outside due to potential risk. The facility policy did not include how the facility would ensure that a resident was assisted in accessing and consuming food brought in by family and other visitors if the resident was not able to do so on his or her own. The Director of Culinary Services was interviewed on 4/11/2024 at 12:00 PM and stated the facility will not store any food brought to the residents from any outside sources. The Director of Culinary Services stated that nursing staff will offer feeding assistance to residents who cannot consume food on their own only when the residents are eating facility-issued food and meals. The Administrator was interviewed on 4/11/2024 at 1:17 PM and stated that they were aware of the federal regulation that the facility must provide handling, storing, and assisting with food brought to residents from outside the facility. The Administrator stated they were involved in the revision of the policy and agreed that the facility would not handle, store, or provide assistance to residents with the food that is brought in from outside the facility. The Administrator stated that persons or family members who bring the food from outside should take full responsibility because the facility does not know how the food was prepared and/or where the food came from. The Administrator stated that residents who were unable to eat on their own would be provided feeding assistance by facility staff only when facility prepared food was consumed. 10 NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during the Recertification Survey and Abbreviated Survey (Complaint # NY00274868) initiated on 3/14/2022 and completed on 3/18/2022, the facility did not ensure accidents were thoroughly investigated to rule out abuse, neglect, or mistreatment for one (Resident #394) of three residents reviewed for accidents. Specifically, Resident #394 had an unwitnessed fall in the facility on 4/21/2021; however, the investigation was not thorough and did not address the root cause of the resident's fall. Additionally, the investigation did not address the resident's behavior of disarming the chair and bed alarms. The finding is: The facility's policy titled Accident/Incident Assessment and Report Completion last reviewed in January 2021, documented to assess the status of the resident and document accurately after an accident or incident in order to provide accurate reporting and assessment of accidents/incidents. Resident #394 was admitted to the facility with diagnoses including Cerebrovascular Accident, Osteoporosis, and Anxiety disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderately impaired cognition. The MDS documented that the resident required extensive assistance of one staff member for bed and chair transfers and walking. The resident was unsteady for surface-to-surface transfers and had a fall within the last month. A Comprehensive Care Plan (CCP) effective 4/15/2021 titled I am at risk for falls related to post-fall documented interventions that included bed alarm when in bed and to check the function and placement every shift; chair alarm when out of bed and to check the function and placement every shift; and intervene if the resident is acting in an unsafe manner. A nursing progress note dated 4/21/2021 at 2:49 PM written by Registered Nurse (RN) #1 documented the resident was found sitting on the floor outside their room. The resident ambulated without assistance; and no injuries were noted. The resident's room was to be changed closer to the nurse's station. The Accident and Incident (A/I) report dated 4/21/2021 at 2:45 PM documented the following: The resident stated they (Resident #394) got out of bed and walked to see if their spouse was present. The A/I documented that the bed and chair alarms were in place and functional. The fall was not witnessed, and the cause of the fall was that the resident was ambulating without assistance. The interventions to prevent a reoccurrence included to change the resident's room closer to the nursing station and continue use of the chair and bed alarm. A written statement from Certified Nursing Assistant (CNA) #1 dated 4/21/2021 in the A/I report documented that the CNA was charting and heard a thump, they (CNA #1) turned around and the resident was on the floor. CNA #1's statement documented that no alarm sounded because the resident turned the chair alarm off. The Registered Nurse (RN #2) Supervisor assessment dated [DATE] in the A/I report documented the resident was sitting on the floor in the room. RN #2 Supervisor assessment did not document the resident's behavior of disarming the bed and chair alarms and did not document whether an alarm was sounding or not. The Risk Manager/Director of Nursing Operations (RM) investigation summary dated 4/22/2021 