**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY00365545) completed 5/7/2025, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for one (Residents #1) of three residents reviewed. Specifically, Resident #1 was unshaven with facial hair longer than ¼ inch. The finding is: The facility policy and procedure titled Activities of Daily Living dated 11/18/24, documented the facility will ensure a resident is given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living. The facility will provide care and services for hygiene-bathing, dressing, grooming and oral care. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain grooming, and personal hygiene. The facility policy and procedure titled Quality of Life-Dignity dated 2/2021, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Treated with dignity means the resident will be assisted in maintaining and enhancing their self-esteem and self-worth. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). Resident #1 had diagnoses which included dementia, cerebral infarction (stroke), and seizure disorder. Review of a Minimum Data Set (a resident assessment tool) dated 12/3/24 documented the resident had severe cognitive impairment and required supervision or touch assist for personal hygiene. Review of a Minimum Data Set, dated [DATE] documented resident sometimes understood, sometimes understands, had severe cognitive impairment and required partial/moderate assistance for personal hygiene. Resident #1 had no rejection of care. Review of the comprehensive care plan initiated on 11/29/24 documented Resident #1 required extensive assist of one with self-care and had a deficit in activities of daily living. An intervention dated 2/18/25 documented personal hygiene was to be done per occupational therapy recommendations. Review of Occupational Therapy Evaluation and Plan of Treatment certification period 2/18/25-3/19/25, documented Resident #1 required partial/moderate assistance with personal hygiene. Review of Resident #1's Progress Notes dated 11/30/24 - 3/1/25 revealed no evidence that the resident refused to be shaved. There were no progress notes from 3/2/25 to 5/6/25. A Bath and Shower Sheet documented Resident #1 received a shower on 5/2/25 and 5/6/25 with no documented indication whether the resident was shaved. No documented evidence that the resident refused to be shaved. During intermittent observations on 5/6/25 at 12:41 PM, and 1:37 PM, and on 5/7/25 at 10:20 AM, Resident #1 had facial hair present longer ¼ inch and appeared unkempt. During an interview and observation on 5/7/25 at 10:22 AM-10:26 AM, Certified Nurse Aide #5 stated shaving usually occurred on the resident's shower days or as needed. Certified Nurse Aide #5 stated Resident #1 should be shaved on their shower days Friday mornings and Tuesday evening, and sometimes Resident #1's family member would also shave them. Upon observing Resident #1, Certified Nurse Aide #5 stated they could use a shave and looked scruffy. Certified Nurse Aide #5 stated it was important for residents to be shaved to feel clean, decent and for dignity. During an interview on 5/7/25 at 10:30 AM, Licensed Practical Nurse #3 stated the nursing staff focuses on shaving of the residents on their shower days. They stated shaving if needed should be done daily for dignity. During an interview on 5/7/25 at 10:32 AM, assigned Certified Nurse Aide #4 stated residents were shaved twice a week on shower days or when needed for hygiene purposes. They stated Resident #1 always needed to be shaved; their hair grew fast. They stated Resident #1 was already out of bed upon the start of their shift today. During an interview on 5/7/25 at 11:03 AM, Licensed Practical Nurse #1, Nurse Manager, stated shaving was part of the resident's shower and Resident #1 should have been shaved yesterday for appearance and dignity. They stated Resident #1 was scheduled for their shower on Tuesday evening and the nurse should have verified Resident #1 was shaved. They stated if a resident refused to be shaved it should be documented. Licensed Practical Nurse #1, Unit Manager, stated they have personally shaved Resident #1 and that it was difficult to do with the facility razors. During a telephone interview on 5/7/25 at 12:21 PM, Licensed Practical Nurse #5 stated Resident #1 received their shower yesterday evening and that if Resident #1 needed to be shaved the Certified Nurse Aide should have shaved them as it was part of grooming and for dignity. Licensed Practical Nurse #5 stated they checked Resident #1's skin last evening but did not believe they were shaved and did not know why. During a telephone interview on 5/7/25 at 12:28 PM, Certified Nurse Aide #7 stated they gave Resident #1 their shower yesterday evening and forgot to shave them. They stated it was important for residents to be shaved so they felt and looked good. They stated shaving was a part of grooming and dignity. During an interview on 5/7/25 at 2:05 PM, the Director of Nursing stated shaving should be completed by the certified nurse aides or nurses on the resident's shower day or whenever necessary to maintain the resident's dignity. 10NYCRR 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview conducted during an Abbreviated survey (Complaint #NY00365545 and #NY00373162) the facility did not ensure that there were housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for one (Second Floor) of two resident floors in the South Campus and one (C Wing) of four resident wings in North Campus. Specifically, there were dirty and sticky floors; stain ceiling tiles; window blinds with missing or damaged slats; residue (substance/film) on the surface in shared bathroom sink; room labeled detailed- full clean with debris on floor, in drawers, on bed frame, and bathroom sink; bedpans, wash basins on floors in shared bathrooms (Second Floor-South Campus); window blinds with missing or damaged slats; soiled, damaged fall mat; soiled wall and toilet seats in resident rooms (C-Wing). The findings are: The policy titled Cleaning and Disinfecting Resident's Rooms dated 11/1/2017, documented that resident rooms housekeeping surfaces such as floors and tabletops will be cleaned on a regular basis; environmental surfaces shall be disinfected or cleaned on a regular basis or when visibly soiled; and walls, blinds, and window curtains will be cleaned when these surfaces are visibly contaminated or soiled. Terminal room cleaning is done when the resident is transferred, discharged , or expires. Clean all high-touch furniture items (bedside tables, overbed tables, chairs and beds). Clean all high-touch personal use items (lights, phones, call bells, bedrails, etc.). The policy titled Cleaning and Disinfecting Environmental Surfaces dated 3/10/2020, documented that environmental surfaces shall be cleaned on a regular basis, when spills occur, and when the surfaces are visibly soiled. The policy titled Quality of Life-Home Environment dated 6/1/2017, documented residents are provided with safe, clean, comfortable and homelike environment. The facility staff and management shall maximize, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary and orderly environment. The job description of a Housekeeper documented they were to implement required housekeeping procedures in an efficient, cost-effective manner meeting all federal, state, and local requirements while providing a safe environment for residents. Specific Job Function: maintain resident rooms by cleaning restroom, walls, baseboards, moving furniture to dry and wet mop floors, dust and clean all furniture and fixtures in resident rooms and terminal cleaning of resident room upon transfer, discharge, or death. 1. South Campus building observations on 5/6/25 between 9:40 AM to 11:35 AM revealed the following on the second floor: -Resident room [ROOM NUMBER]- there was food debris, sugar packets along the wall baseboard behind bed and under nightstand; the room floor was dirty and dull; two unlabeled bedpans and one wash basin under sink in shared bathroom. - Resident room [ROOM NUMBER]- tissues, paper and food debris on the floor and under the bed in room; floor dirty, dull and tacky. -Resident room [ROOM NUMBER]- a paper was posted outside the room on the name plate and documented Detail-full clean, date May 5-25 by Housekeeping Aide #1. The floor was dull, dirty with bright pink debris present; the call bell cord was dirty with black debris and a piece of cloth white tape wrapped around it. The bed control cord with scrunched up dirty appearing plastic. The bed frame was soiled with dried liquid and gray dust like matter. There was toilet paper wrapped behind sink faucet, fecal matter in the toilet; and debris, linens in closet and drawers in room. -Resident Rooms #222, 223, 227- the window blinds had missing or damaged slats. room [ROOM NUMBER] had no blind over left side of window. -Resident room [ROOM NUMBER]- had unlabeled bed pans on floor in a shared bathroom under the sink; thick grayish colored residue in the bathroom sink; brown/yellow bowing and stained ceiling tile in bathroom over toilet with additional surrounding stained ceiling tiles. South Campus building observations on 5/7/25 between 8:45 AM to 9:49 AM revealed the following on the second floor: -Resident room [ROOM NUMBER]- the floor was dirty and dull; two unlabeled bedpans, one wash basin remained under sink in shared bathroom. -Resident room [ROOM NUMBER]- the floor was dirty, dull and tacky. -Resident room [ROOM NUMBER]- the unlabeled bed pans on floor in shared bathroom under the sink; thick grayish colored residue/physical scum in bathroom sink; brown/yellow bowing, stained ceiling tile in bathroom over toilet with surrounding stained ceiling tiles all remained. -Resident Rooms #222, 223, 227- had blinds with missing or damaged slats. Resident room [ROOM NUMBER] had no blind over left side of window. During an interview on 5/6/25 at 10:11 AM, Housekeeping Aide #1 stated housekeeping was responsible for thoroughly cleaning the resident's rooms every day. They stated they were responsible for cleaning the resident's bathroom which included cleaning inside and around toilets, cleaning sinks, emptying garbage, sweeping and mopping the floor. They stated if they noticed anything in disrepair, they would notify maintenance. During an interview and observation on 5/6/25 at 10:15 AM, the Housekeeping Supervisor stated the Housekeeping Aides should clean the rooms like their family member was in there. They stated all touch surfaces should be wiped, garbage should be removed, surfaces dusted, bathroom sink, toilets cleaned, floors swept and mopped every day. The Housekeeping Supervisor stated a room that was labeled as detailed meant the room had been cleaned and was ready for the next admission. Upon observing the handwritten sign posted on the name plate room [ROOM NUMBER], the Housekeeping Supervisor stated the room should be ready for a new admission. The Housekeeping Supervisor observed the inside of the room and stated there was nail polish on the floor; the plastic on the bed control cord was very dirty and should have been removed; the call bell cord should have been wiped clean and be free of debris for infection control purposes. They stated nothing should have been left in the room, and everything should have been wiped cleaned with no debris left behind. Additionally, they stated the floors were dull and needed to be buffed. During a follow up interview on 5/6/25 at 10:30 AM, Housekeeping Aide #1 stated they completed the detail on room [ROOM NUMBER] on 5/5/25 at 12:30 PM. They stated they had three other rooms to detail yesterday (5/5/25), and added room [ROOM NUMBER] would not be acceptable to their family because it was dirty. They stated staff utilize unoccupied resident rooms, bathrooms after they were cleaned and stash linen in the drawers. During an interview on 5/6/25 at 10:44 AM, Resident #2 stated their room was not homelike. They stated the floor in their room was disgusting, dirty as hell and the blinds didn't fit the window. They stated they have only seen a housekeeper once since they have been there. During a follow up interview on 5/6/25 at 11:04 AM, the Housekeeping Supervisor stated there should not be food debris, sugar packets on resident floors, behind beds or dressers, and under beds. They stated floors with debris present were not clean and could attract bugs or rodents. During an interview on 5/6/25 at 11:09 AM, Certified Nurse Aide #1 stated the floors on the second floor needed some attention. They stated the floors were not desirable and they do not shine. They stated floors should be cleaner for infection control purposes, and to be more environmentally pleasing to people coming into facility. Additionally, they stated when they notice window blinds in disrepair, they notify the nurse or unit clerk. During an interview on 5/6/25 at 11:17 AM, Registered Nurse #1 stated unclean floors were an infection control concern. They stated unclean (sticky, cluttered, debris) on floors were a concern for residents and families. They stated residents should live in a clean space. During an interview on 5/6/25 at 11:20 AM, Licensed Practical Nurse #4, Rehabilitation Nurse Manager, stated they had concerns with the floors not looking clean, and looking dull on the second floor. They stated they have brought this concern up to the Housekeeping Supervisors and during morning report. They stated they expected rooms to be clean, so they were nice and presentable to the residents. Additionally, they stated they have told staff not to go into rooms that have been detailed but that housekeeping should still check all the rooms every day. During an observation of Resident room [ROOM NUMBER]'s bathroom and interview on 5/7/25 at 9:11 AM, Certified Nurse Aide #3 stated bedpans and wash basin should not be on the floor; they were not labeled and did not know who they belonged to. They stated bedpans and wash basins should be labeled to prevent cross contamination and stored separately in the resident's bottom drawer. During an observation of Resident room [ROOM NUMBER] bathroom and interview on 5/7/25 at 9:15 AM, Certified Nurse Aide #1 stated the unlabeled bedpans on the bathroom floor should be put in the garbage. Bedpans should be labeled and not stored on the floor for infection control purposes. They stated the residue in the sink was an environmental issue and would not be homelike in their home. Additionally, they stated the ceiling tile needed to be replaced because it was stained and not homelike. During an observation of Resident room [ROOM NUMBER]'s bathroom and interview on 5/7/25 at 9:24 AM, Registered Nurse #1 stated the bedpans on the floors in the bathrooms were an infection control concern and should not be stored there. They stated the ceiling tile looked like it could come down on someone's head and was a safety issue and the sink was dirty and was not homelike. During an observation and interview of Resident room [ROOM NUMBER] bathroom on 5/7/25 at 9:35 AM, the Housekeeping Supervisor stated the dirty condition of the bathroom sink made them pissed. They stated they wouldn't brush their teeth in that sink. They stated there should not be build up in the sink, it should be cleaned every day for infection control purposes and to prevent dirt buildup. Additionally, they stated the ceiling tile was dangerous, it could fall on staff or a resident and there could be mold on it. During an interview on 5/7/25 at 9:45 AM, Maintenance Assistant stated the stained ceiling tile in the bathroom of room [ROOM NUMBER] was from water damage. They stated stained ceiling tiles were not homelike and not environmental clean. During an interview on 5/7/25 at 9:49 AM, the Director of Housekeeping and Laundry stated they expected housekeeping staff to do a fine job and follow policy when cleaning resident rooms every day. They stated this was the resident's home and their environment should be clean. Additionally, they stated they have had staff issues and have had to wait for cleaning supplies. During an interview on 5/7/25 at 10:06 AM, the Director of Maintenance stated they would expect nurses, nurse managers to report things to maintenance if there was an issue in a resident room. They stated they were aware of the condition of the window blinds in resident rooms, and if they had any blinds available, they would replace them. They stated there were no window blinds available and there were issues with purchasing. They stated there should be blinds on windows for privacy and for a homelike environment. Additionally, they stated ceiling tiles are part of the homelike environment and should not be stained. They stated they were made aware of stained ceiling tiles through walking rounds and reports from staff. 2. North Campus C-Wing observations on 5/6/25 between 12:15 PM to 1:37 PM revealed the following: -Resident room [ROOM NUMBER]- the window blinds had damaged slats; and there was a urine odor to the room. -Resident room [ROOM NUMBER]- there was a fall safety mat in disrepair with foam exposed, edges curling/peeling up and was soiled; there was buildup of tan/brown dried substance on the close wall; the toilet seat in bathroom was dirty with brown splatter. North Campus C-Wing observations on 5/7/25 between 10:17 AM to 11:03 AM revealed the following: -Resident room [ROOM NUMBER]- the window blinds had damaged slats. -Resident room [ROOM NUMBER]- the toilet seat in bathroom remained soiled with brown splatter. During an interview on 5/6/25 at 12:16 PM, Resident #4 stated this place is a (expletive) hole, smells and was not homelike. At 1:26 PM, Resident #4 stated it bothered them that blinds were damaged because it let too much sunlight in. During an interview on 5/6/25 at 12:51 PM, Licensed Practical Nurse #2 stated the cleanliness of the building was terrible. The building was old, run down, and the substance on floors cannot be removed. They stated the staff try their best to make it homelike. Additionally, they stated if a staff member sees a mess, they should clean it up or make housekeeping aware. During an observation and interview on 5/6/25 at 1:12 PM, Certified Nurse Aide #8 stated the tan/brown debris in room [ROOM NUMBER] on the closet wall looked like poop or chocolate. They stated housekeeping was responsible for wiping down the walls. Certified Nurse Aide #8 stated the floor mat should be replaced because someone could trip over the curling corner and that foam should not be exposed. They stated it was not sanitary or homelike to for the walls and floors to be dirty. During an observation and interview on 5/6/25 at 1:19 PM, Licensed Practical Nurse #3 stated there was chocolate or poop on the wall and the floor mat in room [ROOM NUMBER] needed to be removed. They stated the floor mat edge was curled up posing a tripping hazard, and the exposed foam on the mat could not be cleaned properly. They stated this was not homelike and needed to be cleaned for infection control purposes. During an observation and interview on 5/6/25 at 1:30 PM, Licensed Practical Nurse #1, C-Wing Nurse Manager, stated they did not know what the tan/brown substance was on the wall in room [ROOM NUMBER] but it needed to be cleaned. They stated it was important to maintain cleanliness to prevent the spread of germs and because this was the resident's home. Additionally, Licensed Practical Nurse #1, C-Wing Nurse Manager, stated the floor mat in room [ROOM NUMBER] was dirty, and it needed to be replaced. They stated it was unsanitary and not homelike. During an interview on 5/7/25 at 10:30 AM, Licensed Practical Nurse #3 stated the toilet seats should be clean for infection control purposes. During an observation and interview of Resident room [ROOM NUMBER]'s bathroom on 5/7/25 at 10:41 AM, Certified Nurse Aide #5 stated the brown debris on the toilet seat looked like poop, was degrading, unsanitary, and needed to be cleaned. They stated it was everyone's job, if aides see it, they should wipe it clean and let housekeeping know. During an observation and interview of Resident room [ROOM NUMBER] bathroom on 5/7/25 at 10:54 AM, Housekeeping Aide #2 lifted the toilet seat and revealed brown splatter under the toilet seat. Housekeeping Aide #2 stated it had been a while since they worked C-Wing and that the housekeepers were responsible and should be cleaning the toilets every day for infection control purposes. During an interview on 5/7/25 at 11:03 AM, Licensed Practical Nurse #1, C-Wing Nurse Manager, stated they expected nursing staff to wipe down and sanitize toilet seats when they notice there were dirty and then have housekeeping follow behind. During an interview on 5/7/25 at 2:05 PM, the Director of Nursing stated they expected wash basins, bed pans to be labeled and put away after use. They stated they should not be stored on the floor for infection control purposes. They stated they expected that resident rooms to be thoroughly cleaned by housekeeping between residents. The Director of Nursing stated if staff noticed any environmental concerns, they would expect them to notify the nurse manager or maintenance, so the concern was addressed. During an interview on 5/7/25 at 2:20 PM, the Assistant Administrator stated they expected the policy to be followed for daily cleaning of resident rooms and that maintenance was notified of concerns. 