Every finding on record at Brooklyn Gardens Nursing & Rehabilitation Center

Based on observation, record review, and interviews conducted during the Complaint Survey (Complaint 711914), the facility did not ensure medical records were complete and accurately documented in accordance with accepted professional standards and practices. This was evident for 1 of 3 Residents ( Resident #2). Specifically, Resident #2 had physician's order for the treatment of the right medial bunion. A review of the treatment administration record revealed that the treatments were not documented on several occasions.The findings are:The facility's policy and procedure titled Documentation in the Medical Record which was last reviewed on 04/13/2022 documented that progress notes must document all events pertaining to the residents stay in the facility. The Licensed Professional must maintain medical records on each resident in accordance with acceptable professional standards and practices that are complete and accurately documented.Resident #2 was admitted with diagnoses that included Non-Alzheimer's Dementia, Congestive Heart Failure and Peripheral Arterial Disease. The Comprehensive Minimum Data Set assessment dated [DATE] documented that Resident #2 was cognitively impaired and had two unstageable deep tissue injuries.The Care Plan Titled Pressure Injury to the Right Medial Bunion with an effective date of 02/10/2024 documented that it was a hospital acquired Deep Tissue injury with risk factors of decreased mobility present. The interventions included to administer treatment as ordered, wound care consult, and offload pressure ulcer site.The physician's order dated 02/09/2024 documented to cleanse right medial bunion wound with normal saline, pat dry, then clean with skin prep and leave open to air, once daily and as needed. The order was transcribed in the Treatment Administration Record to document completion during 7:00 AM to 3:00 PM shift.The Treatment Administration Record from 04/01/2024 to 05/31/2024 revealed that wound treatment were left blank on 04/03/2024, 04/05/2024,04/09/2024, 04/13/2024, 04/14/2024, 04/15/2024,04/19/2024, 04/20/2024, 04/21/2024, 04/27/2024, 05/01/2024, 05/04/2024, 05/11/2024, 05/12/2024, 05/14/2024, 05/15/2024, 05/19/2024, 05/25/2024 and 05/26/2024The Nursing Progress Notes from 04/01/2024 to 05/31/2024 did not contain any documentation related to wound treatment on 04/03/2024, 04/05/2024,04/09/2024, 04/13/2024, 04/14/2024, 04/15/2024,04/19/2024, 04/20/2024, 04/21/2024, 04/27/2024, 05/01/2024, 05/04/2024, 05/11/2024, 05/12/2024, 05/14/2024, 05/15/2024, 05/19/2024, 05/25/2024 and 05/26/2024.On 10/14/2025 at 10:22AM, Licensed Practical Nurse #2 was interviewed and stated that they do not recall Resident #2. They stated they worked on 04/09/2024 but was not sure why the treatment was not documented for that date. They stated it was the wound care team who often did the wound care for the residents at that time and that could be the reason why they had not signed off on the treatment administration record. On 10/14/2025 at 11:12 PM, Licensed Practical Nurse #1 was interviewed and stated they do not recall the resident. The Licensed Practical Nurse stated if they did not sign on the administration record, it is either the resident was not in the unit or they refused. The Licensed Practical Nurse #1 further stated that if they had rendered wound treatments, they would have documented it in the treatment administration record because that is proof it has been done. On 10/10/2025 at 1:02 PM, the Wound Care Doctor was interviewed and stated that they had been following the Resident #2 wounds since admission. The order in place for April 2024 and May 2024 was to cleanse the right medial bunion with skin prep and leave it open to air daily. Nursing staff are supposed to document in the system once treatment is done. If it is not documented, either the nurse may have forgotten to do it or did not do it at all. The goal of skin prep is to protect the skin and if it is not administered properly, the skin can open. The wound care doctor further stated that if a wound care treatment is not done properly, the wound can deteriorate.On 10/10/2025 at 12:53PM, The Assistant Director of Nursing was interviewed and stated that despite looking in the resident's chart they could not find any other documentation in regard to why the treatment was not signed off. The Assistant Director of Nursing stated that they are not sure if the treatment was rendered, and the staff may have forgotten to sign off on the treatment administration record. However, there is no documentation in the treatment administration record regarding why the treatments on those dates were left blank. The Assistant Director of Nursing further stated that if the treatment administration record is not signed off for, that means that care was not rendered.On 10/10/25 at 1:28 PM, the Director of Nursing Services was interviewed and stated they had not received any complaints about Resident #2 wound treatments not being given, therefore wound treatments were most likely administered on those dates. They stated that nurses and nursing supervisors are responsible for ensuring that treatments are properpy documented. 10 NYCRR 415.22(a)(1-4)

Based on observation, record review, and interviews during the Complaint Survey (iQIES 711881), the facility failed to notify the designated representative of Resident #4's significant weight loss. The findings are: The facility's policy titled Notification of Changes with effective date 12/22/2020 and last reviewed date 12/22/2024 documented the facility was to inform resident and resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status. It also documented the family/representative would be notified of the change by either nurse or social worker. It further documented the date and time of the notification would be documented in the medical record.Resident #4 had diagnoses which included End stage renal disease; Pressure ulcer of unspecified site, stage 3; and Pressure ulcer of unspecified site, stage 2.