documented that the resident was found sitting on the floor just outside the room, toileted at 2 PM, seen lying in bed at 2:30 PM, bed alarm was sounding. There was no evidence of abuse, neglect, or mistreatment. The Risk Manager's conclusion did not document the resident's behavior of disarming the bed and chair alarms. CNA #1 was interviewed on 3/17/2022 at 1:21 PM and stated on 4/21/2021 they (CNA #1) were working at the kiosk in the hallway and Resident #394 was right in front of their (Resident #394) room doorway in their wheelchair. The resident knew how to turn the wheelchair and bed alarms off. The CNA stated the resident hated the alarm and was non-compliant. CNA #1 stated they (CNA #1) had previously found the resident once or twice undoing the chair alarm. The CNA stated when the resident fell the alarm did not go off. CNA #1 stated they (CNA #1) told RN #4, who was the nurse for the resident, about the resident's behavior of disarming the bed and chair alarms. CNA #1 stated they (CNA #1) put the resident in bed before the CNA went to lunch, and when the CNA came back from lunch the resident was in the wheelchair. CNA #1 stated the resident had the ability to transfer on his own from bed to chair and was non-compliant. RN #1, who was the RN on the unit and responded to the fall on 4/21/2021 was interviewed on 3/17/2022 at 1:44 PM. RN #1 stated the resident never complained about the chair and bed alarms and they (RN #1) were not aware the resident was turning off their bed and chair alarms. RN #1 stated that CNA #1 did not notify them (RN #1) about the resident's behavior of turning off the bed and chair alarms. RN #1 stated that all the alarms were in place and functional. The RM was interviewed on 3/17/2022 at 2:02 PM and stated that after reading CNA #1's written statement in the 4/21/2021 A/I report, they (RM) became aware of the resident's behavior of turning off the bed and chair alarms. The RM stated that in the accident and incident investigation dated 4/21/2021 they (RM) concluded that the bed alarm was sounding because they (RM) just assumed that the bed alarm was sounding, and the resident had shut off the alarm. The RM did not know if the bed alarm was actually sounding. The RM did not recall if the resident's care plans were updated after the incident to indicate non-compliance and the resident's behavior of turning off the alarms. RN #2 (nursing supervisor) was interviewed on 3/17/2022 at 3:05 PM and stated they (RN #2) did not recall if anyone had reported that the resident was disconnecting the alarms. RN #2 stated that if they (RN #2) had known about the resident's behavior, they (RN #2) would have updated the Falls care plan and the CNA profile so that staff were aware of the resident's behavior. The [NAME] President of Clinical Services (VPCS) was interviewed on 3/18/2022 at 10:00 AM and stated that the investigation conclusions should not be based on assumptions. The VPCS stated they (VPCS) were not sure if the nurses read CNA #1's statement in the 4/21/2021 A/I report, but there is a post-fall huddle that is part of the A/I report with questions to ask after a fall. The VPCS stated RN #4, who was assigned to Resident #394 during the shift when the fall occurred, is no longer employed at the facility. The VPCS stated that care plans and the CNA profile should have been revised to include the resident's behavior of disarming the bed and chair alarms. A review of the post-fall huddle part of the 4/21/2021 A/I report signed by RN #1, CNA #1, and RN #4 revealed no documentation related to the resident disconnecting bed and chair alarms. 415.4(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during the Recertification Survey and Abbreviated Survey (Complaint # NY00274868) initiated on 3/14/2022 and completed on 3/18/2022, the facility did not ensure that each resident's comprehensive care plan (CCP) was reviewed and revised to meet the needs of the resident. This was identified for one (Resident #394) of three residents reviewed for Accidents. Specifically, Resident #394 who was at risk for falls was identified by the facility staff with behaviors of turning off their bed and chair alarms. The CCP was not updated and revised to reflect the resident's behavior. Subsequently, on 4/21/2021 the resident had an unwitnessed fall with no alarm sounding. The CCP was not revised after the fall to include the resident's behavior of disarming the chair and bed alarms. The finding is: The facility's policy titled Comprehensive Person-Centered Care Planning, dated 3/5/2017, documented the facility must develop a comprehensive, person-centered care plan for each resident that includes measurable objectives and time frames to meet each resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment. Resident #394 was admitted to the facility with diagnoses including Cerebrovascular Accident, Osteoporosis, and Anxiety disorder. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderately impaired cognition. The MDS documented that the resident required extensive assistance of one staff member for bed and chair transfers and walking. The resident was unsteady for surface-to-surface transfers and had a fall within the last month. A Comprehensive Care Plan (CCP) effective 4/15/2021 titled I am at risk for falls related to post-fall documented interventions that included bed alarm when in bed and to check the function and placement every shift; chair alarm when out of bed and to check the function and placement every shift; and intervene if the resident is acting in an unsafe manner. The Resident Care Profile (Certified Nursing Assistant (CNA) accountability record) effective 4/15/2021 documented bed alarm when in bed-check function and placement every shift, chair alarm when out of bed-check function and placement every shift. A nursing progress note dated 4/21/2021 at 2:49 PM written by Registered Nurse (RN) #1 documented the resident was found sitting on the floor outside their room. The resident ambulated without assistance; and no injuries were noted. The resident's room was to be changed closer to the nurse's station. The Accident and Incident (A/I) report dated 4/21/2021 at 2:45 PM documented the following: The resident stated they (Resident #394) got out of bed and walked to see if their spouse was present. The A/I documented that the bed and chair alarms were in place and functional. The fall was not witnessed, and the cause of the fall was that the resident was ambulating without assistance. The interventions to prevent a reoccurrence included to change the resident's room closer to the nursing station and continue use of the chair and bed alarm. A written statement from Certified Nursing Assistant (CNA) #1 dated 4/21/2021 in the A/I report documented that the CNA was charting and heard a thump, they (CNA #1) turned around and the resident was on the floor. CNA #1's statement documented that no alarm sounded because the resident turned the chair alarm off. CNA #1 was interviewed on 3/17/2022 at 1:21 PM and stated Resident #394 knew how to turn off the wheelchair and bed alarms. CNA #1 stated the resident hated the alarm and was non-compliant. CNA #1 stated they (CNA #1) had previously found the resident once or twice undoing the chair alarm. CNA #1 stated when the resident fell the alarm did not go off. CNA #1 stated they (CNA #1) told RN #4, who was the nurse for the resident, about the resident's behavior of disarming the bed and chair alarms. The Risk Manager/Director of Nursing Operations (RM) was interviewed on 3/17/2022 at 2:02 PM and stated that they learned of the resident's behavior of turning off the bed and chair alarms from CNA #1's written statement. The RM did not recall if the resident's care plans were updated to indicate the resident's behavior of turning off the alarms. The CCP for I am at risk for falls related to post-fall dated 4/21/2021 was updated on 4/22/2021 by the RM and included interventions: observation for 3 days, resident educated to not transfer unassisted and to use the call bell, and room changed closer to the nursing station. There was no documentation in the CCP related to the resident's behavior of disarming the bed and the chair alarms. The facility did not provide evidence of a behavior care plan to address the resident's behavior of turning off the bed and the chair alarms. Updates to the Resident Care Profile (CNA accountability record) dated 4/21/2021 included Fall: Activity Consult and Fall: Initiate Fall Prevention Program. There was no documentation indicating the resident's behavior of turning off the bed and chair alarms. RN #2 (nursing supervisor) was interviewed on 3/17/2022 at 3:05 PM and stated they (RN #2) did not recall if anyone had reported that the resident was disconnecting the alarms. RN #2 stated that if they (RN #2) had known about the resident's behavior, they (RN #2) would have updated the Falls care plan and the resident care profile (CNA accountability record) so that staff were aware of the resident's behavior. The [NAME] President of Clinical Services (VPCS) was interviewed on 3/18/2022 at 10:00 AM and stated that the investigation conclusions should not be based on assumptions. The VPCS stated they (VPCS) were not sure if the nurses read CNA #1's statement in the 4/21/2021 A/I report, but there is a post-fall huddle that is part of the A/I report with questions to ask after a fall. The VPCS stated that care plans and the CNA profile should have been revised to include the resident's behavior of disarming the bed and chair alarms. 415.11(c)(2)(i-iii)