10 NYCRR 415.5(h)(1)(2)

Based on interview and record review conducted during a Complaint investigation (#NY00332426) during a standard survey completed on 10/28/24, the facility did not ensure that all alleged violations involving abuse, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made to the facility's Administrator and the State Survey Agency for one (Resident #62) of five residents reviewed. Specifically Resident #62 was found to have an injury of unknown source to their forehead, and it was not reported within the required timeframe. The finding is: The policy and procedure titled Abuse, Neglect and Exploitation of Residents, reviewed 2/29/24, documented that if abuse is suspected, personnel will report their observation to their supervisor immediately and without delay, and the Administrator, Director of Nursing or designee will notify the appropriate state agencies per state regulations. 1. Resident #62 had diagnoses including unspecified dementia, status post fractured hip, and disorientation (a mental state of confusion about time, place, or one's identity). The Minimum Data Set (a resident assessment tool) dated 1/26/24, documented Resident #62 was severely cognitively impaired, rarely or never understood and rarely or never understands. They were dependent on staff for toileting and transfers, and incontinent of bowel and bladder. The comprehensive care plan dated 5/19/23 documented Resident #62 was a risk for injury, with a Hoyer lift (mechanical lift) and required two staff members for transfers. Review of the ACTS (ASPEN Complaint/ Incidents Tracking System) Complaint/Incident Investigation Report submitted on 1/29/24 at 11:14 AM, revealed Resident #62 was found to have a 1.0 centimeter x 1.5 centimeter closed hematoma (a collection of blood under the skin, caused from a broken blood vessel) to their forehead on 1/26/24 around 9:00 PM, and the origin was unknown. Review of the facility investigation, dated 2/2/24, revealed Resident #62 was found to have the 1.0 centimeter x 1.5 centimeter hematoma to their forehead when being cared for by two Certified Nurse Aides. The resident had no recent falls, and no reported resident to resident altercations or other incidents. Neurological checks were monitored and remained within normal limits. No mental harm was found. Staff stated they noticed the area during care, and none observed prior. Staff statements were dated 1/26/24. Actions taken following the investigation included staff re-education regarding safety during care, transfers, and the monitoring of residents for any change in condition. Review of Resident #62's progress notes from 1/26/24-1/29/24 revealed the following: 1/26/24 at 10:49 PM Licensed Practical Nurse #4 documented the Certified Nurse Aide (#10) notified them of a bump on Resident #62's forehead. The supervisor was notified, neurological checks were initiated and within normal limits, and the resident had no pain or discomfort. 1/27/24 at 5:30 AM Nursing Supervisor, Registered Nurse #3, documented there were no delayed injuries at this time. 1/29/24 at 1:25 PM Assistant Director of Nursing #2 documented there were no delayed injuries from incident on 1/26/24. Forehead hematoma with ecchymosis (bruising) noted. Will continue to monitor the resident. During an interview on 10/24/24, Certified Nurse Aide #1 stated they did not recall the incident with Resident #62 from January but Resident #62 could have hit their head during a Hoyer transfer but Resident #62 did not have the ability to self-transfer on their own. During a telephone interview on 10/24/24, Licensed Practical Nurse #4 stated they did not recall the incident with Resident #62 from January. The progress note dated 1/26/24 at 10:49 PM was reviewed with LPN #4 and stated based on their documentation they notified the supervisor of the injury after checking on the resident. However, stated they were unsure when the supervisor assessed the resident. During a telephone interview on 10/25/24 at 10:23 AM, Assistant Director of Nursing #2 stated they did not specifically remember the incident with Resident #62 in January. They stated that injuries of unknown origin needed to be reported within two hours. The supervisor should have called them or the Director of Nursing immediately. They might have needed to assess the resident and they could have reported it on time. During an interview on 10/25/24 at 10:59 AM, Director of Nursing #1 (current Director) stated they were not employed by the facility at the time of the incident with Resident #62, but it was important for all injuries of unknown origin to be reported to the Director of Nursing immediately. An injury of unknown origin could be abuse, and it needed to be investigated as soon as possible. During a telephone interview on 10/25/24 at 12:03 PM, Director of Nursing #2 (Director at time of occurrence) stated they should have been notified by Nursing Supervisor (RN #3) as soon as they assessed the resident. Director of Nursing #2 stated they were notified on Monday 1/29/24 of the injury, and that's when it was reported to the department of health. An injury of unknown origin should have been reported to the state within two hours because injuries of unknown origin could be suspicious of abuse. During an interview on 10/25/24 at 12:39 PM, the Interim Administrator stated the injury should have been reported to the Director of Nursing immediately so they could start the investigation. They might have found that it was not an unknown at all. All injuries of unknown origin need to be reported to the state within two hours. The staff were all aware of the importance of reporting immediately. 10 NYCRR 415.4 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 10/28/24, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for two (Residents #71 and #127) of five residents reviewed. Specifically, issues involved unkempt long, dirty, jagged fingernails (#71, #127). In addition, Resident #71 had presence of unwanted facial hair. Additionally, the 3rd floor Bath & Shower Sheet dated 10/23/24 for #71 was inaccurately documented, that care had been provided. The findings are: The policy and procedure titled Activities of Daily Living created 2/13/23 documented a resident who was unable to carry out activities of daily living would receive the necessary services to maintain good grooming and personal hygiene. The policy and procedure titled Care of Fingernails issued 6/26/18 documented nail care was to include daily cleaning and regular trimming on resident assigned bath/shower days and unless otherwise permitted, nails of diabetic residents or residents with circulatory problems were to be trimmed only by licensed nurses. If a resident did not receive a bath/shower or refused on the scheduled bath/shower day, nail care was to still be provided on the scheduled bath/shower day. Finally, the nurse supervisor was to be notified if the resident refused care. 1. Resident #71 had diagnoses including hemiplegia (paralysis on one side of body), dysphagia (difficulty swallowing), and diabetes mellitus. The Minimum Data Set, dated [DATE] documented Resident #71 was moderately cognitively impaired, was understood and understands. The Minimum Data Set documented Resident #71 was substantial/maximal assistance for personal hygiene. The certified nurse aide care profile (a guide used by staff to provide care) dated 8/18/24 documented scheduled bath days were twice weekly on the 7:00 AM to 3:00 PM shift on Wednesdays and Saturdays. The comprehensive care plan revised on 8/23/23 documented Resident #71 was diabetic and the plan documented to trim fingernails weekly. The 3rd floor shower/bath scheduled verified as current by Licensed Practical Nurse #6 Unit Manager documented Resident #71's scheduled baths/showers were scheduled for Wednesday and Saturday during the 7:00 AM to 3:00 PM shift. A physician's order dated 8/23/23 revealed an active physician's order to trim fingernails weekly. During an observation and interview on 10/22/24 at 10:21 AM, Resident #71's fingernails were jagged, and dirty with dried brown debris. The resident also was unkempt and had one-inch white whiskers on their face, chin, and neck. Resident #71 stated their nails were ugly and would like them cleaned and that they were embarrassed to have such long whiskers. Resident #71 stated they haven't had a bath or shower in 2 weeks. Observation on 10/23/24 at 12:03 PM revealed Resident #71's fingernails were jagged, dirty and had dried brown debris. Resident #71's whiskers remained on their face, chin and neck and they stated they did not receive their scheduled shower this morning. Review of the nursing progress notes dated 10/1/24 through 10/23/24 revealed there was no documented evidence that nail care was provided, that Resident #84 was bathed, or refused showers and nail care. Review of the 3rd floor Bath & Shower Sheets dated 10/2/24, 10/9/24, and 10/16/24 revealed there was no documented evidence the resident's nails were trimmed and cleaned or had been shaved. Further review of the 3rd floor Bath & Shower Sheets dated 10/23/24 revealed Certified Nurse Aide #4 documented Resident #71's fingernails were cleaned and trimmed, and Resident #71 was shaved. Review of the Treatment Administration Record from 10/1/24 through 10/23/24 documented an active physician order to trim fingernails weekly. The Treatment Administration Record documented that Resident #71's fingernails were trimmed on 10/9/24 and blank on 10/2/24, 10/16/24, and 10/23/24. Further observation and interview on 10/24/24 at 10:13 AM Resident #71 stated the staff were too busy. No one had offered them their shower on 10/23/24. Resident #71 had jagged fingernails dirty with dried brown debris and facial and neck whiskers. The resident stated they hoped to be shaved and have their nails cleaned. During an interview on 10/25/24 at 8:45 AM, Certified Nurse Aide #4 stated they did not give Resident #71 a shower on 10/23/24. There was no sling. Certified Nurse Aides were responsible for providing nail care and shaving unless the resident had a diagnosis of diabetes, then the nurse would be responsible for nail care. I should have informed the nurse the shower was not done or grabbed a sling from laundry. During an interview on 10/25/24 at 10:30 AM, Licensed Practical Nurse #8 stated they were unaware if Resident #71 had their shower on 10/23/24. Certified Nurse Aide #4 never notified them to complete a skin check. Therefore, likely the shower was not given. Resident #71 was diabetic and Licensed Practical Nurse #8 stated they did not clean or trim Resident #71's nails. During an interview on 10/25/24 at 10:33 AM, Licensed Practical Nurse #6, Unit Manager stated they expected proper care daily which included cleaning fingernails, and shaving. 2. Resident #127 had diagnoses of diabetes mellitus type 2 and dementia with mood disturbance. The Minimum Data Set, dated [DATE] documented Resident #127 was severely cognitively impaired and was dependent on staff to perform personal hygiene. The comprehenisve care plan and the certified nurse aide care profile (a guide used by staff to provide care) the dated 9/26/24 did not include instructions for staff regarding nail care. During an observation on 10/22/24 at 9:56 AM, Resident #127 had long yellow fingernails and were dirty with dark brown debris. During follow-up observations on 10/23/24 at 9:16 AM, 10/25/24 at 10:23 AM, and 10/28/24 at 10:13 AM, Resident #127's nails were long and yellow with no dark brown debris under them. During an interview on 10/28/24 at 11:04 AM, Certified Nurse Aide #8, stated they only cleaned under Resident #127's nails and did not clip them, as Resident #127 was diabetic and nurses would need to clip their nails. During an interview on 10/28/24 at 10:15 AM, Licensed Practical Nurse #2 Unit Manager D-wing stated they were the only licensed nurse on the unit for this shift and were also responsible for passing medications scheduled during this day shift. At this time, Licensed Practical Nurse #2 reviewed the month's Bath & Shower Sheets for Resident #127, stated they were to receive a bath or shower on Wednesday during the AM shift and on Saturday during the PM shift. They stated the most recent Wednesday AM check was documented on 10/9/24 and only documented that skin was checked. None of the other categories (nails) were checked off, and there was no Saturday evening check documented during October 2024. They stated they had not been made aware of any bath/shower refusals by Resident #127. During an interview on 10/28/24 at 11:15 AM, Assistance Director of Nurses (ADON) #1, stated Resident #127's fingernails were too long and needed to be clipped. They stated that any resident with a diagnosis of diabetes was to have their nails trimmed by a Licensed Nurse, not a Certified Nurse Aide. They stated it was expected that facility staff notify their supervisor when residents refused baths or showers. They were not aware of any refusals by Resident #127. 10NYCRR 415.12(a)(3)

Based on observation, interview, and record review conducted the Standard survey completed on 10/28/24, the facility did not ensure that residents who had an indwelling (foley) catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for one (Resident #84) of one resident reviewed. Specifically, Resident #84 was symptomatic for a urinary tract infection, and the foley catheter drainage bag was not draining to gravity below their bladder. The finding is: The policy and procedure titled Catheter Care: Urinary revised on 4/30/24 documented the purpose of this procedure is to prevent catheter-associated urinary tract infections. The position of the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Resident #84 had diagnoses which included anxiety, stage IV pressure ulcer (most severe type of pressure ulcer and involves full-thickness tissue loss that exposes bone, tendon, or muscle), and urinary tract infection. The Minimum Data Set (MDS- an assessment tool) dated 10/4/24 documented Resident #84 had moderate cognitive impairment, was understood, understands. Resident #84 had an indwelling foley catheter. The undated resident care profile (tool used by staff to provide care) documented Resident #84 was dependent for toileting needs and to offer toileting every 2-3 hours. There was no documentation the resident had an indwelling foley catheter. The comprehensive care plan dated 4/12/24 documented Resident #84 had a foley catheter with a history of urinary tract infections, and to monitor for signs and symptoms of infection. Review of the nursing progress notes dated 10/22/24, revealed Resident #84 complained of burning on 10/21/24. The nurse practitioner was notified. The foley catheter was changed, an order was obtained for a urinalysis (a laboratory test that provides important clinical information on kidney function). The urine sample was collected and sent on 10/22/24. During observation and interview on 10/23/24 at 9:22 AM and 10:06 AM, Resident #84 was in their wheelchair next to the bed. An empty blue privacy bag was hanging off the bottom of the wheelchair. The foley catheter drainage bag was lying flat and was empty on Resident #84's lap. There was visible yellow urine with white mucous shreds contained throughout the catheter tubing. At 10:06 AM Resident #84 stated that's where they left it when they got me up. Resident #84 stated they had a burning sensation. Further observation and interview on 10/23/24 at 10:10 AM, Certified Nursing Assistant #5 stated they got Resident #84 into the wheelchair at 8:00 AM and was sidetracked, left the room, leaving the bag on Resident #84's lap. The foley drainage bag should have been placed in the privacy bag and should be below the bladder to prevent infections. During an interview on 10/23/24 at 12:48 PM, Licensed Practical Nurse #7 stated foley drainage bags were positioned below the bladder and drained to gravity. Resident #84 had complained of burning and a urine had been collected on 10/22/24. Review of the Physicians' Order Form as of 10/23/24 revealed a physician's order for a Urinalysis to be collected on 10/22/24. Review of the Bacteriology preliminary report dated 10/23/24 revealed a urinalysis collected on 10/22/24 had a colony count greater than 100,000 colony forming units/milliliters Escherichia Coli and was signed by Licensed Practical Nurse #6, Unit Manager on 10/24/24. During an interview on 10/24/24 at 10:39 AM, Nurse Practitioner #1 stated they'd expect foley drainage bags be positioned below the bladder to avoid the risk of urinary tract infections. During an interview on 10/28/24 at 9:17 AM, Licensed Practical Nurse #6 Unit Manager stated Resident #84 was on antibiotics for a urinary tract infection. Certified Nursing Assistant #5 should have placed the drainage bag in the privacy bag under the wheelchair and not on Resident #84's lap to prevent discomfort or the backflow of urine into the bladder. During an interview on 10/28/24 at 10:45 AM, the Director of Nursing stated foley drainage bags should never be placed on someone's lap. The urine flow would back into the bladder and for someone with a urinary tract infection, could make the infection worse. During an interview on 10/28/24 at 12:05 PM, Corporate Quality Assurance/Infection Preventionist stated foley drainage bags left on the lap was an infection control issue, and lead to urinary tract infections. 10NYCRR 415.12 (d) (2)