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #4 had weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not on physician-prescribed weight-loss regimen. The Weight monitor record documented Resident #4 had 5.79% weight loss from 207 lbs on 12/6/2023 to 195 lbs on 1/8/2024. The Dietary note dated 01/10/2024 documented Resident #4 had 6% weight loss in 1 month. There was no documented evidence in medical record that Resident #4's representative was notified of Resident #4's weight loss of more than 5% in one month. On 10/10/2025 at 11:08 AM, Registered Nurse #2 was interviewed and stated they did not notify Resident #4's representative of the weight change. The Registered Nurse also stated the dietitian was responsible to notify the representative if there was any concern for nutrition. On 10/10/2025 at 2:59 PM, Social Worker #1 was interviewed and stated the dietitian was responsible to notify the representative of a resident's weight change. On 10/10/2025 at 10:05 AM, Dietitian #1 was interviewed and stated Resident #4 was on dialysis and was transferred to the hospital on [DATE] and 12/26/2023. The Dietitian stated Resident #4 lost weight during their hospitalization and that the resident had more than 5% weight loss after re-admitted to the facility on [DATE]. Dietitian #1 also stated it was considered a significant weight loss for more than 5% in a month. Dietitian further stated they should notify the representative of the significant weight loss and documented the notification in the dietary note. Dietitian #1 reviewed the dietary notes from December 2023 to January 2024. Dietitian #1 stated they were not able to find any documented evidence that the representative was notified of the significant weight loss. On 10/10/2025 at 12:37 PM, the Administrator was interviewed and stated the facility had to notify the representative if a resident had a significant weight. The Administrator also stated 5% weight loss in 1 month was considered significant weight change. The Administrator further stated the dietitian should notify the representative and document the communication of significant weight change in the dietary note. 10 NYCRR 415.3(f)(2)(ii)(c)

Based on record review, and interviews conducted during an Abbreviated Survey (Incident # 2616975), the facility did not ensure that the results of all investigations pertaining to alleged violations involving abuse, neglect, exploitation or mistreatment, were reported to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five (5) working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This was evident for three (3) of seven (7) residents (Resident #1, #2, #3) sampled for abuse. Specifically, on 09/14/2025 at 12:40 AM, Resident #3 hit Resident #1 and Resident #2 with a footrest from a wheelchair. Resident #1 sustained injury above their right eyebrow, and Resident #2 sustained a large swelling to their right arm. The facility investigated the incident, but did not submit the results of the findings within five (5) days to the New York State Department of Health. The facility submitted the results of the findings on 09/22/2025 at 10:59 AM. The findings are:The facility's Policy and Procedure titled Abuse Prevention dated 12/29/2023, documented that the results of all investigations must be completed, and available to the New York State Department of Health within five (5) working days of the alleged violations is verified appropriate corrective action must be taken.Resident #1 was admitted to the facility with diagnoses including End Stage Renal Disease, Diabetes Mellitus, and Depression. The Minimum Data Set (an assessment tool) dated 06/13/2025 documented Resident #1 had moderately impaired cognition.Resident #2 was admitted to the facility with diagnoses including Depression, Hypertension, and Cerebrovascular Disease. The Minimum Data Set, dated [DATE] documented Resident #2 had intact cognition.Resident #3 was admitted to the facility with diagnoses including Depression and Pain.The Minimum Data Set, dated [DATE] documented Resident #3 had intact cognition.A facility's Investigation Summary dated 09/19/2025 documented, without provocation, Resident #3 hit Resident #1 with a footrest of Resident #1's wheelchair on 09/14/2025 at 12: 40 AM. Resident #1 sustained injury above their right eyebrow. Resident #3 also chased Resident #2, who was responding to the noise in the hallway, into their room and hit them with the footrest on their right forearm which resulted in a large swelling. The facility concluded that the incident did not meet definition of abuse as there was no prior pattern of aggression, no clear malice or intent to inflict harm. A review of Nursing Home Investigative Report revealed the facility submitted result of the investigation to New York Department of Health on 09/22/2025 at 10:59 AM.During an interview on 09/24/2025 at 2:12 PM, the Director of Nursing stated they were informed about the incident by Registered Nurse Supervisor #1 on 09/14/2025 at 1:06 AM. The Director of Nursing stated that the Administrator is responsible for reporting the initial and submitting of the five (5) day report to the New York State Department of Health. The Director of Nursing stated they are responsible for reporting all the reportable accident/incidents to the New York State Department of Health, when the Administrator is absence. The Director of Nursing stated the five (5) day submissions are due within five (5) days after the initial submission of the reportable to the New York State Department of Health. During an interview on 09/25/2025 at 4:24 PM, the Administrator stated they were informed about the alleged incident by Registered Nurse Supervisor #1 on 09/14/2025 at 1:15 AM. The Administrator stated that they are responsible for reporting the initials and the five (5) day to the New York State Department of Health. The Administrator stated the facility has five (5) business calendar days from the date that the incident was reported to the New York State Department of Health, to submit the five (5) day report to the New York State Department of Health. The Administrator stated they submitted the five (5) day to the New York State Department on 09/22/2025 and that it should have been submitted 09/19/2025. The Administrator stated they do not know why the five (5) day report was submitted late. 10 NYCRR 415.4(b)(2)

Based on record review and interviews conducted during an abbreviated survey (Incident #711926), the facility failed to ensure that residents are free from resident-to-resident abuse. This was evident in two (2) of seven (7) residents (Resident #5 and Resident #7) sampled. Specifically, Resident #5, a known wanderer, wandered into Resident #7's room from a shared bathroom on 01/14/2025 at 8:10 AM. As a result, Resident #5 and Resident #7 were engaged in a resident-to-resident altercation, and Resident #5 sustained an abrasion and swelling to their upper lip. The findings are: The facility's Policy and Procedure titled Abuse Prevention dated 12/29/2023, documented that the intent of the policy was to prevent/prohibit resident abuse. The facility provides a safe resident environment that protects residents from abuse, including verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. This includes staff to resident abuse of any type, resident to resident abuse of any type and visitor to resident abuse of any type. Resident #5 was admitted to the facility with diagnoses including Alzheimer's Dementia, Psychotic Behavior, and anxiety disorder.The Minimum Data Set (an assessment tool) dated 12/18/2024, documented Resident #5 had severe cognitive impairment. A Behavioral/ at Risk for Abuse Care Plan dated 11/25/2024 documented interventions for staff to observe the resident during rounds and care, monitor for changes in mood, and keep the resident away from other peers whenever possible. A review of the Resident Nursing Instructions dated 01/10/2025 documented Resident #5 had behaviors of wandering, kicking/hitting, using abusive language, threatening, and resisting care.A review of a nursing note by Registered Nurse Supervisor #3 dated 01/14/2025 documented Resident #5 was found on the floor with their buttocks positioned near the bedside of Resident #7's room. Upon assessment, Resident #5 was observed to have a small cut to the inner part of the upper lip, swelling noted in the area, and bleeding. The bleeding was controlled upon immediate intervention, and cold compression was applied. Resident #5 was alert and oriented with no acute distress but noted with confusion. The [NAME] pain scale assessment was completed; Tylenol 650 milligram tablets were administered. A review of a Medical Progress Note by Medical Doctor #2 dated 01/14/2025 documented Resident #5 had an altercation with Resident #7, and they were punched. Resident #5 had a mild swelling of the upper lip, especially on the left side. Resident #5 also had a small wound like to the right angle 0.5 cm in the upper inner left lip in the mucous membrane, not open. The resident denies any complaint except mild pain in the upper lip and no other signs of injury. A review of the 'Nursing Rounds' sheet dated 01/14/2025 documented Resident #5 was last seen in their room sitting on the bed at 8:00 AM by Certified Nursing Assistant #4, as evidenced by their initials. Resident #7 was admitted to the facility with diagnoses including Alzheimer's Dementia, Schizophrenia, and Legal Blindness.The Minimum Data Set, dated [DATE], documented Resident #7 had intact cognition. The Resident Nursing Instructions dated 10/29/2024 documented Resident #7 had behaviors of yelling and screaming. A Risk for Abuse Care Plan, due to diagnoses of weakness, paranoid schizophrenia, movement disorder, and anxiety disorder, dated 11/27/2024 documented interventions including staff to continue monitoring and redirect as needed. A review of the facility's Accident/Incident Report Form dated 01/14/2025 documented at 8:10 AM, Resident #5 was found in Resident #7's room, sitting on the floor. Resident #5 was observed with bleeding and swelling to their upper lip. Resident #7 admitted to punching Resident #5 when Resident #5 refused to leave their room. The facility's Summary of Investigation documented that on 01/14/2024 at around 8:10 AM, Resident #5 entered Resident #7's room (next door) thinking it was their room and was assaulted by Resident #7. The facility concluded that there was no credible evidence to believe that neglect, abuse, and mistreatment occurred. During a telephone interview on 10/03/2025 at 1:50 PM, Certified Nursing Assistant #4 stated that Resident #5 and Resident #7 resided in separate private rooms but shared a bathroom. Certified Nursing Assistant #4 stated they responded to the call bell from Resident #7's room and observed Resident #5 sitting on the floor on 01/14/2025 (unsure of time), and they immediately notified the nurse on the unit. Certified Nursing Assistant #4 stated Resident #7 is verbally aggressive and does not want people coming into their room. Certified Nursing Assistant #4 stated they performed hourly rounding to ensure residents are safety. Certified Nursing Assistant #4 stated they redirected Resident #5 whenever they observe them wandering in the hallway. Certified Nursing Assistant #4 stated Resident #5 usually stays in the dining room and participates in activities. Certified Nursing Assistant #4 stated they were assigned to Resident #5 and Resident #7 on 01/14/2025 on the 7:00 AM - 3:00 PM shift. Certified Nursing Assistant #4 stated Resident #5 was last seen at 8:00 AM in their room sitting on the bed watching television and Resident #7 was in their room sitting in their wheelchair. Certified Nursing Assistant #4 stated they have never observed Resident #5 wandering into other resident's room. During a telephone interview on 10/03/2025 at 1:52 PM, Licensed Practical Nurse #3 stated they responded to Resident #7's room and observed Resident #5 sitting on the floor with a cut to the upper lip and bleeding. Licensed Practical Nurse #3 stated Resident #5 reported that they were punched by Resident #7, and Resident #7 reported that Resident #5 came into their room, and they hit them. Licensed Practical Nurse #3 stated that Resident #7 does not want anyone entering their room. Licensed Practical Nurse #3 stated they cleaned Resident #5's lips with normal saline and applied cold compression to stop the bleeding. Licensed Practical Nurse #3 stated that Resident #5 is a wanderer, but they usually stay in the dining room engaged in activities. Licensed Practical Nurse #3 stated there are staff members who monitor the hallway to redirect Resident #5 if they are seen wandering. Licensed