Based on observation, interview, and record review conducted during a Standard Survey completed on 10/28/24, the facility did not provide separately locked, permanently affixed compartments for the storage of controlled drugs for one (A Wing North Building) of three medication rooms observed for medication storage. Specifically, three bottles of liquid Lorazepam (a Schedule IV controlled substance-sedative/antianxiety medication) were stored in a removable locked box inside a small refrigerator that was not permanently affixed, which was located in a room with an unlockable door. This involved Resident #32. The finding is: The policy and procedure titled Controlled Substances with effective date 12/1/17 documented that refrigerated controlled substances must be stored in a refrigerator that has a locked, affixed narcotic box inside of the refrigerator with a separate lock on the outside of the refrigerator. The refrigerator must be affixed to the floor or wall. The refrigerator and interior narcotic container must remain locked at all times. During a medication storage room observation on 10/23/24 at 3:42 PM, Licensed Practical Nurse #9 unlocked the refrigerator in the medication room and removed a small, locked metal box that was not in an affixed compartment. The small metal box contained three bottles of Lorazepam concentrate 2 milligrams per milliliter for Resident #32. Bottle #1 for Resident #32 had 27 milliliters remaining; bottle #2 for Resident #32 was unopened and had 30 milliliters remaining; bottle #3 for Resident #32 was unopened and had 30 milliliters remaining. Further observation revealed the medication refrigerator was not affixed to the wall or counter and was in a room with an unlockable door. During an interview on 10/23/24 at 3:42 PM, Licensed Practical Nurse #9 stated they had not been using the locked compartment inside the medication refrigerator because there was no key. They stated they were not sure if the locked box needed to be affixed. During an interview on 10/23/24 at 4:44 PM, the [NAME] President of Clinical Services stated that they were unaware that the medication refrigerator on the A wing was not affixed or secured and should have been. They stated they did not know how long it had been unsecured or why and they would have maintenance address the issue immediately. During an interview on 10/24/24 at 9:52 AM, Licensed Practical Nurse Unit Manager #5 stated they had not been aware the medication refrigerator was not secured and was unsure why the affixed locked compartment in the refrigerator was not being used to store controlled substances. They stated when the residents transferred over from B wing in June the medication refrigerator was already in place on the unit. Licensed Practical Nurse Unit Manager #5 stated they believed the nurse was not aware they had a key to the affixed locked compartment for the medication refrigerator. During an interview on 10/24/24 at 10:14 AM, Licensed Practical Nurse #9 stated they were not aware they had a key on their key ring for the affixed locked compartment in the medication refrigerator. During an interview on 10/28/24 at 9:46 AM, the Director of Nursing #1 stated they were unaware that the medication refrigerator on the A wing was not secured and did not know why the affixed locked compartment in the refrigerator was not being used for controlled substances. The Director of Nursing #1 stated they would have expected both the medication refrigerator and narcotic box to be affixed and secured to ensure no one could remove and walk out with medications. During an interview on 10/28/24 at 10:25 AM, the Interim Administrator stated they would expect all medication refrigerators to be secured, not removable and would expect that controlled substances were stored in a locked box that was affixed to the refrigerator. They stated this would be important as someone could walk away with the controlled substances if not securely stored. 10 NYCRR 415.18 (e)(1)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 10/28/24, the facility did not provide or obtain dental services to meet the resident's needs for one (Resident #84) of one resident reviewed. Specifically, there was no follow up to recommendations for a crown for a chipped tooth. In addition, the care plan was not revised to include Resident #84's chipped tooth. The finding is: The policy and procedure titled Dental Services with a revised date 1/28/20 documented routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. The Director of Nursing, or his/her designee, is responsible for notifying Social Services of a resident's need for dental services and coordinate appointments with Medical Records/Unit Clerks. Social Services personnel will be responsible for assisting the resident/family in making dental appointments and transportation arrangements as necessary whenever an outside appointment is requested. The Medical Records Department/Unit Clerks will schedule and track resident dental appointments as per the required and recommended visits in the medical appointment tickler tracking system document. The policy and procedure titled Quality of Life - Dignity dated 9/1/17 documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Treated with dignity means the resident will be assisted in maintaining and enhancing his/her self-esteem and self-worth. Resident #84 had diagnoses which included anxiety, stage IV (4) pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle), and urinary tract infection. The Minimum Data Set (a resident assessment tool) dated 10/4/24 documented Resident #84 had moderate cognitive impairment, was understood, understands, and had no mouth or facial pain, or difficulty chewing. The undated resident care profile (used by staff to guide care) documented Resident #84 was dependent on staff for oral hygiene. The comprehensive care plan dated 4/12/24 documented that Resident #84 had poor dentition. The plan included dental consults annually and as needed, and to monitor for pain or problems with chewing. The comprehensive care plan documented to examine the oral cavity and assess for lesions, broken or missing teeth on admission, annually and as needed. Resident #84's chipped front tooth was not reflected on the plan of care. During observation and interview on 10/21/24 at 10:20 AM, Resident #84 stated they had a cracked tooth and hadn't seen the dentist. The tooth wasn't painful, they were self-conscious about it, and wished it was fixed. Resident #84's right front tooth was visibly chipped. Review of the Dental Orders and Progress Notes Form dated 7/29/24 documented Resident #84 was seen by the facility dentist for an initial visit and had obvious broken natural teeth. Tooth #8 was chipped. The tooth would need a crown and Resident #84 would have to follow up with an outside dentist as this service was not provided by the facility dentist. The dental progress note was signed by the medical provider on 8/6/24. Review of the nursing progress notes from 7/29/24 through 8/10/24 revealed no documented evidence the dental recommendations were addressed, or an appointment had been arranged. During an interview on 10/25/24 at 11:31 AM, Licensed Practical Nurse #6, Unit Manager stated dental consults were placed in medical records mailbox by the dentist. Medical records staff distributed the consults to the units. Unit managers addressed recommendations with the medical provider and Unit Clerks were responsible to schedule the outside appointments. Licensed Practical Nurse #6, Unit Manager stated Resident #84's dental consult was signed by the medical provider on 8/6/24 and Licensed Practical Nurse #10, Unit Manager should have followed up on the recommendations. There were no nursing progress notes that reflected Resident #84 had been seen by the dentist on 7/29/24. The process was not working because this was obviously missed. Resident #84's care plan should have reflected the chipped tooth for monitoring potential weight loss, pain or difficulty chewing. During an interview on 10/25/24 at 11:32 AM, Unit Clerk #2 stated the dental consult was given to Licensed Practical Nurse #10, Unit Manager and could not recall that an outside appointment was made and must have been overlooked. Typically, it was the responsibility of unit managers or unit clerks. During a telephone interview on 10/25/24 at 12:51 PM, Director of Nursing #2 stated dental consults went directly to medical records. Medical records distributed the consults to the unit managers who reviewed them for recommendations. Unit clerk #2 was responsible for arranging follow up appointments once the medical provider agreed. During an interview on 10/25/24 at 1:17 PM, the Director of Medical Records stated dental consults were given to medical records staff after a resident had been seen. Medical records staff then distributed them to the units for the unit manager to address any recommendations with the provider. Unit managers would inform the unit clerk if an outside appointment needed to be scheduled. Unit Clerk #2 should have made the appointment. During an interview on 10/25/24 at 1:25 PM, the Interim Administrator stated Licensed Practical Nurse #10, Unit Manager was unavailable for interview until further notice. During an interview on 10/28/24 at 1:28 PM, the Interim Administrator stated Licensed Practical Nurse #10, Unit Manager should have reviewed Resident #84's dental consult for recommendations and Unit Clerk #2 should have scheduled the appointment. There needed to be an extra step in the process to ensure the appointments were really scheduled or why it was missed. 10 NYCRR 415.17(c)

Based on observation, interview, and record review conducted during the Standard survey completed on 10/28/24, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #84) of three residents reviewed for infection control practices during care. Specifically, Certified Nurse Aide's #2, 4, 5, and 6 did not wear appropriate personal protective equipment (PPE) during care activities for a resident on enhanced barrier precautions who had an indwelling catheter (tube inserted into the bladder to drain urine) and a stage IV pressure ulcer. The findings are: The undated policy and procedure titled Enhanced Barrier Precautions documented enhanced barrier precautions are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms to residents. Enhanced Barrier Precautions employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gowns are applied prior to performing the high contact care activity. Examples of high-contact care activities requiring the use of a gown and gloves for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, urinary catheter care and wound care. Enhanced Barrier Precautions remain in place for the duration of the resident's stay or the discontinuation of the medical device that places them at increased risk. Staff are trained prior to caring for residents on Enhanced Barrier Precautions. Signs are posted in the door or wall outside the resident room. Resident #84 had diagnoses which included stage IV pressure ulcer (the most severe type of pressure ulcer and involves full-thickness tissue loss with exposed bone, tendon, or muscle), obstructive uropathy (blockage of urinary flow) and urinary tract infection. The Minimum Data Set (MDS- an assessment tool) dated 10/4/24 documented Resident #84 had moderate cognitive impairment. #84 had an indwelling foley catheter and a stage IV pressure ulcer. The undated resident care profile (guide used by staff to provide care) documented Resident #84 was dependent on 2 staff members for toileting needs and transferred with a mechanical lift. Resident #84 had a pressure ulcer of the sacral region. There was no documentation the resident had an indwelling foley catheter. Enhanced Barrier Precautions were included as special instructions under Infection Control. The comprehensive care plan revised on 9/16/24 documented that Resident #84 had a foley catheter, monitor for infection, maintain precautions as needed, and impaired skin integrity related to a pressure ulcer of the sacral region. During an observation on 10/21/24 at 10:20 AM outside Resident 84's room an orange sign was posted and indicated Enhanced Barrier Precautions with the directive to wear gloves and a gown for high contact care activities. The high contact activities included dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use which included urinary catheter, and wound care: any skin opening that required a dressing. Additional observation revealed a clear plastic bin outside of Resident #84's room with 3 drawers that contained gowns, facial masks, and surgical gowns. During a mechanical lift transfer observation on 10/23/24 at 12:50 PM Certified Nurse Aide's #5 & #6 each donned (put on) a pair of gloves. Certified Nurse Aide's #5 & #6 lifted Resident #84 out of their wheelchair using a mechanical lift. During the transfer Certified Nurse Aide #5 removed Resident #84's foley catheter drainage bag from the privacy bag and held the catheter tubing during the transfer and lowered Resident #84 onto the bed. Certified Nurse Aide's #5 & #6 rolled Resident #84 over and removed Resident #84's incontinence brief. Resident #84 had a large dressing affixed to their sacrum. Certified Nurse Aide #5 removed the catheter tubing through the pant leg and placed the foley drainage bag onto the bed frame. Certified Nurse Aide's #5 then changed their gloves, completed hand hygiene and gathered supplies for fecal incontinence care. There were no gowns worn during this care observation by either staff member. During an observation on 10/23/24 at 1:02 PM Certified Nurse Aide #5 donned a clean pair of gloves and performed fecal incontinence care as Certified Nurse Aide #6 assisted with bed mobility. Certified Nurse Aide #2 entered Resident #84's room at 1:08 PM, donned a pair of gloves and assisted Certified Nurse Aide #5 with fecal incontinence care. Certified Nurse Aide #6 continued to assist with bed mobility. Certified Nurse Aide #4 then entered Resident #84's room at 1:11 PM donned a pair of gloves and finished fecal incontinence care with Certified Nurse Aide's #2, 5 & 6 then completed hand hygiene and left Resident #84's room. No gowns were worn by any of the staff during this care observation. During an observation on 10/23/24 at 1:15 PM, Certified Nurse Aide #5 donned a pair of gloves and emptied 750 milliliters of yellow urine into a graduate (container), then emptied the container into the toilet in Resident #84's bathroom. During an interview on 10/23/24 at 1:19 PM, Certified Nurse Aide #2 stated enhanced barrier precautions included wearing gowns, gloves, and masks when providing direct care for residents with foley catheters and wounds to reduce the risks of infection. We all should have had on gowns, masks, and gloves. During an interview on 10/23/24 at 1:20 PM, Certified Nurse Aide #6 viewed the orange enhanced barrier precaution sign outside Resident #84's room and stated that they should have worn a gown and mask in addition to wearing gloves. During an interview on 10/23/24 at 1:22 PM, Certified Nurse Aide #4 stated they should have had additional personal protective equipment on due to Resident #84's urinary catheter and wound. During an interview on 10/23/24 at 1:33 PM, Certified Nurse Aide #5 enhanced barrier precautions were used during direct care for residents who were at a higher risk of infection such as pressure ulcers and foley catheters. Certified Nurse Aide # 5 stated they should have worn a gown and mask during care for Resident #84 to avoid cross contamination. During an interview on 10/23/24 at 2:30 PM, Licensed Practical Nurse #7 stated the additional protection was a reminder to the staff and protected the residents and others from transmission of germs. I should have enforced them to follow the enhanced barrier precautions. During an interview on 10/28/24 at 8:49 AM, Licensed Practical Nurse #6, Unit Manager stated gowns, gloves, and masks were located outside of resident rooms who required enhanced barrier precautions. Certified Nurse Aides were expected to acknowledge the postings outside the resident's room by wearing the appropriate personal protective equipment. Licensed Practical Nurse #7 should have ensured that Certified Nurse Aide # 2, 4, 5, & 6 had worn a gown, glove, and a mask during the high contact care activity. During an interview on 10/28/24 at 10:41 AM, Director of Nursing #1 stated residents with foley catheters and wounds were susceptible to infection. Certified Nurse Aides #2, 4, 5, & 6 should have worn a gown and masks in addition to gloves for infection control purposes. During an interview on 10/28/24 at 12:05 PM, the Corporate Quality Assurance/Infection Preventionist stated they would expect the staff to wear gloves, gown, and a mask for residents on enhanced barrier precautions. During an interview on 10/28/24 at 1:28 PM, the Interim Administrator stated staff were educated on the policy, signage, expectations and were expected to follow it. NYCRR10 415.19(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review conducted during a Complaint investigation (Complaint #NY00353284, #NY00329150) during the standard survey completed on 10/28/24, the facility did not ensure that there was sufficient nursing staff on a 24-hour basis to provide care for all residents. Specifically, one of one facility reviewed for sufficient staffing the facility did not meet their assessed minimum staffing levels for Certified Nurse Aides on 8/24/2024, 9/8/2024, 9/16/2024, 9/22/24, 10/5/2024, 10/6/2024, and 10/20/2024 to meet the needs of the residents. The finding is: Refer to F 677 Activities of daily living care for dependent residents. The policy and procedure titled Nursing Department Staffing dated 2/17/2021 documented the facility provides adequate staffing to meet needed care and services for our resident population. It documented that Certified Nurse Aides are available on each shift to provide the needed care and services of each resident as outlined in the resident's comprehensive care plan. The policy and procedure titled Resident Rights dated 3/1/2017 documented that residents have the right to have communication with and access to people and services, both inside and outside the facility. The resident council meeting minutes dated 7/31/2024 documented that residents were concerned about low staffing and how it impacted their care and treatments. The resident council meeting minutes dated 9/19/2024 documented that multiple residents stated that nursing staff was shorthanded and affected how residents were treated. The resident council meeting minutes dated 10/17/2024 documented the residents were concerned that being short staffed affected personal hygiene and showers were not a priority. The resident census analysis report for August 2024 documented that on 8/25/2024 there were 169 residents in the facility. The resident census report for September 2024 documented that on 9/8/2024 and 9/16/24 there were 167 residents in the facility; and on 9/22/2024 there were 171 residents in the facility. The resident census analysis report for October 2024 documented that there were 172 residents in the facility on 10/5/2024, 10/6/2024, and 10/20/2024. The facility assessment dated [DATE] documented minimum staffing levels for Certified Nurse Aides were 12 aides on the day shift (7:00 AM to 3:00 PM), 10 aides on the evening shift (3:00 PM to 11:00 PM), and five aides on the night shift (11:00 PM to 7:00 AM) for a facility census of 171 residents. The facility nursing daily staffing sheets documented the following: 8/25/2024 - 10 Certified Nurse Aides on the day shift (down 2). 9/08/2024 - 9 Certified Nurse Aides on the day shift (down 3) and 8 Certified Nurse Aides on the evening shift (down 2). 9/16/2024 - 11 Certified Nurse Aides on the day shift (down 1). 9/22/2024 - 5 Certified Nurse Aides on the day shift (down 7). 10/5/2024 - 10 Certified Nurse Aides on the day shift (down 2). 10/6/2024 - 10 Certified Nurse Aides on the day shift (down 2). 10/20/2024 - 8 Certified Nurse Aides on the day shift (down 4) and 9 Certified Nurse Aides on the evening shift (down 1). During an interview on 10/21/2024 at 10:03 AM, Resident #70 stated that over the weekend there were two Certified Nurse Aides working on the day shift. They stated that they wanted to get out of bed at 10:00 AM but did not get out of bed until 2:30 PM. Resident #70 stated that sometimes they don't get out of bed at all because there was not enough staff During an interview and observation on 10/22/2024 at 10:21 AM, Resident #71 stated that the staff were too busy to clean their fingernails or shave them. They stated they were embarrassed about the chin hairs, their nails were ugly and would like them cleaned. Resident #71 was observed with long, white whiskers on their chin and long nails with brown debris underneath. During an interview on 10/22/2024 at 11:16 AM, the Staffing Coordinator stated they have trouble staffing the facility on the weekends. They stated they try to get staff to come and work shifts but that doesn't always happen. During an interview on 10/24/2024 at 10:57 AM, Certified Nurse Aide #3 stated they cannot get showers or nails done when there were only two aides working on a shift. They stated they try to get showers completed by the next day but that was not always possible. During an interview on 10/25/2024 at 9:31 AM, Licensed Practical Nurse #1 stated they cannot get their charting done on residents when there were not enough Certified Nurse Aides working. They stated they have to help the Certified Nurse Aides transfer patients and other things which take away from their nursing duties. During an interview on 10/25/2024 at 11:03 AM, Registered Nurse Nursing Supervisor #1 stated that it was very difficult for them to be on a medication cart and be a supervisor at the same time. If they have to do an assessment on a resident, they have to leave the floor and the Certified Nurse Aides have to watch the floor until they come back. Then the other floor nurse must cover the floor they were working on as well. During an interview on 10/25/2024 at 11:04 AM, Certified Nurse Aide #4 stated they work double shifts because the facility was short staffed. They stated the weekends were terrible. They stated they can't get people out of bed if they only have two aides working on a unit. During an interview on 10/25/24 at 11:18 AM, Registered Nurse Nursing Supervisor #2 stated they cannot do what they need to do in providing care for the residents. They stated if they were on a medication cart, watching a floor, and being a supervisor at the same time, a 16-hour shift turns into 18 hours just to complete everything they need to complete. During an interview on 10/25/24 at 1:12 PM, the Assistant Director of Activities stated there were times when residents miss activities because there wasn't enough staff to change the resident's brief or to toilet the residents. They stated residents come in late or miss activities a couple of times a week because there wasn't enough staff to take care of them. During an interview on 10/25/2024 at 1:23 PM, the Director of Nursing #1 stated they do not have enough staff to take care of the residents' needs on a daily basis. They stated that they have been trying to get staffing for the facility, but it has been very difficult. During an interview on 10/28/2024 at 9:20 AM, the Interim Administrator stated the issue of not having enough Certified Nurse Aides was that personal hygiene and care was getting missed for the residents. This included showers, nail care, and shaving. They stated they have been working getting more staff. During an interview on 10/28/2024 at 10:48 AM, Licensed Practical Nurse Unit Manager #2 stated they cannot get resident care done with only two Certified Nurse Aides working on a shift. They stated that resident showers may be shortened with no nail care or shaving done on the residents. 10NYCRR 415.13(a)(1)(i-iii)