Practical Nurse #3 stated that Resident #7 did not want a STOP sign banner to be placed a crossed their room door. Licensed Practical Nurse #3 stated they and the Certified Nursing Assistants performed hourly rounds to ensure residents are safety. During a telephone interview on 10/03/2025 at 2:36 PM, Registered Nurse Supervisor #3 stated Resident #5 and Resident #7 reside in separate rooms, but shared a bathroom located between both resident's room. Registered Nurse Supervisor #3 stated that Resident #5 wandered into Resident #7's room from the shared bathroom. Registered Nurse Supervisor #3 stated staff would have redirected Resident #5 if Resident was observed wandering and entering from the hallway. Registered Nurse Supervisor #3 stated they are responsible for initiating and updating the care plans as needed. Registered Nurse Supervisor #3 stated the interventions implemented were the best intervention for Resident #5. Registered Nurse Supervisor #3 stated Resident #5 was kept in the dining room with assigned staff for monitoring and activities to keep them engaged. Registered Nurse Supervisor #3 stated Resident #5 was on hourly rounding that was effective in preventing Resident #5 from wandering into other residents' rooms. Registered Nurse Supervisor #3 stated that Resident #7 is on hourly monitoring because they are verbally aggressive. Registered Nurse Supervisor #3 stated staff on the unit continues to redirect residents from entering Resident #7's room. During an interview on 09/25/2025 at 2:00 PM/4:00 PM, the Director of Nursing stated they were not the Director of Nursing at the time of the incidents involving Resident #5 and Resident #7. The Director of Nursing stated Resident #7 has been placed in a room with a compatible roommate that they get along with no concern identified. The Director of Nursing stated all the residents continue to be monitored hourly. The Director of Nursing stated Resident #7's behavior was unpredictable. The Director of Nursing stated Resident #7 was transferred to another unit. The Director of Nursing stated Resident #5 and Resident #7 continue to be monitored closely to ensure their safety. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review, and interviews during the Recertification Survey conducted from [DATE] to [DATE], the facility failed to ensure that parenteral fluids were administered consistent with professional standards of practice. This was evident in 2 of 3 residents reviewed for hydration. Specifically, 1.) On [DATE], Resident #37, who had physician orders for administration of intravenous solution was observed receiving expired intravenous fluids. 2.) On [DATE], Resident #482's peripheral intravenous catheter insertion site dressing was observed undated. Additionally, the physician's order for Resident #482's intravenous hydration did not include the infusion rate, and assessment and maintenance of intravenous site. The findings include: The facility's policy titled Intravenous Therapy with a last reviewed date of [DATE] stated residents receiving intravenous therapy will receive therapies safely, timely, and efficiently in accordance with physician's order. Intravenous lines will be maintained according to evidenced based practices to reduce the risk of infection associated with intravenous catheters. The policy stated the physician's order for the insertion of the intravenous line and the type of access will be ordered under the General Order Group. Orders for intravenous hydration will be placed under medication and include the intravenous formula, rate and duration of infusion. The order for care and management of intravenous catheter site will be placed in the Treatment Order Group. This order will include site inspection and assessment every shift, dressing changes every 3 days and as needed if damaged or soiled for peripherally placed catheters. The nurse is responsible to label the dressing with date and time and sign the electronic Medication Administration Record. 1.) Resident #37 had diagnoses of Dysphagia and Encounter for attention to gastrostomy and Alzheimer's Disease. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #37 was severely cognitively impaired. A nurse's progress note dated [DATE] at 7:50 PM documented they were made aware that Resident #37's percutaneous endoscopic gastrostomy tube was dislodged. The Nurse Practitioner stated they would insert the tube tomorrow. A new order was placed for dextrose 5% ,d+[DATE] normal saline at 45 milliliters per hour for one (1) day. A physician's order dated [DATE] at 7:40 PM documented dextrose 5% and 0.45% sodium chloride intravenous solution, infuse 45 milliliters per hour by intravenous route once daily for 1 day for unspecified hypoglycemia. During observation on [DATE] at 12:59 PM, Resident #37 was observed in a geriatric chair with their back elevated to a semi-sitting position. Resident #37 was receiving 5% dextrose and 0.45 sodium chloride intravenously through a peripheral access to the left hand. The one (1) liter bag of intravenous solution was ,d+[DATE] full. The bag had a documented lot number Y383714 and an expiration date of [DATE]. During an interview on [DATE] at 3:51 PM, Licensed Practical Nurse #4 stated that Registered Nurse #1 entered the order for intravenous hydration and inserted the peripheral access for Resident #37. They stated they hung the bag of intravenous fluid which they found in a storage drawer in the nurses' station without checking the expiration date. Licensed Practical Nurse #4 stated they are aware they need to check the expiration date on the intravenous solution bag before administering them to the resident. During an interview on [DATE] at 1:43 PM, Registered Nurse #1, who was the Unit Manager was interviewed and stated they did rounds before 8:00 AM this morning and observed Resident #37's intravenous solution was already hanging and running. They stated they were not aware of the expired intravenous solution. During an interview on [DATE] at 1:28 PM, the Director of Nursing stated nurses must check if the intravenous fluids the resident is getting match the doctor's orders and nurses must also check the expiration date. The Director of Nursing stated that nurses must check for signs of infection or infiltration, the intravenous solution bag must have a date when it was started, and the intravenous site and tubing must be dated. 