Based on interview and record review conducted during a Standard survey completed on 10/28/24, the facility did not implement an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one of one infection control program reviewed. Specifically, the facility did not provide documentation showing that antibiotics were being monitored and tracked to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. This involved Resident #84. The finding is: The policy and procedure titled Antibiotic Stewardship - Review & Surveillance of Antibiotic Use & Outcomes, dated 8/2018, documented that Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form, and all clinical infections treated with antibiotics will undergo review by the Infection Preventionist. All Antibiotic starts will be reviewed by the Infection Preventionist within 48 hours to determine if continued therapy is justified, justified with needed intervention, or not justified. Resident #84 had diagnoses including chronic pain syndrome, stage 4 pressure ulcer of the sacral region (wound on the lower back, above the buttocks, that includes full thickness skin loss that extends into muscle, bone, or supporting structures), and osteomyelitis (bone infection) of the sacral region. The minimum data set (a resident assessment tool) dated 7/12/24, documented Resident #84 was moderately cognitively impaired, was always understood, always understands, had a wound infection and was on an antibiotic medication. The comprehensive care plan, revised 9/16/24, documented Resident #84 had an infection. Interventions included to observe for side effects from antibiotic therapy and report to the provider. Review of Resident #84's Physician's Order Form dated 10/23/24, revealed they had multiple antibiotics ordered including Cefdinir oral capsule 300 milligrams every 12 hours for pressure ulcer from 6/7/24-9/12/24, and 9/13/24-9/17/24. Bactrim DS oral tablet 800-160 milligrams, 1 tablet by mouth every 12 hours for cellulitis, from 7/23/24-8/3/24. Ertapenem sodium injection 1 gram intravenously daily for urinary tract infection, from 9/17/24-9/17/24. Review of the Antibiotic Stewardship binder contained no documentation that the facility had an effective antibiotic stewardship program. There was no tracking of antibiotics used in the facility for the months of July 2024 - October 2024. During an interview on 10/28/24 at 8:49 AM, Licensed Practical Nurse #6, stated they used to keep track of the antibiotics on their unit, but since recently returning from a leave, they did not know if there was a process in place. They used to track them on a list and give it to the Director of Nursing at the beginning of each month, but no one had been tracking them recently. During an interview on 10/28/24 at 9:30 AM, the Corporate Infection Preventionist stated they oversaw the Antibiotic Stewardship program in the facility. The Director of Nursing, that recently left, used to be responsible for it. They were in the process of training the new Director of Nursing and Assistant Director of Nursing to take over the responsibility. They stated they used the McGeer criteria (a standardized set of guidelines for identifying infections in long term care facilities) as their guide for antibiotic stewardship. They stated that recently they had been running a report from their electronic medical record to track antibiotic use. They were unable to provide the monthly documentation to support their process. They stated the previous Director of Nursing left in early September; however, they were unable to locate the tracking documentation from July 2024 - current. The Corporate Infection Preventionist also stated the unit managers should have lists of residents on antibiotics for their units, however they were unable to provide that documentation. During an interview on 10/28/24 at 10:13 AM, the Director of Nursing #1 stated they were not yet involved in the antibiotic stewardship program, but they started the infection preventionist training to take it over. They stated it was important to track and monitor antibiotic use, so residents didn't develop a resistant infection and to monitor for side effects, lab values, or cultures, and make sure they were on the correct antibiotic. During an interview on 10/28/24 at 12:24 PM, the Pharmacy Consultant stated their role in antibiotic monitoring was to check if the order had an accurate duration and diagnosis for the treatment. They were not directly involved in the antibiotic stewardship process. During an interview on 10/28/24 at 12:47 PM, the Interim Administrator stated that having an effective antibiotic stewardship was very important. The purpose of the Antibiotic Stewardship program was to make sure they didn't overuse antibiotics and to make sure the residents were on the appropriate antibiotic. They should track whether it's been effective, and if the resident has responded appropriately. They can also use the information to track trends like which units are having more infections and then can use that to educate staff or monitor more closely. The Acting Administrator stated that the system they currently had was not an effective process and they needed to be more consistent. During an interview on 10/28/24 at 1:11 PM, The [NAME] President of Clinical Services stated they were unable to locate the antibiotic tracking sheets from the last few months. 10 NYCRR 415.19(a)(1,3)

Based on interview and record review conducted during an Abbreviated survey (Compliant #NY00289521) completed on 1/24/24, it was determined that the facility did not ensure that that residents receive treatment and care in accordance with professional standards of practice. Specifically, one of three residents (Resident #1) reviewed for delay of treatment had complained of left hip pain on 1/9/22 and was not sent to the hospital for a confirmation of a broken hip until 1/12/22. The finding is: The policy and procedure titled Laboratory and Diagnostic Test Results - Clinical Protocol dated 2/1/2017 documented that all laboratory and diagnostic tests will be scheduled, collected, and tracked timely to ensure the physician receives timely reports to ensure there is no delay when notifying the physician whenever abnormal findings are identified. Resident #1 was admitted to the facility with diagnoses of stroke and dementia. The Minimum Data Set (a resident assessment tool) dated 1/22/22 documented Resident #1 was severely cognitively impaired, was understood and usually understands. Resident #1 required a wheelchair for mobility and extensive assist of one person for bed mobility. Review of progress notes dated 1/9/22 to 1/12/22 revealed the following: -1/9/22 1:30 PM Registered Nurse Nursing Supervisor #1 documented Resident #1 complained of left hip pain, yelling out in pain when range of motion was performed. Registered Nurse #1 notified the provider and received a new order for a stat (immediate) x-ray and the orders were faxed to a mobile diagnostic company. -1/9/22 7:21 PM Licensed Practical Nurse #2 documented they had called the mobile diagnostic company and asked when they would perform the x-ray. The mobile diagnostic company stated that they do not come out after 5:00 PM. The mobile diagnostic company stated to fax the order in the morning. Resident #1 had denied pain at that time. -1/9/22 10:58 PM Licensed Practical Nurse #2 documented Resident #1 complained of pain in their left hip; medication was given with positive effect. -1/10/22 3:09 PM Licensed Practical Nurse #3 documented the x-ray results were pending, and the resident was medicated for pain. -1/10/22 10:22 PM Licensed Practical Nurse #4 documented the resident did not have complaints of pain and the x-ray results were still pending. -1/11/22 2:41 PM Licensed Practical Nurse #3 documented the x-ray results were negative. -1/12/22 4:11 PM Licensed Practical Nurse #5 documented the resident complained of left hip pain; pain medication given with some effect. -1/12/22 6:13 PM the Director of Nursing documented they became aware of the x-ray report which stated that x-ray results reported the resident had a history of an open reduction internal fixation (a repair of severely broken bones using medical hardware to stabilize the bones); an acute subcapital fracture (a fracture that occurs on the hip joint) irregularity is seen; a CT scan (a imaging tool that takes multiple x-rays) of the region is suggested; the family was contacted and the resident was sent to the hospital. Review of the radiology report dated 1/10/22 documented that an x-ray was performed on the resident at the facility on 1/10/22. Further review of the radiology report documented that the x-ray was reviewed by the radiologist on 1/10/22 at 11:57 AM and the report documented status post ORIF (open reduction internal fixation for broken bones) with suspected acute fractures suggest a CT scan. Review of the facility's investigation dated 1/12/22 documented that Resident #1 suffered a broken hip and was hospitalized until 1/24/22. The investigation further documented that Licensed Practical Nurse #2 stated that the mobile x-ray company could not come to the facility for a stat x-ray on 1/9/22. Additional review of the investigation Licensed Practical Nurse #3 stated that they do not recall anything remarkable happening to the resident on 1/9/22. During a telephone interview on 1/23/24 at 9:13 AM, Licensed Practical Nurse #2 stated they do not recall calling about a stat x-ray or the resident breaking their hip. A telephone message was left with Licensed Practical Nurse #3 on 1/23/24 but it was not returned. During a telephone interview on 1/23/24 at 1:00 PM, Registered Nurse Nursing Supervisor #1, stated the expectation was for Licensed Practical Nurses to contact a supervisor if they were not able to obtain a STAT or an immediate x-ray. They stated that this was so the provider could be contacted, and the provider could make the decision to send the resident to the emergency room. They stated that if they could not get a hold of the provider, then the resident should be sent out for an x-ray. During a telephone interview on 1/23/24 at 2:50 PM, the resident's current Physician #1, they stated that they were not the Physician at the time of the incident, however, they were familiar with this incident. They stated that they expected the nurses to notify the provider right away if they cannot get a STAT (immediately) x-ray for a resident. They stated that if they couldn't get a STAT (immediately) x-ray for a resident, then they can decide if the resident should be sent to the emergency room. They stated that since they have become the resident's provider, they have stopped the nurses from taking verbal reports from radiology departments. Physician #1 stated they now expect nurses to send the x-ray report to themselves, the Nurse Practitioners, or the Physician Assistants so the report can be reviewed. During an interview on 1/23/24 at 3:11 PM, the current Director of Nursing stated they expected the nurses to contact the provider if they could not get a STAT (immediately) x-ray, and it was up to the provider to determine if the resident should be sent to the emergency room to obtain an x-ray. The Director of Nursing stated they expected staff to send the reports to the physician right away for the report to be reviewed. During an interview on 1/23/24 at 3:29 PM, with the Regional Director of Nursing and the Administrator, they both stated they expected the nurses to contact the physician if they could not obtain an x-ray immediately. They stated that the licensed practical nurses should contact the Nursing Supervisors, the Nursing Supervisors should contact the physician, and then follow the directions of the physician. During a telephone interview on 1/24/24 at 1:52 PM, the Operations Manager at the mobile x-ray company stated they remember this incident concerning Resident #1. They stated that they told the person they spoke with that they do not come out to facilities after 5:00 PM on weekends. They stated they remembered that they went to the facility to obtain the x-rays on 1/10/22 at approximately 11:00 AM. The x-rays were digitally sent to the radiologist for the radiologist to read after the x-rays were completed. They stated that the report was sent to the facility after the radiologist read it at approximately 12:00 PM. They stated that they do not, as a policy, give verbal report to facilities. They stated that the facility had the capability to review the x-ray report through a customer portal but did not know if nurses were able to use the portal at that time. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 3/17/23, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for two (Residents #153 and #155) of 8 residents reviewed. Specifically, Residents #153 and #155 had unkempt (long/jagged/dirty) fingernails. Additionally, Resident #155 was unkempt had oily disheveled hair and the presence of unwanted facial hair. The findings are: The policy and procedure (P&P) titled Activities of Daily Living (ADLs) Maintain Abilities dated 2/13/2018 documented the facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. The facility will provide care and services for the following ADLs: Hygiene - bathing, dressing, grooming and oral care. A resident who is unable to carry out ADLS will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The P&P titled Care of Fingernails dated 6/26/18 documented the purposes of this procedure are to clean the nail bed, to keep nails trimmed and prevent infections. Nail care incudes daily cleaning and regular trimming on resident assigned bath/shower day. Unless otherwise permitted, do not rim the nails of diabetic residents or residents with circulatory impairments. Only Licensed Nurses will cut diabetic nails and document weekly on MAR (Medication Administration Record). If a resident does not receive a bath or shower (per resident's choice) and did not bath/shower or refuse on the scheduled bath / shower day, nail care is still to be provided on scheduled bath day. The P&P titled Shaving the Resident dated 3/1/2017 documented the purpose of this procedure is to promote cleanliness and to promote dignity and respect. The policy documented to shave residents daily when providing AM/PM care or non-bath/shower days and during the scheduled shower/bath days. 1. Resident #153 had diagnoses that included Diabetes Mellitus (DM) Type 2, cerebral infarction (stroke) affecting the right dominant side, and hypertension (high blood pressure. The Minimum Data Set (MDS-a resident assessment tool) dated 2/28/23 documented Resident #153 had moderate cognitive impairment and did not exhibit rejection of care. Resident #153 required extensive assistance of one person for personal hygiene. During intermittent observations on 3/13/23 at 9:52 AM, 3/14/23 at 1:13 PM, 3/15/23 at 9:07 AM and 12:32 PM, 3/16/23 at 7:40 AM and 9:53 AM, revealed Resident #153's fingernails on both hands were long (over the tips of the fingers) with dark brown debris, and jagged edges noted on the 3rd and 5th fingers on their right hand. Review of Resident #153's Bath & Shower Sheet dated 3/11/23 and 3/15/23 revealed there was no documented evidence the resident's nails were trimmed and cleaned. Resident #153's undated Care Profile (a guide for staff to provide care) (identified as current by the Director of Nursing (DON)) documented the resident required 1 assist for personal hygiene/grooming. Resident #153's undated comprehensive care plan (CCP) (identified as current by the DON) documented the resident had a diagnosis of DM. The care plan did not documented the resident's nails were to be trimmed and cleaned by a nurse. Review of Resident #153's progress notes dated 2/16/23 through 3/17/23 revealed there was no documented evidence the resident refused care. Review of Monthly MAR (Medication Administration Record) and TAR (Treatment Administration Record) dated 3/1/23 through 3/17/23 revealed there was no documented evidence the resident's nails were trimmed and cleaned by a nurse. During an interview on 3/15/23 at 9:07 AM, Resident #153 stated they did not like their nails long and dirty (dark brown debris) but they were unable to trim and clean them independently. During an interview on 3/16/23 at 9:55 AM, Certified Nursing Assistant (CNA) #8 stated they provided care to Resident #153 last evening, and it was their scheduled shower day. CNA #8 stated the resident refused their shower and was cooperative with care. CNA #8 stated CNAs were responsible for providing nail care unless the resident has a diagnosis of DM, then the nurse would be responsible for the resident's nail care. CNA #8 stated they did not know if the resident had a diagnosis of DM. During an observation and interview on 3/16/23 at 10:00 AM of Resident #153's fingernails CNA #8 stated the resident's fingernails were long, dirty and the right hand had some jagged fingernails. During an interview on 3/16/23 at 10:03 AM, Unit Manager (UM) Licensed Practical Nurse (LPN) #1 stated Resident #153's fingernails were to be checked on shower days and should be cleaned and trimmed on shower days and as needed. UM LPN #1 stated Resident #153 has a diagnosis of DM and fingernails were to be cleaned and trimmed by a nurse and it is to be documented on the MAR or TAR. UM LPN #1 reviewed Resident # 153's Bath and Shower Sheet and stated the form was incomplete and did not document if nail care was offered. During an observation on 3/16/23 at 10:05 AM UM LPM #1 stated all of Resident #153's fingernails were dirty and long and had a few jagged fingernails on the right hand. During an interview on 3/17/23 at 8:06 AM, the DON stated Bath Shower Sheets should be completed to verify the care provided. The DON reviewed the Bath Shower Sheets dated 3/11/23 and 3/15/23 and stated the forms did not indicate nail care was offered and would have expected the nurses to ensure the forms were completed and nail care offered. The DON stated a resident with a diagnosis of DM the fingernail care should be listed on the TAR. Upon review of the March 2023 MARs and TARs the DON stated nail care was not listed on the MAR or TAR and it should have been. The UM was responsibility to ensure nail care was on the TAR. The DON stated they would have expected the CNAs and nurses to have identified fingernail care was needed during care. 2. Resident #155 had diagnoses that included cerebral infarction, DM Type 2, unspecified visual loss, and major depressive disorder. The MDS dated [DATE] documented Resident #155 was understood and could understand, had moderate cognitive impairment, and did not exhibit rejection of care. In addition, Resident #155 required extensive assistance of one person for personal hygiene. Review of Resident #155's Care Profile created on 2/22/23 documented the resident required 1 assist for personal hygiene/grooming. Review of Resident #155's Bath & Shower Sheet dated 3/3/23, 3/7/23, 3/10/23, and 3/14/23 revealed there was no documented evidence they refused shower, that nails were trimmed/cleaned or the resident was shaved. Review of Resident #155's Progress Notes dated 2/12/23 through 3/14/23 revealed there was no documented evidence resident was offered or refused hands on care, including bathing/showers, nails care, and shaving. During intermittent observations on 3/13/23 at 1:41 PM, 3/14/23 at 12:23 PM, 3:45 PM, 3/15/23 at 8:00 AM and 1:38 PM, and 3/16/23 at 8:22 AM, revealed Resident #155's fingernails on both hands were long (over the tips of the fingers), uneven, dirty (dark brown debris) with chipped red nail polish. The resident's hair was oily and disheveled. Additionally, Resident #155 was noted with thick dark facial hair on both cheeks, chin, and upper lip. During an observation and interview on 3/14/23 at 12:27 PM, Resident #155 was using their left-hand fingers to feed themselves food from their lunch tray. Resident #155 stated they cannot use their right hand to use a fork, so they use their left hand and eat with their fingers. During an interview on 3/15/23 at 8:00 AM, Resident #155 stated it bothered them that they had facial hair and they needed help to shave. Resident #155 stated that their nails were too long and the last time a nurse cut them was a couple of months ago. Resident #155 stated their shower days were scheduled on Tuesdays and Fridays, and nobody offered or gave them their shower yesterday. Resident #155 stated they had not been bathed in 3-4 weeks and I stink right now! During an observation and interview on 3/15/23 at 1:48 PM, CNA #1 stated Resident #155 didn't look groomed, their facial hair was noticeable and the resident's fingernails needed to be clipped and cleaned. CNA #1 stated Resident #155 was not capable of trimming their own nails. During an interview on 3/15/23 at 2:03 PM, LPN #5 stated Resident #155 did not look groomed and they should have noticed the resident's nails needed to be cut because they were long and dirty. During an interview and observation of Resident #155 on 3/15/23 at 2:09 PM, LPN UM #1 stated Resident #155 needed to be shaved and should be shaved on shower days automatically or any day in between if needed. LPN UM #1 did not know off the top of my head when Resident #155 was scheduled for showers. LPN UM #1 stated the nurses were responsible to cut Resident #155s nails and that Resident #155s nails were long with food debris noted under nails. Nail care was important to be maintained for infection purposes. During an interview on 3/15/23 at 4:08 PM, CNA #3, stated they were assigned to Resident #155 on 3/14/23 but did not know it was their scheduled shower dat. CNA #3 stated they observed that Resident #155 had facial hair yesterday, and they should have asked they resident if they wanted to be shaved. If that was me, I would like to be shaved. Additionally, CNA #3 stated they didn't think they were allowed to trim resident fingernails, but it was important for residents to receive showers and be shaved so they feel presentable and clean. During an interview on 03/15/23 at 4:17 PM, CNA #4 stated they worked yesterday on 3/14/23, evening shift and they completed their assignment together with CNA #3. CNA #4 stated they should have offered Resident #155 a shower, technically we should have given it (shower). During an interview on 03/16/23 at 5:33 PM, DON stated their expectation would be for staff to make an effort to get resident showers done as scheduled. DON stated, basic care is essential and required. Additionally, DON stated there they would expect nursing to document refusals of care. 10 NYCRR 415.12 (a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 3/17/23, the facility did not ensure that the residents' environment remains as free from accident hazards as is possible. Specifically, three (First Floor, Second Floor, Third Floor) of three resident use floors in one (South Building) of two buildings had issues with water temperatures exceeding 120 degrees Fahrenheit (°F). This involves Resident #86. The findings are: The facility policy and procedure titled, Water Temperatures, Safety of, issued 11/9/16, documented tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Water heaters that service resident rooms, bathrooms, common areas, and tub/ shower areas shall be set to temperatures of no more than 120 °F. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. During an observation on 3/12/23 at 10:30 AM, the hot water was checked from the sink in Resident room [ROOM NUMBER], and the surveyor could not leave their hand under the running water because it was too hot. Observations on 3/12/23 between 10:30 AM and 12:00 PM, revealed the following hot water temperatures were obtained in the South Building using digital stem-type thermometers: Second Floor Resident room [ROOM NUMBER] - 124.9 °F Resident room [ROOM NUMBER] - 122.9 °F Third Floor Resident room [ROOM NUMBER] - 123.8 °F Resident room [ROOM NUMBER] - 123.2 °F Resident room [ROOM NUMBER] - 121.7 °F Resident room [ROOM NUMBER] - 120.9 °F Resident room [ROOM NUMBER] - 120.5 °F Observation on the First Floor of the South Building on 3/12/23 at 12:12 PM revealed the door to the Beauty Shop was unlocked and the room was unattended. The hot water from one of two sinks in the room was measured at 128.0 °F with the Surveyor's [NAME] 351 thermocouple thermometer. The other sink in the room was not in service. Immediately upon discovery of the hot water temperature, the Administrator was called into the Beauty Shop. During an interview at this time, the Administrator stated the Surveyor's thermometer did show the hot water from the Beauty Shop sink at 128.0 °F. The Administrator stated hot water should be below 120 °F and the door to the Beauty Shop should be locked when unattended. At this time, the Administrator shut off water service to the sink, locked the Beauty Shop door, and informed the Maintenance Director. On 3/12/23 from 12:22 PM until 1:02 PM, hot water temperatures were obtained in the presence of the Maintenance Director, using the Surveyor's [NAME] 351 thermocouple thermometer and the facility's brand-new digital stem-type thermometer. It was observed that the Surveyor's thermometer and the facility thermometer's readings were within one degree Fahrenheit in all locations during this time period. The following values were obtained from the Surveyor's thermometer during this time period: Third Floor Resident room [ROOM NUMBER] - 128.3 °F Resident room [ROOM NUMBER] - 125.4 °F Second Floor Resident room [ROOM NUMBER] - 124.0 °F Resident room [ROOM NUMBER] - 123.8 °F Resident room [ROOM NUMBER] - 122.0 °F Observation in the South Building's Basement on 3/12/23 at 11:42 AM revealed the Boiler Room was equipped with one boiler and one holding tank for domestic hot water. The hot water system was not equipped with a mixing valve. At this time, the thermometer on the boiler indicated it was at 130 °F, and the operator read 110 °F. During the observation, the Maintenance Director stated the operator was the controller that communicated between the hot water boiler and the hot water holding tank. The Maintenance Director stated the system was not equipped with any control or alarm to prevent or alert to high hot water temperatures. At this time, the thermometer on the outgoing hot water line indicated hot water was leaving the holding tank and traveling to the resident units at approximately 120 °F. The Maintenance Director stated hot water will lose temperature as it travels to the resident units, and maintenance staff performed weekly hot water temperature checks the temperatures were usually between 106 and 110 °F. During an interview on 3/12/23 at 12:30 PM, the Maintenance Director stated the sinks in resident rooms were not equipped with individual mixing valves and they could not explain the hot water temperature spikes above 120 °F. The Maintenance Director stated hot water must be below 120 °F at all times. A second observation in the South Building Boiler Room on 3/12/23 at 1:13 PM revealed the operator was at 115 °F and the outgoing hot water temperature was approximately 122 °F according to the thermometer on the outgoing water line. During the observation, the Maintenance Director stated plus or minus a degree or so from 115 °F was possible, but there should not be spikes above 120 °F. Additionally, the Maintenance Director stated there had been no recent changes to the hot water system. During an interview on 3/12/23 at 4:10 PM, the Maintenance Director stated the Beauty Shop should be locked when not in use. The Maintenance Director stated the thermometer used for the weekly temperature checks done by maintenance staff was a different thermometer than the brand new one used to measure water temperatures today. They stated they did not calibrate or check the accuracy of their usual thermometer. On 3/13/23 at 8:30 AM, the Maintenance Director's usual thermometer was compared to the Surveyor's [NAME] 351 thermocouple thermometer, and readings were within 0.3 °F of each other. Review of the maintenance log called Water Temps: Test and Log the Hot Water Temperatures for the last eight months revealed hot water temperatures were taken from two random resident rooms and two bathing rooms almost weekly. The results ranged from 102 °F to 106 °F. During the Resident Council interview on 3/13/23 at 10:38 AM, Resident #86 stated that the hot water was too hot at times, that you have to turn the cold water on, so you do not burn yourself. 10 NYCRR 415.12 (h)(1)

Based on interview and record review conducted during a Standard survey completed on 3/17/23, the facility did not ensure that residents who require dialysis, received services consistent with professional standards of practice for one (Resident #166) of one resident reviewed. Specifically, Resident #166 did not receive ongoing monitoring of vital signs upon return to the facility after dialysis. The finding is: The facility policy and procedure (P&P) titled Care of a Resident with End-Stage Renal Disease revised 9/5/18, documented to monitor for vital signs (VS) especially blood pressure (BP) before and after the dialysis session and as needed. Additionally, the nurse will document pertinent information in the progress notes, 24-hour report and care plan when indicated. The facility P&P titled Dialysis revised 1/19/19, documented post dialysis monitoring: licensed nurse to obtain blood pressure and pulse. 1. Resident #166 was admitted to the facility with diagnoses including end-stage renal disease (ESRD), type 2 diabetes mellitus, and morbid obesity. The Minimum Data Set (MDS- a resident assessment tool) dated 2/4/23 documented Resident #166 was understood, understands and was cognitively intact. The MDS documented the resident received dialysis. The physician orders documented VS one time a week starting 1/23/23. The comprehensive Care Plan (CCP) initiated 11/4/22 documented Resident #166 needed dialysis three times per week related to ESRD. Interventions included to monitor VS as indicated. Progress notes from 2/1/23 through 3/14/23, revealed there was no documented evidence Resident #116 was assessed upon return to the facility to include VS. Further review revealed a progress note dated 3/15/23 that documented the resident had complaints of lightheadedness and headache per dialysis. The Daily Unit Report sheets dated 2/1/23 through 3/15/23 lacked documented evidence Resident #116 was assessed post dialysis to include VS. The untitled vital sign log dated 1/25/23 through 3/8/23 documented VS were obtained on Wednesday mornings, excluding Monday and Friday dialysis days. During an interview on 3/16/23 at 1:56 PM, Licensed Practical Nurse (LPN) #6, stated vital signs including blood pressure should be taken when a resident returns from dialysis and documented in the progress notes. It is standard for nurses to take vital signs when a resident returns from dialysis. During a telephone interview on 3/17/23 at 9:01 AM, the dialysis center Registered Nurse (RN) stated, VS and assessment should be followed up on when residents return to the facility if there is an issue with their dialysis; any issues during dialysis are written on a dialysis communication form that is sent back to the facility with the resident. During an interview on 3/17/23 at 9:32 AM, Director of Nursing (DON) stated the expectation is for the nurse or team leader on the unit to obtain VS when a resident returns from dialysis. The VS should be documented in the progress notes. During an interview on 3/17/23 at 9:39 AM, the Physician stated it was the expectation for nursing staff to check vitals when a resident returns from dialysis and then every eight hours. Additionally, it was expected for nursing staff to document the vital signs in the resident's chart. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Recertification survey and complaint investigation (#NY00306577) completed on 3/17/23, it was determined that the facility did not ensure that housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for five (North Building: Units B, C, and D & South Building 2nd and 3rd Floor) of five resident units and one laundry room in the North building. Specifically, the issues involved soiled floors, walls, furniture, and doors; garbage on the floors; window blinds in disrepair; stained privacy curtains; personal care supplies directly on the floor; dusty vents and heaters; rusty toilet paper holders; stained ceiling tiles and urine odors. Additionally, the laundry room had piles of visibly soiled linens on the floor next to and in front of washing machines; visibly soiled incontinent wipes on the floor in front of dryers; standing water on the floor, and soiled incontinent briefs on the floor between a garbage can and a sink. The findings are: The Policy and Procedure titled (P&P) Laundry/Laundering revised on 10/22/22 documented that dust and debris are to be removed on top of and behind the dryers. The P&P titled Safe/Clean/Comfortable/Homelike Environment revised on 10/22/22 documented that the facility will maintain a housekeeping and maintenance system services necessary to maintain a sanitary, orderly, and comfortable interior; and resident beds and bed linens are clean and good condition. Further review of the policy documented that resident room walls, floors, furnishings, and bathrooms should be spot cleaned, dust mopped, and wet mopped daily. The P&P titled Direct Supply TELS Management revised on 10/22/22 documented that staff are to use the TELS Management to place work orders for facility environmental issues or items that need repair. North Building: Unit C During observations on 3/12/23 at 9:39 AM revealed Resident room [ROOM NUMBER]P (private) the floor was soiled with dried, brown colored footprints that extended from the bathroom door to the front of the resident's dresser. North Building: Unit B Intermittent observations on 3/13/23 between 7:45 AM and 1:28 PM revealed the following: -Resident room [ROOM NUMBER]D (door) there was a build-up of brown grime/debris around entire length of baseboard and in front of doorway. The hallway floor in front of this room had 20 feet of splattered drops of brown dried substance and yellow dried substance that extended to the soiled lined room; and a 48 in diameter area of a dried yellow substance. - Resident room [ROOM NUMBER]P there was a soiled glove on floor; and a dried brown substance 12 by 12 area on floor next to bed; and a dried brown substance scattered on floor throughout the resident's room. - Resident room [ROOM NUMBER]D had a brown substance five inches from the baseboard scattered around the room, splattered brownish/ black substance scattered throughout the floor of room with heavier soiled areas at foot of bed and in middle of the room. - Resident room [ROOM NUMBER]D the was floor dirty with food debris underneath the bed and garbage on the floor (jelly packet and clear plastic wrap); bed frame was soiled with a dried substance; and the wall next to the left side of the resident's bed was dirty with a smeared reddish-brown substance. - Resident room [ROOM NUMBER]W (window) there was scattered dry brown substance on the floor throughout the room; a large, soiled area on the floor that measured 24 inches by 6 inches of a dried green substance next to the resident's bed. - Resident room [ROOM NUMBER]D there was five inches of built-up brown debris around entire length of baseboard; the shared bathroom toilet, seat and floor was dirty with a dark brown substance. - Resident room [ROOM NUMBER]D there was a brown smeared substance on the wall next to resident's bed; brown dried debris scattered all over floor; dried pink debris on floor in an area 48 to 12 located near the foot of the bed. North Building: Unit C - Resident room [ROOM NUMBER]D there was a bedpan and a basin in a shared bathroom on the floor with no barrier. - Resident room [ROOM NUMBER]P the floor remained in the same condition as described in the previous observation. - C Wing Bathing Room - shower curtain that separated the tub area from the remainder of the room was stained with gray marks, several orange splatters, and brownish/grayish streaks throughout; the four floor tiles were stained with an orange-colored substance that did not lift off when the Maintenance Director attempted to wipe it, and a large splatter on the wall to the left of the sink that appeared to be food debris stuck to the wall. During an interview at the tie of the observation the Maintenance Director stated the curtain needed to be washed and the wall needed to be cleaned. North Building: Unit D - Resident room [ROOM NUMBER]W the walls were bare, with no personal items noted. There was a dried cream-colored substance splashed on dresser and the floor was soiled with food debris. - Resident room [ROOM NUMBER]P the bed and room had a had a strong odor of urine; the floor was sticky and there was garbage underneath the bed that included empty milk cartons, used straws, an emptied disinfectant wipes container, wet brown paper towels, and used napkins. Intermittent observations on 3/14/23 between 12:23 PM and 4:00 PM revealed the following: North Building: Unit B - Resident Rooms #128D, 138P, 140D, 142D, 142W, 144D, 146D all remained in the same condition as described in the previous observations. North Building: Unit C - Resident Rooms #204D, #207P remained in the same condition as described in the previous observations. North Building: Unit D - Resident Rooms #242W, #247P remained in the same condition as described in the previous observations. South Building-2nd Floor - Resident room [ROOM NUMBER] (2:25 PM) the privacy curtains had several splatters, about one inch diameter each. This privacy curtain also touched the floor and had light brown discoloration across the bottom, that appeared to be water stains. During an interview at the time of the observation, the Assistant Director of Housekeeping and Laundry stated the curtain was too long for this room and needed to be replaced. - Resident room [ROOM NUMBER] the center of the floor was marbled with a grayish/ tan color. - Resident room [ROOM NUMBER] the floor tiles inside were ripped. The ripped areas where the floor tile was missing ranged from one inch by three inches to six inches by three inches. - Resident Rooms room [ROOM NUMBER] - floor tiles were ripped. The ripped areas where the floor tile was missing ranged from one inch by three inches to six inches by three inches. South Building- 3rd Floor - Resident room [ROOM NUMBER] (3:20 PM) there was missing the decorative chair rail along the length of the wall at the window side bed, for a length of eight feet. The area on the wall had visible, dried, discolored glue. During an interview at the time of the observation, the Maintenance Director stated the remainder of the chair rail needed to be removed and the wall needed to be sanded and painted. - Resident room [ROOM NUMBER] (3:00 PM)- a three-inch diameter hole through the wall behind the bed. - Third Floor Bathing Room (3:15 PM)- a white cloth with brownish gray colored stains covered over the clean linen rack and three of four ceiling vents were coated in a visible layer of dust. During an interview at the time of the observation, the Assistant Director of Housekeeping and Laundry stated the white cloth needed to be washed and the ceiling vents were dirty and needed to be cleaned. During an interview on 3/14/23 at 2:02 PM, the Assistant Director of Housekeeping and Laundry stated the facility currently had an open position for Floor Technician and they were actively recruiting to fill the position. In the absence of a Floor Technician, the Assistant Director of Housekeeping and Laundry stated they personally were performing the floor stripping and waxing tasks. Intermittent observations on 3/15/23 between 8:00 AM and 4:30 PM revealed the following: North Building: Unit B - Resident room [ROOM NUMBER] (12:15 PM)- had brown substance on the edge of the bathroom door that measured two inches long by one-half inch wide. During an interview at the time of the observation, the Assistant Director of Housekeeping and Laundry stated doors and walls were supposed to be cleaned daily, but the facility was currently short four Housekeepers. Additionally, they stated surfaces needed to be wiped down daily with a germicidal product to help prevent COVID-19 and other infections. - Resident room [ROOM NUMBER] (12:20 PM) - the wall behind the resident's bed was dirty with yellow and brown streaks on the wall behind the resident's bed and there was a small area of a brown substance near the bathroom door handle. - Resident room [ROOM NUMBER]D -The room and hallway