48876 2.) Resident #482 was admitted to the facility with diagnoses that included Diabetes Mellitus, Iron Deficiency Anemia, and Major Depressive Disorder. The admission Minimum Data Set assessment dated [DATE] documented that Resident #482 had intact cognition. On [DATE] at 9:31 AM, Resident #482 was observed with a right upper extremity peripheral intravenous catheter dressing that was undated. A care plan for intravenous therapy was initiated for Resident #482 on [DATE]. The care plan documented Resident #482 has a need for intermittent intravenous therapy due to diarrhea. The facility interventions included monitoring for changes in device insertion site, notify the physician of abnormal findings, giving the intravenous treatment for hydration as per physician's order. A physician's order for Resident #482 dated [DATE] at 2:23 PM documented to give sodium chloride 0.9% by intravenous route for 3 days for diarrhea. The order was discontinued on [DATE] at 4:44 AM. The physician's order did not include the rate of infusion. A nurse's progress note dated [DATE] documented that Resident #482 required intravenous hydration. A 24-gauge angiocatheter was placed in the left hand and the administration of 0.9% sodium chloride solution was started. A physician's order for Resident #482 dated [DATE] at 4:03 PM documented to give sodium chloride 0.9% by intravenous route every shift for 2 days for diarrhea. The physician's order did not include the infusion rate. A further review of Resident #482's physician's orders from [DATE] through [DATE] revealed there was no physician's order for insertion of peripheral intravenous line. There was no physician's order for dressing changes, and/or care and maintenance of the intravenous site. The Medication Administration Record dated [DATE], [DATE], and [DATE] documented that Resident #482 was administered 0.9% sodium chloride intravenous solution given by intravenous route for 3 days. There was no documented rate of infusion. The [DATE] Treatment Administration Record for Resident #482 was blank. There was no documentation in the Treatment Administration Record that the intravenous insertion site was inspected and assessed every shift or that dressing change every 3 days or as needed was completed. On [DATE] at 10:13 AM, an observation of Resident #482's undated right peripheral intravenous dressing was performed with Registered Nurse #8, who was the nursing supervisor. Registered Nurse #8 was interviewed and stated that a peripheral intravenous line was inserted for Resident #482 on [DATE]. The intravenous access was infiltrated and was discontinued. They stated Registered Nurse #3 inserted a new peripheral intravenous catheter on [DATE]. Registered Nurse #8 stated Registered Nurse #3 should have dated the intravenous access dressing at the time of insertion. On [DATE] at 3:37 PM, Registered Nurse #3 was interviewed and stated that on [DATE], they reinserted Resident #482's peripheral intravenous catheter but did not put a date on the insertion site dressing because another nurse told them they would. Registered Nurse #3 further stated they should have dated the insertion site dressing to ensure that it would be changed every 72 hours. On [DATE] at 11:39 AM, Registered Nurse #7, the licensed nurse who entered Resident #482's physician's order dated [DATE], was interviewed and stated they reviewed the intravenous hydration order for Resident #482 and noted it was missing the dose or frequency of hydration. Registered Nurse #7 stated there were no physician's orders for intravenous insertion, and or dressing changes. They stated the missing and incomplete orders are an oversight. On [DATE] at 8:39 AM, the Director of Nursing was interviewed and stated that according to Registered Nurse #3, they wrapped the insertion site with kerlix gauze after inserting the peripheral intravenous line onto Resident #482 on [DATE], and whoever removed the kerlix gauze must have removed the dated label. The Director of Nursing stated that Registered Nurse #3 should have not wrapped the insertion site with kerlix and should only have added the date on the dressing. During a subsequent interview with the Director of Nursing on [DATE] at 11:15 AM, they stated the physician enters the orders for the residents. They stated that the Registered Nurses who took the verbal order from the physician may also enter the physician's order in the resident's medical record. They stated the unit manager is responsible for ensuring the accuracy of the physician's order every shift. The Director of Nursing stated physician orders for intravenous infusions must contain the medication name, dose, frequency, intravenous insertion, dressing changes, and flushes. On [DATE] at 3:26 PM, Attending Physician #1 stated they had not signed the intravenous orders for Resident #482. They stated they reviewed the orders and noted that they were incomplete. The orders did not contain the frequency or dosage for the intravenous hydration, there was also no physician's order to insert a peripheral venous catheter. On [DATE] at 3:39 PM, the Medical Director was interviewed and stated that the medical providers / attending physicians must review the order for accuracy and completeness on the same day the orders are written and must be signed off. The Medical Director stated if there were inaccuracies in the physician's orders, the Director of Nursing may reach out to them to discuss the issues 10 NYCRR 415.12(k)(2)