remained in the same conditions as described in the previous observations. - Resident room [ROOM NUMBER]P the cold-water faucet was not working properly as only a trickle of water come out when spigot was turned on. During an interview on 3/15/23 at 8:40 AM with Licensed Practical Nurse (LPN) #1 Unit Manager, they stated they were not aware of the cold water not working and expected their staff to report any issues to them so it could be reported to Maintenance to be fixed via the TELS system. - Resident room [ROOM NUMBER] (12:30 PM) - visible cobwebs on the inside of the window. At the time of the observation, the Assistant Director of Housekeeping and Laundry stated cleaning resident room windows were an everyday task. They also stated the window blinds in this room were not working, which might have prevented the Housekeeper from cleaning behind the blinds. The Assistant Director of Housekeeping and Laundry also stated Housekeepers were to move items on windowsills and clean the area, but it looked like it had been a while since this window area was last cleaned. - Resident room [ROOM NUMBER] (12:35 PM) a bathroom ceiling tile was stained above the toilet and the wall above the garbage can was soiled with yellow streaks. During an interview at the time of the observation, the Assistant Director of Housekeeping and Laundry stated walls should be wiped daily and this area appeared to have accumulation of greater than one day, and the housekeeping department was dealing with staffing challenges. - Resident room [ROOM NUMBER] (12:45 PM) there was grayish marbling on the floor tiles and rust spots on the floor under each bed leg. The Assistant Director of Housekeeping and Laundry stated the floor in this room needed to be stripped and waxed and it was a priority on the list. - Resident room [ROOM NUMBER]P (12:55 PM) the floor continued to have a dried brown substance on the floor next to the bed and scattered on floor throughout resident's room; a dark gray coating around the perimeter of the floor fall mat; and the floor had a grayish/ brown tone around and behind the door. During an interview on 3/15/23 at 12:55 PM, the Assistant Director of Housekeeping and Laundry stated the goal was to strip and wax the floor of each resident room annually. They stated they try to strip and wax the floors of two resident rooms each day, but that was hard to accomplish because they were sidetracked with other duties. The Assistant Director of Housekeeping and Laundry also stated room [ROOM NUMBER] was another high priority room for floor stripping and waxing because it appeared as if it had been more than one year since it was done. - Resident room [ROOM NUMBER]D (1:05 PM) had a brown substance five inches from the baseboard scattered around room, and splattered brownish black debris scattered around floor of room with concentrated areas at foot of bed and middle of room. The Assistant Director of Housekeeping and Laundry stated, during an interview at the time of the observation, the substances could be feces, and needed to be cleaned with a germicidal cleaner. - Resident room [ROOM NUMBER]D remained in the same condition as described in previous observations. During an interview on 3/15/23 at 2:03 PM, LPN #5, stated that they could not guess what was on the wall in room [ROOM NUMBER], but the wall should not be dirty. LPN #5 also stated that housekeeping was responsible for cleaning a resident's room, but everyone can pick up items off the floor. - Resident room [ROOM NUMBER]W - remained in the same condition as described in previous observations. - Resident room [ROOM NUMBER]D - remained in the same condition as described in previous observations. - Resident room [ROOM NUMBER] (1:15 PM) had a brownish/ gray marbling in an area around the bed. At this time, the Assistant Director of Housekeeping and Laundry stated the marbling was wear and tear and the floor needed to be stripped and waxed. - Resident room [ROOM NUMBER]D remained in the same condition as described in previous observations. - Outside Resident room [ROOM NUMBER] (1:20 PM) the electric wall heater had a visible layer of dust in the center of the vent that measured eight inches in diameter. During an interview at the time of the observation, the Assistant Director of Housekeeping and Laundry stated the wall heater should be dusted daily, but it appeared to have been more than one day since it was last dusted, which was possibly due to staffing challenges. - Resident room [ROOM NUMBER] (1:25 PM) had a soiled black layer around the door side of the resident's floor safety mat and the mat was stuck to the floor. At this time, the Assistant Director of Housekeeping and Laundry stated the black layer was the sticky backing of a floor fall mat and the floor needed to be stripped and waxed. North Building: Unit C - Resident room [ROOM NUMBER]D there was a bedpan and a basin in a shared bathroom on the floor with no barrier. During an interview on 3/17/23 at 9:30 AM, LPN #2 stated that wash basins and bedpans should not be on the floor of the bathroom. - Resident room [ROOM NUMBER]P the floor remained in the same condition as described in the previous observations. - Resident room [ROOM NUMBER] (3:40 PM) the privacy curtains were soiled with several brown and red splatters. At the time of the observation, the resident in the room stated the curtains have been like that since they have resided in this room and the curtains could be changed. - Resident room [ROOM NUMBER] (3:50 PM) there was a bright yellow, blue, and red dried substances on the floor around resident's bed. The substance appeared on twelve floor tiles. Additional observation revealed a dark grayish/ black substance under the window side bed. At the time of the observation, the Maintenance Director tried to remove the yellow, blue, and red substances and stated they would not come off and appeared to be latex paint. At this same time, LPN #7 stated the bright colored substances looked like paint. LPN #7 they were not sure if the black layer was dirt or old age of the floor tiles, but the floor looked like it could be cleaned. - Resident room [ROOM NUMBER] (4:15 PM) there were 30 three-quarter of an inch circular purple items were on the floor under both beds. When one of the purple items was removed by the Maintenance Director, it left a pink stain on the floor. Also, under the door side bed were four rust stains under the bed legs. LPN #2 stated the rust-colored stains under the bed were likely caused by the bed scraping the floor, and they communicated often with the Assistant Director of Housekeeping and Laundry to let them know which resident rooms had the highest need for cleaning and this room had a high need for cleaning now. - C Wing Corridor - the electric wall heater in the C Wing corridor had a visible layer of dust and hairs in the center eight inches of the vent. Unit D - Resident room [ROOM NUMBER] (2:35 PM) four slats were missing on window blind. During an interview at the time of the observation, a resident inside room [ROOM NUMBER] stated they would like the blinds fixed. - Resident room [ROOM NUMBER] (2:40 PM) the floor was littered with food wrappers, napkins, plastic utensils, and salt packets. There was also a dried red substance on the side of the bed's fitted sheet in an area that was eight inches long by four inches wide. The perimeter of this room had a [NAME]/ dusty light brown residue and an area of the floor in front of the television had a visible dried substance. At the time of the observation, the resident of room [ROOM NUMBER] stated the floors in the room had not been cleaned in about three months, and nurses took out the garbage. Additionally, the resident stated they had a nose- bleed two days ago and wiped the blood on the side of the fitted sheet and no one changed the sheet. During an interview at the time of the observation, the Maintenance Director stated the floor residue in this room would likely come off with a wet mopping. - Resident room [ROOM NUMBER] (2:55 PM) there were rust spots underneath each leg of the resident's bed. - Resident room [ROOM NUMBER] W (3:05 PM) there were rust spots on the floor that did not coincide with the location where bed legs were positioned. During an interview at the time of the observation, the Maintenance Director stated there was probably a different style metal bed in this room that caused the rust marks. - Resident room [ROOM NUMBER]W remained in the same condition as described in the previous observations. During an interview and observation on 3/16/23 at 9:10 AM, Housekeeper #2 stated that it was housekeeping who was responsible for wiping down the walls and resident furniture. Housekeeper #2 stated that the floors were to be swept and mopped every day. At this time, Housekeeper #2 stated they could not identify the substance and stated that resident rooms should be neat, clean, and sanitized. - Resident room [ROOM NUMBER] (3:15 PM) there were streaks of a brown substance on the bathroom wall and door. - Resident room [ROOM NUMBER]P remained in the same condition as in the previous observations listed. During an interview on 3/16/23 at 11:03 AM, Housekeeper #2 stated they have not cleaned the floor in room [ROOM NUMBER] in over a month and that the Assistant Director of Housekeeping and Laundry was to clean that room. During an interview and observation on 3/16/23 at 11:20 AM, the Assistant Director of Housekeeping and Laundry stated the Housekeepers should be collecting trash, sweeping, mopping the floors, and identifying any foul odors. The Assistant Director of Housekeeping and Laundry stated room [ROOM NUMBER] needed an intense detailed cleaning, smelled like urine, and required immediate attention. - D Wing Bathing Room (3:00 PM) there was a visible layer of dust on three of five ceiling vents. During an interview at the time of the observation, the Maintenance Director stated ceiling vents should be feather dusted by Housekeeping on a regular basis, but in the vents in this room needed to be vacuumed with a shop vac by Maintenance Observation in the North Building on 3/16/23 at 2:10 PM revealed the metal toilet paper holders in the bathrooms inside resident rooms [ROOM NUMBER] were fully coated with a layer of corrosion/ rust. During an interview at the time of the observation, the Maintenance Director stated metal toilet paper holders original to the North Building should be checked to see if they can be cleaned or if they should be replaced. During an interview on 3/15/23 at 11:30 AM, the Assistant Director of Housekeeping and Laundry stated that they were falling behind on the assigned floor stripping and waxing tasks as they were only one person, and they were personally trying to cover all aspects of the job while the director was out. During an interview on 3/15/23 at 2:09 PM, LPN #1 Unit Manager, stated that housekeeping should be cleaning the residents' rooms including walls, sweeping, and mopping the floors. LPN #1 Unit Manager also stated that staff on the unit can pick up items off the floor. During an interview on 3/16/23 at 10:55 AM, Housekeeper #1 stated floors were to be swept and mopped daily in all resident rooms. 2. North Building Laundry Room: Observations on 3/15/23 at 8:50 AM and 12:54 PM revealed there was a pile of visibly soiled linen on the floor in front of a washing machine and linen noted with light red colored and yellow colored stains; one pile of soiled residents' clothes were on the floor next to a 12 by 12 puddle of standing water; one pile of resident lift slings were next to the same washer and puddle of standing water; three incontinent wipes with brown streaks in front of the dryer; one soiled brief between a garbage can and between a sink; and a layer of dust on top of and behind the dryers covering the back of the dryers and dryer connections. A grey bin labeled clean linen was empty behind the washers against the wall. During an interview on 3/15/23 at 9:21 AM, Laundry Aide #1, stated that they were unsure who was responsible for cleaning behind the dryers and hey stated that sometimes they have dirty linen on the floor if they were trying to find something. During an interview on 3/17/23 at 10:51 AM, the Director of Nursing (DON) stated that if there are any environmental issues and it is still not cleaned within 24 hours, they would expect staff to report it to them so it could be taken care of. The DON stated that they should not have dirty linen on the floor of the laundry room. The dirty linen should be in dirty linen bins or carts until they are washed by the laundry staff. The DON stated that staff need to be re-educated that sometimes residents will say inappropriate things to staff but that resident rooms still need to be cleaned daily. During an interview on 3/17/23 at 12:20 PM, the Administrator stated that they expect dirty linens to stay in the dirty linen bins until the dirty linen is put into the washer. They also stated that there is a TELS reporting system where staff can report things that need to be repaired including resident care equipment. They stated if there was an emergency situation with resident rooms or equipment that maintenance should be paged right away. They also stated that expect staff to throw used items like gloves or briefs to be thrown away immediately and not in the laundry. Interviews with Residents: - 3/13/23 at 8:51 AM, Resident A stated the floor was always dirty and the housekeeping staff mop the floor with dirty water. - 3/13/23 at 7:45 AM, Resident B stated the floors in the hallway and in their room were not always clean. - 3/13/23 at 1:28 PM, Resident C stated that there was feces on the wall and the walls were filthy. - 3/15/23 at 3:40 PM, Resident F stated the curtains have been soiled since they have resided in this room and the curtains could be changed. 10 NYCRR 415.5(h)(2)

Based on observation, interview, and record review conducted during a Standard survey completed 3/17/23, the facility did not provide food and drink that was palatable, and at a safe and appetizing temperature for five (South building: 2nd floor, 3rd floor and North building: B Unit, C Unit and D unit) of five test trays. Specifically, food and beverages during meals were served at suboptimal temperatures and were not palatable. Residents' #62, #77, #89, #128, #155 and #166 were involved. The findings are: The policy and procedure titled Food Preparation and Service dated 6/26/18 documented the food service employees shall prepare and serve food in a manner that complies with safe food handling practices. The danger zone for food temperatures is between 41 degrees (°) and 135° Fahrenheit (F). This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, potentially hazardous foods must be maintained at 40°F or below or at 136°F or above. During an interview on 3/12/23 at 12:14 PM, Resident #77 stated the food here sucks and the food was cold at all meals. Additionally, Resident #77 stated oatmeal and potatoes were served cold. During an interview on 3/13/23 at 9:46 AM, Resident #89 stated I hate the food here! The food has no flavor and was served lukewarm. Additionally, Resident #89 stated the macaroni and cheese was always cold. During an interview on 3/13/23 at 10:46 AM, Resident #62 stated every day the food was cold. It's never warm and most of it does not taste good. During an interview on 3/13/23 at 1:27 PM, Resident #155 stated the food was horrible. It's never on time, has no flavor, and not always warm. During a resident council interview on 3/13/23 at 10:38 AM, Resident #128 stated the hot food were served cold, and the food does not taste good. During tray line observation in the South building on 3/16/23 from 11:47 AM to 12:43 PM, the dietary carts were completed and sent to the floors at the following times: Third Floor/1st Cart- 12:04 PM Third Floor/2nd Cart- 12:19 PM Second Floor/1st Cart- 12:32 PM Second Floor/2nd Cart- 12:43 PM During a lunch meal observation on 3/16/23 the dietary cart arrived on third floor of the South Building at 12:21 PM. All the meal trays from the dietary carts were passed to the residents by 12:33 PM. The test tray temperatures were then taken by the surveyor and the Food Service Director (FSD #1), using the Food Service Director's dial thermometer at 12:34 PM. The results were as follows: -Roasted Turkey with gravy- measured 103 °F, tasted lukewarm, appeared unappetizing, and tasted salty. -Mashed potatoes- measured 120 °F and tasted lukewarm. -Milk- measured 50 °F and tasted lukewarm. During a lunch meal observation on 3/16/23 on the second floor of South building from 12:31 PM-12:43 PM. During an interview on 3/16/23 at 12:41 PM, the Food Service Director (FSD) #2 stated hot foods should arrive to the unit with temperatures ranging from 120 °F to 125 °F. FSD #2 stated there has been a problem keeping beverages cold because the ice machine was broken. The results were as follows: - Mashed potatoes- measured 132 °F and tasted bland. -Turkey- measured 105 °F and tasted lukewarm - Milk- measured 50 °F - felt cool but not cold - Orange juice- measured 49 °F - tasted cool but not cold. During a lunch meal observation on 3/16/23 the dietary cart arrived at the first floor, North building dining room at 12:25 PM. All of the meal trays were passed to the residents in dining room and B Unit by 12:38 PM. The test tray temperatures were taken by the Assistant Food Service Director #2, using the facility's dial thermometer . During an interview at the time of the observation 3/16/23 the Assistant Food Service Director stated hot food temperatures should be between 140-160 °F, and cold food temperatures should be between 35-40 °F. The results were as follows: - Ground Turkey with gravy-measured 98 °F, tasted lukewarm and the gravy was salty. - Mashed potatoes with gravy- the gravy tasted salty. - Vegetable -Peas- measured 100 °F, tasted lukewarm, undercooked and tough. - Coffee- measured 112 °F and tasted lukewarm. During a lunch meal observation on 3/16/23 the dietary cart arrived on D Unit, North building, at 1:05 PM. All the meal trays for D Unit were passed to the residents by 1:19 PM. The test tray temperatures were then taken by the Assistant Food Service Director #2 using the facility's dial thermometer at 1:20 PM. The results were as follows: - Ground turkey with gravy - measured 100 °F and tasted lukewarm and very salty. - Mashed potatoes - measured 102 °F and tasted cold and bland. - Vegetable -Pees- measured 99 °F and tasted cold and bland. - Peaches and cream desert (chilled desert)- measured 48 °F, and tasted warm During a lunch meal observation on 3/16/23 the dietary cart arrived on C Unit, North building, at 1:09 PM. All the resident meal trays for C Unit were passed. The test tray temperatures were started at 1:16 PM and taken by the Assistant Food Service Director #2 using the facility's thermometer. The results were as follows: - Ground turkey with brown gravy- measure 90 °F, tasted lukewarm and the gravy was salty. - Mashed potatoes with brown gravy- measure 100 °F, tasted cold, the potatoes were gritty, and the gravy was salty. - Milk 2% carton- 44 °F and tasted cool but not cold. During an interview on 3/16/23 12:40 PM, the Assistant Food Service Director #2 stated the turkey, gravy and peas should have been hotter. During a follow up interview at 1:25 PM, the Assistant Food Service Director #2 stated typically cold foods were served between 35 °F and 40 °F degrees. Warm foods should be served between 140 °F and 160 °F. The test tray temperatures were too cold and should have been much higher. Additional interviews: During an interview on 3/16/23 at 12:47 PM, Resident #166 stated their meal was served cold and the appearance, taste and texture of the turkey was unappetizing. Additionally, when butter was added to the corn, the corn was not warm enough to melt the butter. During an interview on 3/16/23 at 1:32 PM, Resident #89 stated the turkey with mashed potatoes were cold and did not taste good. 10 NYCRR 415.14(d)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey started 3/12/23 and completed 3/17/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one (South) of two kitchens. Specifically, the South kitchen had issues with soiled floors, walls, and storage shelves. The dish-room walls and ceiling were soiled with dried food debris, and thick dust hanging from the light fixture. The kitchen commercial hood and mobile heated dish dispenser had a build-up of grease and dust. The walk-in freezer's floor was soiled with spilled frozen food products, there was no thermometer, and had undated/outdated/unlabeled food. The stand-up and walk in cooler had undated/outdate/unlabeled food items. Dietary staff were not wearing face masks positioned appropriately and dietary staff with facial hair were not wearing beard nets. Two (Second Floor, Third Floor) of two nourishment room refrigerators in the South building had issues with undated/outdated and unlabeled food and liquids. In addition, the North building Second Floor Dining Room had a refrigerator with no thermometer and a gasket in disrepair. The findings are: The policy and procedure (P&P) titled Food Receiving and Storage dated 2/17/2017 documented food services, or other designated staff, will maintain food storage areas at all times; all food stored in the refrigerator or freezer will be covered, labeled, and dated (use by date), The P&P titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices dated 2/17/2017 documented hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens. The P&P titled Food Preparation and Service dated 6/26/18 documented food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Thermometers will be placed in hot and cold storage areas and checked for accuracy in accordance with accepted public health standards. Dietary staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food. The P&P titled Cleaning Instructions dated 2/17/2018 documented kitchen and dining room floors will be cleaned and sanitized regularly. Sweep and clean kitchen floors after each meal. Move major appliances at least once a month in order to facilitate cleaning behind and underneath them. Small appliances will be cleaned and sanitized after and prior to each use. Stove hoods and filters will be cleaned according to a cleaning schedule, or at least monthly. Hoods and filters should be cleaned professionally at least semi-annually. The cook/chef on each shift is responsible for keeping the range and/or griddle as clean as possible during the preparation of the meal. The range/griddle will be cleaned after each use. Spills and food particles will be wiped up as they occur. The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. A cleaning schedule will be posted for all cleaning tasks and staff will initial the tasks as completed. A. Observation of the kitchen on 3/12/23 from 9:18 AM-10:00 AM revealed the following: -Dietary staff member with full beard was observed without a face mask and beard restraint. -Main kitchen and dish room floors were soiled and had dark brown/black foot traffic marks and debris throughout, was un-swept and there were scattered gloves and tissues on the floor. -A clear plastic container was under the dish room sink pipe and contained a dark brown colored liquid. -The tiled walls had multiple dried splatters of food debris throughout the kitchen at the workstations. -A stand up refrigerator had an undated plated green salad, 3 undated cottage cheese & fruit plates; a stainless-steel pan labeled macaroni and cheese dated 3/8/23; a stainless steel pan of chicken salad (identified by [NAME] #1) that was undated and unlabeled; a stainless-steel pan (identified as leftover goulash by [NAME] #1) that was undated and unlabeled; 6 prepared sandwiches wrapped in clear plastic wrap that were unlabeled and undated; and a plastic bag (identified by [NAME] #1 as smiley face French fries) that were undated and unlabeled. -The walk-in cooler had container of applesauce covered with clear plastic wrap dated 3/8/23 and prepared tuna (with a white colored liquid on top) dated 3/8/23, a container labeled cheese dated 3/8/23 and sliced pears in cups on a tray that were uncovered. -Storage shelves under stainless-steel counters were soiled with food crumbs. -Walk-in freezer in basement had no thermometer and had spilled frozen food (vegetables and pasta) on floor. Food Service Director (FSD) #1 identified on a shelf two blue plastic bags of frozen food that was undated and unlabeled as diced chicken and frozen breaded chicken that was unsealed/ unlabeled and undated. There was also an empty 4-ounce container of orange juice on shelf. -Walk-in cooler/freezer temperatures were last recorded on 2/14/23 per the document hanging in clear sleeve outside freezer door. During an interview on 3/12/23 at 9:27 AM, [NAME] #1 stated it is important for everything to be labeled and dated so they know how long it had been in the refrigerator. [NAME] #1 stated all the cooks were responsible for checking the refrigerators every day. [NAME] #1 stated unlabeled, undated food should not be used and thrown away. Additionally, [NAME] #1 stated labeled, prepared, leftover food should only be in the refrigerator for 3 days then thrown away. During an interview on 3/12/23 at 9:45 AM, Food Service Director (FSD) #1 stated dietary staff must make sure all food and beverages are labeled and dated. FSD #1 stated the walk-in freezer needed a good sweep and clean. FSD #1 stated extra opened frozen food should be labeled, dated with last day used. FSD #1 was unaware that freezer didn't have a thermometer and was unable to say how long freezer had been without one. FSD #1 stated last recorded temperature of freezer was on 2/14/23. Additionally, FSD #1 stated staff should not be drinking beverages in freezer. b. Observation in the South Building Third Floor nourishment refrigerator on 3/12/23 at 9:50 AM revealed a 64-ounce container of cranberry juice was about one-third full and was not labeled with the date opened. c. Observation in the South Building Second Floor nourishment refrigerator on 3/12/23 at 10:15 AM revealed the following items: -one quart of Chinese restaurant food in a cardboard takeout container labeled with a resident name and room number, but no date -three small facility-made lettuce salads with no name or date -one store-made lettuce salad with no name, and the store label stated sell by 3/7 -one plastic leftover container of approximately three ounces of rice labeled with a room number and the date 2/23/23 -one unopened half-pint of chocolate milk stamped by the manufacturer as sell by [DATE] -three sandwiches in plastic wrap with no names or dates, one of these sandwiches was on a tray, but the tray had no visible date label, and the other two sandwiches were not located on a tray d. Observation in the South Building Kitchen on 3/12/23 at 3:35 PM revealed six of six filters in the extinguishment hood had a visible layer of dust. The sticker on the side of the extinguishment hood indicated hood cleaning had last occurred in September 2022 and was due March 2023. During an interview at the time of the observation, the Maintenance Director stated the hood filters needed to be cleaned. e. Observation on 3/12/23 at 3:35 PM revealed the South Building Kitchen, near the automatic dishwasher and the entrance to the rear corridor, had visible dust on the ceiling tiles and the upper one-quarter of the walls, and dust was hanging from light fixtures. f. Observation in the North Building Second Floor Dining Room on 3/13/23 at 9:35 AM revealed the Dining Room refrigerator had no thermometer and the refrigerator door's rubber gasket was ripped and detached at the bottom. During an interview at the time of the observation, the Maintenance Director stated the gasket was ripped beyond repair and needed to be replaced. During an interview on 3/15/23 at 11:50 AM, the Assistant Food Service Director stated it was everyone's job to check for outdated food, plus the Food Service Director, the Assistant Food Service Director, and the Food Service Supervisor were all responsible for checking refrigerators and freezers daily. They also stated dietary staff maintained the Dining Room and nourishment refrigerators located on resident units. g. During observation of the kitchen on 3/16/23 between 9:44 AM to 10:26 AM the following was observed: - A clear plastic container containing a dark brown liquid was under the dish room sink and was catching liquid from a leaking pipe. -The Stand- up cooler had a stainless-steel pan with 3 prepared sandwiches individually wrapped in clear plastic wrap unlabeled and undated. -The Mobile heated plate dispenser in the dish room was soiled with splattered food and had a built up of grime on the base and plate enclosure. -The three- basin sink had a metal pot located under water compartment of the sink containing cloudy, dirty water. -Dietary staff's face mask was below their nose and mouth in kitchen; and the dietary aide had exposed beard and was working in the in the walk-in cooler unloading boxes of food and did not have a beard net in place. -Walk-in cooler had a tray of uncovered cups of cottage cheese, pudding, and canned fruit, with paper on tray dated 3/16/23. -Crate of 25 half pint cartons of Vitamin D milk with sell by date of March 13, 2023, was in the walk- in cooler. -Personnel lunch tote was on the top shelf in walk in cooler. -Stainless steel back splash to stove soiled had black thick dry food splatters, and the side of stand-up oven next to stove also had dried food splatters. -Floor under stove was black in color with plastic lids/covers, napkins, box of gloves, hair net. Additionally, behind stove on floor was a stainless-steel whisk, oven mitt and food debris. During an interview on 3/16/23 at 10:01 AM, FSD #1 stated the sandwiches in stand-up cooler were being thrown away because they were not labeled and dated. FSD #1 stated they knew they weren't from today because they never do sandwiches for breakfast, and make all fresh sandwiches that day. During an interview on 3/16/23 at 10:26 AM, FSD #1 stated they check the dates on milk before meals, dietary uses the sell by date as the expiration date and was supposed to be thrown out on this date. FSR #1 stated the food stored in dishes on trays in walk-in cooler should always be covered to be kept fresh, clean and prevent cross contamination. FSD #1 stated staff lunch totes were not allowed to be stored in kitchen coolers. Additionally, FSD #1 stated the hood had grease and steam build up and should be taken down and cleaned. h. During an observation in kitchen during lunch tray line on 3/16/23 at 11:47 AM to 12:55 PM revealed the following: -DA #1 observed in kitchen with their beard exposed around the face mask. -Dietary supervisor observed on tray line covering plates and loading trays into dietary cart with their face mask below their nose and mouth was exposed while talking. - Mobile heated plate dispenser next to steam table for tray line with splattered, built on debris on base and plate enclosure. -Dietary [NAME] #2 observed mixing canned tuna with mayonnaise in large mixing bowl wearing a KN-95 mask with facial hair exposed on both cheeks. During an interview on 3/16/23 at 12:08 PM, Dietary Aide (DA) #1 stated everyone was responsible for cleaning their own workstations after meal prep. The cooks were responsible for cleaning there half, while a DA will sweep and mop floors, as a second DA will clean all the dietary carts after every tray line. DA #1 stated they have not used a beard net because the face mask almost takes care of it and the face mask was worn to stop the spread of germs. During an interview on 3/16/23 at 12:44 PM, the Dietary Supervisor stated they pull their face mask down so that people can hear them, and they should not be. The Dietary Supervisor stated beard nets were available and staff with beards should have a beard net on when they step into the kitchen. During an interview on 3/16/23 at 12:55 PM, [NAME] #1 stated the kitchen should be cleaner because they were working with food, things can become contaminated and cause illness. During an interview on 3/16/23 at 1:02 PM, [NAME] #2 stated they had never been instructed that they needed to wear a beard net and were not aware they needed to wear a beard net. i. Observation in the South Building Second Floor on 3/16/23 at 12:00 PM revealed the nourishment refrigerator contained one plastic container of lettuce salad labeled with a resident name and 3/12/23 and another plastic container of lettuce salad and shrimp labeled with the same resident name and 3/11/23. During an interview at the time of the observation, Licensed Practical Nurse (LPN) Unit Manager #3 stated, After three days, resident food from this refrigerator goes into the garbage. LPN Unit Manager #3 stated they were not sure if the date written on the item counted as day one or day zero when calculating the three days, but the residents were educated about the three-day rule. j. Observation in the South Building Third Floor on 3/16/23 at 12:20 PM revealed the nourishment refrigerator contained a reddish/orange drink in an unlabeled 18-ounce personal water bottle. This refrigerator also contained an unopened half-pint of whole milk that was stamped by the manufacturer as sell by [DATE] and a bag of Chinese food from a restaurant and an egg roll labeled with a resident's name and 3/12. During an interview on 3/16/23 at 1:10 PM, FSD #1 stated it was everyone's responsibility to check dates on food in nourishment refrigerators. After three days, the resident food in these refrigerators must be discarded. Families were reminded about the three-day rule, but it was tough to keep up with families of sub-acute residents, who tended to bring in food frequently. The Food Service Director stated they personally checked the South Building Third Floor nourishment refrigerator at 5:00 AM this morning for temperatures and labels on food items to indicate date and resident name, and they or a Dietary Supervisor checked refrigerators every day. The Food Service Director stated the lettuce salads dated 3/11/23 and 3/12/23 should be thrown out because they were past three days. Additionally, they stated food and drink that had a manufacturer's sell by stamp was to be discarded on the sell by date. During an interview on 3/17/23 at 10:06 AM, FSD #1 stated each dietary aide was responsible to clean their own area, each shift, clean, sanitize and go. FSD #1 stated there was a grid dietary staff can go through for cleaning. FSD #1 stated there was no tracking method at this time, staff were not required to sign off tasks completed and would have no way to verify if something was missed. FSD #1 stated their expectation was that the DAs cover and date all food items stored in coolers. FSD #1 stated all dietary staff were to wear their face masks over their noses, under their chins and staff with beards were expected to wear a beard net while in kitchen for infection control purposes. Additionally, FSD #1 stated debris behind stove needed to be cleaned because it could be a fire risk. During an interview on 3/17/23 a 10:35 AM, the Maintenance Director stated they were aware of the frequent leaks in the South Building Kitchen sinks and re- glue the joint as necessary. The sinks have plastic PVC pipe and the hot water running through them weakens the glued joints. Review of a work order dated 2/7/23 from the facility's automated maintenance department work order system revealed it stated, Drain leaks and water sits in middle of floor in the South Kitchen. The work order stated it was assigned to the Maintenance Supervisor and its status was open. During an interview on 3/17/23 at 10:50 AM, the Maintenance Supervisor stated they checked for new work orders every morning. The Maintenance Supervisor stated they personally checked the South Building Kitchen sinks when they received the work order and found no leaks at that time. The Maintenance Supervisor stated they kept the work order open because they intended to go back to check again later for leaks but has not done another check yet because they got too busy with other projects. During an interview on 3/17/23 at 1:16 PM, Administrator stated their expectation was that the kitchen environment was maintained in a clean and sanitary way. Administrator stated there was a manual with P&P on how to do that and the dietary staff are supposed have a routine in place. Additionally, Administrator stated hoods should be cleaned routinely, annually, and filters should be removed and cleaned monthly by dietary staff. 10 NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure the Binding Arbitration Agreement was explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands; and the resident or his or her representative acknowledges that he or she understands the agreement five (Resident #100, #238, #387, #388 and #389) of five residents reviewed. Specifically, the residents did not understand what an Arbitration Agreement was and did not recall the facility explaining what an Arbitration Agreement was. The findings are: The policy and procedure (P&P) titled Arbitration Agreements with revision date 10/22/22 documented the facility informs residents or their representatives of the nature and implications of any proposed binding arbitration agreement, to inform their decision on whether or not to enter into such agreements. The facility must ensure that the agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands and the resident or his or her representative acknowledges that he or she understands the agreement. The admission Agreement with revision date 8/21/19 documented; The Parties may agree that it is in their mutual interest to provide for a faster, less costly, and more confidential solution to disputes that may arise between them and execute the Binding Arbitration Agreement set forth in the attached Exhibit A. Exhibit A Binding Arbitration Agreement documented: The Parties believe that it is in their mutual interest to provide for a faster, less costly, and more confidential solution to disputes that may arise between them. Accordingly the Parties agree as follows: All disputes and disagreements between the Facility and the Resident and between the Facility and the Responsible Party (as those Parties are indicated below) (or their respective successors, assigns or representatives) arising out of or relating to the admission Agreement or its enforcement or interpretation or to the services provided by Facility to the Resident, including, without limitation, allegations by Resident of neglect, abuse or negligence, or allegations by the Facility for monies owed, shall be submitted to binding arbitration in accordance with the Commercial Arbitration Rules of the American Arbitration Association then in effect. The arbitration shall take place in Vvv County, New York. The arbitrator shall have the authority to issue any appropriate relief, including interlocutory and final injunctive relief. The arbitrator's award shall be binding on the Parties and conclusive and may be entered as a judgment in a court of competent jurisdiction. Each Party shall undertake to keep confidential all awards and orders in the arbitration, as well as all information and materials in the arbitration proceedings not otherwise in the public domain, unless disclosure is required by law or is necessary for the enforcement of a Party's legal rights. While an arbitration proceeding is ongoing, the Facility, Resident and Responsible Party shall continue to perform their respective obligations under the admission Agreement, subject, however, to the right of any Party to terminate the admission Agreement as set forth therein. 1. Resident #238 had diagnoses that included diabetes mellitus (DM) Type 2, hypertension, and gastro-esophageal reflux disease (a chronic disease that occurs when stomach acid or bile flows into the esophagus). The MDS dated [DATE] documented Resident #238 was cognitively intact. Review of the Binding Arbitration Agreement with revision date 8/21/19 revealed Resident #238 had electronically signed the agreement on 3/3/23. During an interview on 3/16/23 at 8:54 AM, Resident #238 stated they don't recall being educated about the Binding Arbitration Agreement, they don't recall signing the Arbitration Agreement and stated they would not have. 2.Resident #387 had diagnoses that included DM Type 2, atherosclerotic heart disease (ASHD - is a thickening and hardening of the walls of the coronary arteries), and chronic pain. The MDS dated [DATE] documented Resident #387 was cognitively intact. Review of the Binding Arbitration Agreement with revision date 8/21/19 revealed Resident #387 had electronically signed the agreement on 2/13/23. During an interview on 3/16/23 at 8:57 AM, Resident #387 stated they don't recall being educated about the Binding Arbitration Agreement, they don't recall signing the Arbitration Agreement and stated they would not have. In addition, Resident #387 stated they believed they signed two forms, one was the admission Agreement and the second was for insurance billing. 