Based on observation, record review, and interviews during the Recertification Survey conducted from 05/21/2025 to 05/29/2025, the facility did not ensure that food was handled in accordance with professional standards for food service safety and staff did not ensure that infection control practices were maintained in the kitchen. Specifically, Dietary Staff #1 and #2 were observed with visible facial hair while handling and preparing food. The findings include: The undated facility policy titled Sanitation and Food Safety - Staff Appearance and Hygiene documented hair will be clean and worn pulled back up if longer than shoulder length. Regardless of length, hairnet or approved chef type hat is required in all production and service areas. Facial hair or of any length or design must be covered by a beard guard. During a tray line observation on 05/23/2025 from 11:48 AM- 12:25 PM the following were observed: Dietary Aide #1 was observed with hair restraint and gloves, with a visible mustache and goatee (chin beard) while putting silverwares into a utensil holder opposite the sandwich making station and the cooking area. They were also observed scooping and placing watermelons in plastic cups. Dietary Aide #2 was observed on the tray line with their beard guard below their mustache while handling food side items such as vegetables, fish, white rice, chicken wing, chopped fish, green beans. During an interview on 05/23/2025 at 12:22 PM, Dietary Aide #1 stated they forgot to put their beard cover when they went to the kitchen. Dietary Aide #1 stated they were supposed to wear beard covering when handling food to make sure hair does not drop in food or utensils. During an interview on 05/23/2025 at 12:25 PM, Dietary Aide #2 stated they were instructed by their previous supervisor to only cover the bottom part of their face. During an interview on 05/28/2025 at 11:24 PM, the Food Service Supervisor stated dietary staff with beard and mustache should be wearing beard guards, so hair does not get into residents' food. During an interview on 05/28/2025 at 11:33 AM, the Food Service Director stated that the required uniform in the kitchen includes the use of hair restraint and beard guard for people with mustache and beard. They stated all facial hair must be covered for infection control and to avoid dropping hair in residents' food during preparation. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews during the Recertification Survey conducted from 05/21/2025 to 05/29/2025, the facility failed to ensure infection control protocol were maintained during medication administration. This was evident in 1 (Licensed Practical Nurse #1) of 5 nurses observed. Specifically, Licensed Practical Nurse #1 failed to perform hand hygiene and did not don appropriate personal protective equipment while administering medications to a resident who had a gastrostomy tube. The findings include: The facility policy and procedure titled Infection Prevention and Control Program - Enhanced Barrier Precautions with a last revised date of 12/12/2023 documented the facility adheres to the Centers for Disease Control and Prevention (CDC) guidelines as related to Enhanced Barrier Precautions in order to prevent the transmission of multidrug-resistant organisms amongst residents and healthcare workers. Staff will perform hand hygiene and don Personal Protective Equipment (PPEs) before entering resident's room. On 05/21/2025 at 9:55 AM, Licensed Practical Nurse #1 was observed administering medications to Resident #121 via gastric tube feeding. Licensed Practical Nurse #1 did not sanitize their hands prior to donning gloves to prepare the medications. Licensed Practical Nurse #1 was observed picking up a medication that dropped on the floor with the same gloved hands and continued to administer medications to Resident #121 without performing hand hygiene and / or changing gloves. Licensed Practical Nurse #1 did not don personal protective equipment prior to entering Resident #21's room to administer medications. There was a signage at the entrance of Resident #121's room that stated staff should observe Enhanced Barrier Precautions when giving care, including administration of medication and wound care treatment. On 05/21/2025 at 12:33 PM, Licensed Practical Nurse #1 was interviewed and stated that Enhanced Barrier Precaution protocol was not observed because they did not notice the signage by the entrance of Resident #121's room. Licensed Practical Nurse stated they did not notice any supplies for enhanced barrier in front or in the resident's room for them to use. Licensed Practical Nurse #1 was not able to explain why they did not perform hand hygiene during medication preparation, after picking up the medication from the floor, and prior to administering medications. On 05/21/2025 at 2:43 PM, Registered Nurse Supervisor #1 was interviewed and stated that in-services on infection prevention protocol are given to staff regularly and during orientation. Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 was newly hired and was provided education during their orientation program on infection prevention protocol that included handwashing / hand hygiene and Enhanced Barrier Precautions. They stated that enhanced barrier precautions is posted at the entrance of Resident #121's room and needed supplies are positioned strategically on the unit for staff to use when giving care to residents that are on Enhanced Barrier precautions. On 05/28/2025 at 11:14 AM, the Director of Nursing/Infection Preventionist was interviewed and stated staff received in-service education on infection control and enhanced Barrier Precautions. These in-services are conducted during orientation and annually. The Director of Nursing stated Licensed Practical Nurse #1 is newly hired, still on probation, and was recently given these in-services. The Director of Nursing stated that there are signages posted on the units to let staff know if a resident is on enhanced barrier precautions. They stated they were surprised that Licensed Practical Nurse #1 stated they had not seen it. 10 NYCRR 415.19 (b)(4)