3. Resident #388 had diagnoses that included DM Type 2, hypertension, and congestive heart failure. MDS dated [DATE] documented Resident #388 was cognitively intact. Review of the Binding Arbitration Agreement with revision date 8/21/19 revealed Resident #388 had electronically signed the agreement on 2/14/23. During an interview on 3/16/23 at 8:52 AM, Resident #388 stated they don't recall being educated about the Binding Arbitration Agreement, they don't recall signing the Arbitration Agreement and stated they would not have. In addition, Resident #387 stated they believed they signed two forms, one was the admission Agreement and the second was for insurance billing. 4.Resident #389 had diagnoses that included Diabetes Mellitus Type 2, major depressive disorder, and GERD. MDS dated [DATE] documented Resident #389 was cognitively intact. Review of the Binding Arbitration Agreement with revision date 8/21/19 revealed Resident #389 had electronically signed the agreement on 2/24/23. During an interview on 3/16/23 at 8:55 AM, Resident #389 stated they don't recall being educated about the Binding Arbitration Agreement, they don't recall signing the Arbitration Agreement and stated they would not have. In addition, Resident #389 stated they believed they signed two forms, one was the admission Agreement and the second was for insurance billing. 5.Resident #100 had diagnoses that included bipolar disorder, anxiety disorder and malignant neoplasm of the tongue. The Minimum Data Set (MDS-a resident assessment tool) dated 1/27/23 documented Resident #100 had moderate cognitive impairment, understood, and understands. Review of the Binding Arbitration Agreement with revision date 8/21/19 revealed Resident #100 had electronically signed the agreement on 2/13/23. During an interview on 3/16/23 at 8:49 AM, Resident #100 stated they don't recall being educated about the Binding Arbitration Agreement, they don't recall signing the Arbitration Agreement and stated they would not have. During an interview on 3/16/23 at 10:41 AM, the Social Work Department Director stated Residents #100, #238, #387, #388, and #389 were alert and independently make decisions. During an interview on 3/16/23 at 11:22 AM, the Director of Admissions and Marketing stated they reviewed the Binding Arbitration Agreement with each of the residents #100, #238, #387, #388, and #389 and they read the Binding Arbitration Agreement verbatim from the form. The Director stated they did not know what an Arbitration Agreement was and did not know the residents were opting out from using legal representation upon signing the form and would only be allowed to use an Arbitrator. The Director of Admissions stated they did not further explain what the Binding Arbitration Agreement means and did not ensure the residents understood the Binding Arbitration Agreement. The Director of admission stated they believe the Binding Arbitration Agreement should be worded in a manner to easily understand and there was no documented evidence in the Binding Arbitration Agreement the resident was allowed to communicate with federal, state, or local officials such as federal and state surveyors, or federal or state health department employees and representatives of the Office of the State Long Term Care Ombudsman. In addition, the Director of admission stated it was possible the residents may be signing the forms because it's part of the admission process and did not understand what they were signing. During an interview on 3/16/23 at 11:54 AM, the Administrator stated the Binding Arbitration Agreement was either written by an attorney or paralegal. Depending on the resident's education level they may not understand what the Binding Arbitration Agreement is without an explanation. The Administrator stated if the Director of Admissions was reading the Arbitration Agreement as written they would expect the Director of Admissions to ensure the residents understood what they were signing. The Administrator stated it would be more beneficial for the residents and their representatives if the Binding Arbitration Agreement was worded in plain terms, so it was easily understood. In addition, the Administrator stated there was no documented evidence in the Binding Arbitration Agreement that the resident was allowed to communicate with federal, state, or local officials such as federal and state surveyors, or federal or state health department employees and representatives of the Office of the State Long Term Care Ombudsman. 10 NYCRR 415.30

Based on interview and record review the facility did not ensure the Binding Arbitration Agreement provides for the selection of a neutral arbitrator agreed upon by both parties and the agreement provides for the selection of a venue that is convenient to both parties. Specifically, five (Resident #100, #238, #387, #388 and #389) of five resident's Binding Arbitration Agreements were reviewed and there is no documented evidence the agreement addresses the selection of a neutral Arbitrator agreed upon by both parties and the selection of a venue that is convenient to both parties. Refer to F 847 E The finding is: The policy and procedure (P&P) titled Arbitration Agreements with revision date 10/22/22 revealed there was no documented evidence the Binding Arbitration Agreement provides for a selection of a neutral Arbitrator agreed upon by both parties and a venue that was convenient to both parties. The facility's Binding Arbitration Agreement dated 8/21/19 revealed there was no documented evidence the Binding Arbitration Agreement provides for a selection of a neutral Arbitrator agreed upon by both parties and a venue that is convenient to both parties. During an interview on 3/16/23 at 11:22 AM, the Director of Admissions and Marketing stated there was no evidence the facility's Binding Arbitration Agreement that was provided to Residents #100, #238, #387, #388 and #389 provided for the selection of a neutral Arbitrator which was agreed upon by both parties and a selection of a venue that was convenient to both parties. During an interview on 3/16/23 at 11:54 AM, the Administrator stated the facility's Binding Arbitration Agreement did not address a selection of a neutral Arbitration agreed upon by both parties and a selection of a venue that was convenient to both parties and was not aware the information was required to be in the Binding Arbitration Agreement. 10 NYCRR 415.30

Based on interview and record review conducted during the Standard survey completed on 5/6/21, the facility did not ensure that all alleged violations involving abuse are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse, to the Administrator of the facility and to appropriate officials (including the State Survey Agency) for one (Resident #60) of four residents reviewed for alleged abuse. Specifically, an alleged incident of sexual abuse was not reported timely to the New York State Department of Health (NYS DOH) within the two-hour timeframe as required. The finding is: Review of the facility policy and procedure (P&P) titled Abuse Prohibition Program revised 11/20/2017 documented facility it is the responsibility of our employees to promptly report any incident or suspected incident of neglect or resident abuse. All alleged violations and results of all investigations shall be reported immediately to the Administrator of the facility and to other officials in accordance with New York State Department of Health (NYSDOH) and Centers for Medicare & Medicaid Services (CMS) Federal regulations. Immediately- means as soon as possible but not to exceed 2 hours after allegation/incident discovery is made if the event that caused the allegation involved abuse or resulted in serious body injury, to the administrator of the facility and to other officials including State Survey Agency. The Administrator or Director of Nursing (DON) must be immediately notified of suspected abuse or incidents of abuse. If such incidents are discovered after hours, the Administrator and DON must be called at home or must be paged and informed of such incident. The facility shall ensure that alleged violations involving abuse are reported immediately upon discovery to the Administrator of the facility or his/her designee. When required by law or regulation, the facility shall ensure timely notification to the DOH. 1. Resident #60 had diagnoses including sepsis, anxiety, and diabetes. The Minimum Data Set (MDS- a resident assessment tool) dated 4/16/21 documented the resident was understood, was able to understand and had moderate cognitive impairment. Review of the Comprehensive Care Plan (CCP) revised 4/17/21 revealed the resident had accusatory behaviors toward staff/residents. Interventions included 2 caregivers at all times and to contact social worker (SW) when needed. During an interview on 4/29/21 at 1:56 PM, Resident #60 stated they thought they woke up and a male resident was touching them, last week, during the night. The resident stated they reported it to staff and said they wanted the police called. The police never came, so the resident called the police themselves. Review of nursing progress note dated 4/17/21 at 1:05 PM, Registered Nurse (RN) Supervisor #1 documented a late entry for the 11:00 PM to 7:00 AM shift. Resident #60 was hallucinating, Certified Nurse Aide (CNA) reported at 6:00 AM the resident reported to the CNA they were raped by a group of men in the resident's room. Report was given to facility Medical Director who was updated on the resident's status. A nursing progress note dated 4/17/21 at 2:49 PM documented the resident was seeing the objects move and that they were raped by another resident. A progress note dated 4/17/21 at 3:13 PM, the SW #1 documented he received a voicemail message from Resident #60 asking to be seen as soon as possible. Prior to their visit, nursing staff reported that the resident reported seeing people that were not there made claims of being raped. SW #1 documented Resident #60 looked disheveled and stressed. Resident #60 stated a resident came into their room and raped them. SW #1 documented they collaborated with the Nursing Supervisor who reported that the previous Nursing Supervisor called the Medical Director. Review of nursing progress note dated 4/17/21 at 6:40 PM, the RN Supervisor #2 documented Resident #60 called 911 and the police were on the unit. RN #2 and SW spoke with police officer about the resident's mentation and medical history. RN #2 spoke with the Medical Director with all parties present. The Administrator was aware and the on call Nurse Manager was made aware. Review of a progress note dated 4/18/21 at 10:25 AM, SW #1 documented a late entry for an encounter on 4/17/21. SW was made aware Resident #60 called 911 via cellphone. SW #1 spoke with police and informed them the resident's claim of being raped was not true due to the resident's current level of mentation, confusion and psych history. The SW #1 documented the resident's claim of who raped them kept changing from a group of men to one resident and that the facility Administrator was notified. Review of the Investigation Summary Form dated 4/17/21 at 3:00 PM signed by SW #1, documented the night shift Nurse Manager was informed Resident #60 reported a group of men raped them. The resident changed the assailant from a group of men to just one resident that raped them and Resident #60 called the police. Review of the Complaint/Incident Tracking System Report (software that logs and tracks nursing home complaints) from 4/17/21 through 5/6/21 revealed the allegation involving Resident #60 was not reported NYS DOH. Attempts to interview the CNA who worked on the date and shift Resident #60 made the allegation were not successful. During an interview on 5/5/21 at 11:23 AM, Licensed Practical Nurse (LPN) #1 Unit Manager (UM) stated she was aware of the incident, but was not working the day of the Resident #60's allegation. She stated the process for investigation for this type of allegation was to notify the DON and Administrator and take direction from them. LPN UM #1 stated the Administrator or DON would be responsible for reporting to NYSDOH. During an interview on 5/6/21 at 7:55 AM, RN Supervisor #1 stated she had worked the unit on 4/17/21 night shift when Resident #60 made the allegation. She stated the resident reported to the CNA that they were raped by a group of men. The RN Supervisor #1 stated she gave report to RN Supervisor #2 that day but did not call the Administrator or DON to notify them of the resident's allegation. RN Supervisor #1 stated she would have called the police, then informed the DON and Administrator if she thought the resident had really been raped but there were no males working on the unit and no group of men went into the resident's room. RN Supervisor #1 stated they were not responsible to report incidents to NYSDOH, the Administrator or DON would do that. During an interview on 5/6/21 at 1:15 PM, the Medical Director stated she was informed of Resident #60's rape allegation by nursing staff. During a telephone interview on 5/6/21 at 2:00 PM, RN Supervisor #2 stated Resident #60 was having behaviors with altered mentation and called the police in their confusion. RN Supervisor #2 stated if the resident's mentation was not altered she would have called the DON or Administrator to report the allegation. RN Supervisor #2 stated she did not feel the resident's mentation warranted her to report the allegation to the DON or Administrator. The DON or Administrator would be responsible for reporting to the NYSDOH. During an interview on 5/6/21 at 10:36 AM, SW #1 stated Resident #60 left a voicemail that they wanted to be seen as soon as possible and the resident sounded a little panicked. When the SW #1 talked to Resident #60, the resident alleged they were raped. SW #1 stated he immediately reported the allegation to the Administrator and that the Administrator or DON would be responsible for reporting to the NYSDOH. During an interview on 5/6/21 at 11:20 AM, the Administrator stated he was aware of timeframes and reporting requirement regulations. The Administrator stated they were informed of Resident #60's rape allegation by SW #1 but didn't remember what time he was notified. The Administrator stated there had to be reasonable suspicion that abuse or neglect occurred for them to report an incident to the NYSDOH. The Administrator stated there was nothing to warrant a reasonable notification and Resident #60's allegation did not rise to that level because of the resident's cognition. During an interview on 5/6/21 at 1:20 PM, the DON stated the expectation of staff for reporting allegations of abuse is that nursing should report right away, to her or the Administrator. Then the determination is made if it fits the reporting requirements, per the DOH Incident Reporting Manual. This allegation did not meet the reporting requirements because they did not have reasonable cause to believe abuse occurred due to the resident's cognitive deficit, hallucinations, that there were no male staff working and no one entered the resident's room. 415.4 (b)(4)

Based on observation, interview, and record review conducted during the standard survey completed on 5/6/21, the facility did not provide food and drink that was palatable, attractive, and served at a safe and appetizing temperature. One (North Building) of two resident units reviewed for food temperatures during the lunch meal on 5/4/21 had issues involving items that were not palatable and not served at appetizing temperatures. Residents #3, 36, 55, 83, 121, 135 and 143 were involved. Review of an undated facility policy and procedure entitled Meal Distribution Policy revealed food is to be transported to the dining locations in a manner that ensures proper temperature maintenance (through the use of a traveling Cambrio (meal cart), which protects against contamination by being covered prior to being placed in the traveling Cambrio) and are delivered in a timely and accurate manner. All items will be transported promptly for appropriate temperature maintenance from the South Kitchen to the North dining room by way of A Wing entrance. Proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point-of-service dining. Review of a facility policy and procedure dated 2/2018 entitled Food Temperatures revealed the temperatures of all food items will be taken and properly recorded prior to service of each meal. All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit (F). Hot food items may not fall below 135 degrees F after cooking unless it is an item which is to be rapidly cooled to below 41 degrees F and reheated to at least 165 degrees F. All cold foods must be stored and served and served at 41 degrees F or below. During an interview on 4/29/21 at 10:50 AM Resident #55 stated the food sucks. TV dinners would be better. No substitutes are offered, and the food is either salty or bland. Eggs are always cold. During an interview on 4/30/21 at 8:50 AM Resident #83 stated the food is not always hot. During an interview on 4/30/21 at 9:06 AM Resident #135 stated the food either has no taste at all or has a nasty taste. All the food is cold. I have never had such bad food in my life. Everything is cold and it really makes you not want to eat. During an interview on 4/30/21 at 9:13 AM Resident #36 stated some of the food is good and some is bad. Sometimes it is hot and sometimes it is not. The food is not good. Review of the North building Resident Council Meeting Minutes dated March 12, 2021 revealed residents on B Wing had multiple complaints that the food was cold for all meals. During an interview on 5/03/21 at 9:40 AM the Food Service Director (FSD) stated the kitchen in the other building (North) has been defunct since 2019. We have been using the South Building kitchen only. We transport food to the other building(North) using a hot box. In the wintertime maintenance shovels, if not we shovel. I do get more food complaints from the North building. During an observation of the lunch meal tray line in the South Building on 5/4/21 at 10:45 AM food for the North Building was observed being put in the hot box/ meal cart. The hot box/ meal cart was transported at 11:30 AM from the South Building to the North Building. The two buildings are approximately 30 feet apart and the meal cart is taken outdoors from the South Building to the North Building. The hot box/ meal cart arrived at the kitchen in the North Building at 11:35 AM. At 1:02 PM the meal cart left the North kitchen dining room. At 1:19 PM the last tray was passed, and the Food Service Supervisor #2 with a facility thermometer took temperatures of the food. The following temperatures were noted: -Pork tempted at 106 degrees F. The food was cold to taste and tough to chew. -Asparagus tempted at 110 degrees F. The food was lukewarm and not hot enough to be palatable. -Au Gratin Potato tempted at 110 degrees F. The food was lukewarm and not hot enough to be palatable. -Coffee tempted at 122 degrees F and lacked flavor and needed to be warmer. -Applesauce tempted at 55 degrees F and was warm to taste. -Juice tempted at 52 degrees F. When the Food Service Supervisor #2 was asked at this time if these temperatures were acceptable, she stated No. During an interview on 5/4/21 at 1:10 PM Resident #121 stated the pork was tough and not hot enough. The food is never hot. During an interview on 5/4/21 at 1:15 PM Resident #143 stated the pork was tough and would like it to be hotter. During an Interview on 5/4/21 at 1:30 PM Resident #3 stated it was warm enough for a change, but the pork was tough, and the asparagus was too mushy. 415.14(d)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Standard survey completed on 5/6/21, the facility did not maintain all essential mechanical, electrical, and patient care equipment in safe, operating condition. Specifically, the plumbing system on one (North Building A Wing) of six resident units had open and unsealed toilet and sink waste lines. The findings are: 1) Observations in the North Building A Wing on 4/29/21 from 2:05 PM until 3:30 PM revealed this 36-bed unit was vacant. a. Observation in the North Building A Wing on 4/29/21 at 2:27 PM revealed the bathroom sink in Resident room [ROOM NUMBER] had an unsealed waste line, with a rag placed at the end of the line. b. Observation in the North Building A Wing on 4/29/21 at 3:28 PM revealed the bathroom toilet in Resident room [ROOM NUMBER] had an unsealed waste line, with a rag covering it. During an interview on 5/4/21 at 2:45 PM, the Maintenance Director stated the sink and toilet were removed from the vacant A Wing to be used elsewhere in the building, within the last month. The Maintenance Director also stated the rag was in pace to prevent sewer gases from escaping, but the waste lines should have been covered with a rubber cap and expansion plug. 415.29(b) 415.29(d)