Based on observation, record review, and interview during the Recertification Survey conducted from 05/21/2025 to 05/29/2025, the facility failed to ensure that notice of availability of the survey results were posted in areas of the facility that are prominent and accessible to the public. Specifically, there were no posted notices throughout the facility of the availability of survey results. The findings are: The facility's policy titled Survey Posting with a reviewed date of 12/04/2024 documented that it is the policy of the facility to comply with all New York State Department of Health and Centers for Medicare & Medicaid Services regulations by ensuring timely and visible posting of all relevant survey results, Plans of Correction, and related public notices in a designated, accessible area within the facility. Documents to be posted in designated posting area of the main lobby include a notice indicating where full reports can be reviewed. Signage will read: Department of Health Survey Results Available for Public Review. The Administrator or designee is responsible for ensuring timely posting and accuracy. During multiple observations on 05/21/2025, there were no notice of availability of survey results posted throughout the facility including the main lobby. During the Resident Council meeting held on 05/21/2025 at 11:53 AM, nineteen (19) residents were in attendance, and all of 19 residents (Residents #3, #18, #32, #35, #36, #45, #49, #53, #69, #87, #109, #135, #142, #147, #150, #152, #160, #187, #206) stated they did not know where to find the survey results and that they have not seen any notice telling them where to find the survey results. The minutes of the Resident Council Meetings held on 02/24/2025, 03/31/2025, and 04/20/2025 had no documentation that information was provided to the residents on where to find the survey results. On 05/22/2025 at 3:07 PM, the Recreation Director was interviewed and stated they had not discussed the locations of survey results or postings of the availability of the survey results during the Resident Council Meeting. The Recreation Director also stated they had not seen any posted signage of the availability of survey results in the facility including the main lobby. On 05/23/2025 at 8:33 AM, the Administrator was interviewed and stated the last time they observed the signage on the availability of survey reports in the lobby was in 04/2025. They stated they were surprised that the posting was not there. The Administrator further stated that someone must have removed the posting and that they have reposted the signage and will increase their auditing of the location to ensure compliance. 10 NYCRR 415.3 (d)(1)(v)

Based on observation, record review, and interviews during an abbreviated survey (NY00359265), the facility did not ensure each resident received adequate supervision to prevent an elopement. This was evident in 1 out 16 residents (Resident #1) sampled for elopement. Specifically, the facility Surveillance Camera Recording dated 11/02/2024 showed Resident #1 walked past Security Guard #1 at 11:00 AM, who was sitting at the front desk in the lobby and exited the automatic front doors and eloped from the facility. Resident #1 then walked past a second (Security Guard #2) who was sitting in a booth at the front gate that leads to the street. Facility staff became aware between 12:30 PM and 1:00 PM that Resident #1 was missing. According to an interview with the Director of Nursing on 12/22/2024 at 12:30 PM, a hospital staff notified facility staff on 11/04/2024 that Resident #1 was at the hospital. Resident #1 was readmitted to the facility on [DATE] with no injuries. The findings include: The facility's Policy and Procedure titled Elopement Prevention/Wandering Behavior Management dated 08/12/2022 states it is the policy of the facility to utilize all possible measures to maintain the safety and well-being of all residents. To have system and tools in place to do all that is reasonable to identify and prevent unsafe wandering and/or elopement and to act quickly and prudently should it occur. The facility's Policy and Procedure titled Security Reception Desk dated 08/31/2023 states that the facility will ensure that the environment is safe and secure for residents, employees, and visitors twenty-four hours throughout the day. The facility will employee trained security guards to work at the Front Desk reception area at all times to monitor entrance and exit from the building and respond to any alarms activated. Resident #1 was admitted to the facility with diagnoses including Schizophrenia Disorder and Cerebral Infarction. The Minimum Data Set (an assessment tool) dated 05/23/2024 documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 12 associated with moderate cognitive impairment. Resident #1 ambulates with a rollator walker. An Elopement Risk assessment dated [DATE] documented Resident #1 was not identified at risk for elopement. Therefore, an elopement care plan was not implemented. A document titled Department of Nursing Rounds dated 11/02/2024 showed Resident #1 was on hourly monitoring and was last seen on the unit at 11:00 AM. A nursing progress note dated 11/02/2024 at 8:27 PM, by Registered Nurse Supervisor #1, documented Resident #1 could not be found on the unit. Registered Nurse Supervisor #1 stated Resident #1 has never verbalized wanting to leave the facility and that Resident #1 had a discharge plan in progress. Resident #1 used a rollator for ambulation. A unit search was done, and Coded Pink (elopement code) called. The Director of Nursing and Resident #1's family member was notified, and 911 was call for missing person. The search continued. A Surveillance Camera Recording dated 11/02/2024 at 11:00 AM, showed Resident #1 exited the elevator in the lobby with their rollator walker, and walked past Security Guard #1 at the front desk and exited through the automatic front door Security Guard #1 was observed talking to Resident #2 at the time exited the automatic front doors. Resident #1 also walked past Security Guard #2, who was sitting in a booth at the front gate, and exited the front gate that leads to the street. Neither Security Guard #1 nor Security Guard #2 stopped Resident #1. An Investigation Summary dated 11/02/2024 documented Certified Nursing Assistant #1 reported that they last saw Resident #1 at 11:00 AM. Certified Nursing Assistant #1 stated at around 12:00 PM they were feeding residents and at 1:00 PM they observed Resident #1 did not eat their lunch. Certified Nursing Assistant #1 stated they checked Resident #1's room and the first floor and Resident #1 was not found. Licensed Practical Nurse #1 and Registered Nursing Supervisor #1 were notified. All floors were search and Resident #1 not located. Code Pink was initiated. Staff members search inside and outside the building and adjacent streets and Resident #1 was not found. Local law enforcement was called and responded. Resident #1 was found on 11/04/2024 and was returned to the facility on [DATE]. The investigation concluded there is no evidence of abuse, neglect, or mistreatment. Resident #1 was schedule for discharge and was waiting for home care approval when they decided to leave the facility. Multiple attempts were made to reach Security Guard #1 and # 2 were unsuccessful. Security Guard #1's statement dated 10/02/2024 (error its 11/02/2024) documented at approximately 2:30 PM they were informed Resident #1 left the facility using a walker. They did not see anyone leaving the premises but was told by another resident (Resident #2) that Resident #1 left during smoke break. Security Guard #2's statement dated 10/02/2024 (dated should have been 11/02/2024) documented at 12:30 PM the nurse asked them if they see Resident #1 with a walker comes out of the elevator. Security Guard #2 documented no because they were printing the logbook and was not paying attention because so many people come in with a walker. They did not see anybody with a walker and a bracelet badge on their right hand walked out. During an interview on 11/22/2024 at 12:00 PM, Licensed Practical Nurse #1 stated they last saw Resident #1 between 10:50 AM and 11:00 AM on the unit walking with their rollator walker. Licensed Practical Nurse #1 stated they came to the lobby at around 12:30-1:00 PM and Resident #2 informed them that they saw Resident #1 going toward the front gate. Licensed Practical Nurse #1 stated they went in search for Resident #1 but did not find them. During an interview on 11/22/2024 at 11:57 AM, Registered Nurse Supervisor #1, who worked on 11/02/2024 on the 7:00 AM to 3:00 PM shift, stated Resident #1 was on hourly monitoring and was last seen at approximately 11:00 AM on the unit ambulating with their rollator walker. Registered Nurse Supervisor #1 stated Resident #1 was ambulating to and from their room into the hallway. Registered Nurse Supervisor #1 stated Resident #1 never verbalized wanting of leave or exhibited any exit seeking behavior. Registered Nurse Supervisor #1 stated Resident #1 had a discharge planning in progress and that Resident #1 was aware. Registered Nurse Supervisor #1 stated there were two Security Guards (#1 and #2) on duty at the time Resident #1 exited the facility. Registered Nurse Supervisor #1 stated Security Guard #1 was assigned to monitor the front desk and Security Guard #2 the front gate. Registered Nurse Supervisor #1 stated the process is that security must check identification and asked questions to ensure a resident is not leaving the facility. Registered Nurse Supervisor #1 stated Resident #1 was wearing an identification band when they exited the facility. Registered Nurse Supervisor #1 stated approximately 12:30 PM -1:00 PM (not sure of the time) staff observed that Resident #1 was not on the unit. Registered Nurse Supervisor #1 stated the staff searched for Resident #1, but the resident was not found in the building and Code Pink was activated. Registered Nurse Supervisor #1 stated they called the Director of Nursing and informed them, and they were instructed to call 911. Registered Nursing Supervisor #1 stated 911 was called at 1:00 PM and responded at 5:28 PM. Registered Nurse Supervisor #1 stated all residents are assessed for elopement risk upon admission to the facility. Registered Nurse Supervisor #1 stated Resident #1 was not identified to be an elopement risk. During an interview on 11/22/2024 at 2:00 PM, the Administrator stated they were made aware of the elopement at 2:00 PM on 11/02/2024. The Administrator stated they went to Resident #1 last known address at 7:45 PM and the doorbell was not answered. The Administrator stated they searched many areas including shelters and hospital but Resident #1 was not located. The Administrator stated Resident #1 exited the building via the front door while Security Guard #1 was at the front desk and Security Guard #2 was at the front gate. The Administrator stated Security Guard #1 and #2 received classroom education and buddy up with a co-worker prior to them starting work. The Administrator stated Security Guard #1 supposed to check all visitors and resident entering and leaving the facility. The Administrator stated Resident #1 was wearing an arm band with their name and room number. The Administrator stated that visitors entering the facility are given a pass to wear in the facility after signing the Kiosk. Visitors must return the pass whenever they are leaving the facility. The Administrator stated Security Guard #1 and #2 did not follow the facility policy and were terminated. The Administrator stated they are responsible for tracking and monitoring all the security guards working in the facility. During an interview on 11/22/2024 at 2:30 PM, the Director of Nursing stated Resident #1 was assessed for elopement risk upon admission and was not identified at risk for elopement. The Director of Nursing stated that Certified Nursing Assistant #1 signed Resident #1's monitoring sheet at 12:00 PM identifying Resident #1 was Off Unit. The Director of Nursing stated all staff members received in-service that they must visually see the resident before signing the hourly sheet. The Director of Nursing stated the investigation concluded that there is no evidence of abuse, neglect, or mistreatment. Resident #1 was schedule for discharge and was waiting for home care approval when they decided to leave the facility. Based on the following corrective actions taken, there were sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement 11/18/2024 prior to surveyors' s onsite visit on 11/22/2024. A Plan of Correction is not required for this citation. The facility implemented the following corrective action prior to surveyor entrance on 11/22/2024. The facility's Director of Nursing investigated the elopement incident and the team concluded that Resident #1 leave the facility unescorted. The facility developed an action plan which includes the following: On 11/02/2024 local law enforcement was called 11/02/2024 at 1:00 PM and responded on 11/02/2024 at 5:28 PM. Resident # 1 information and picture was given to the local police. On 11/02/2024 facility re-in-serviced staff members from all departments on elopement, visual monitoring, and checking identification band (in-service ongoing). Quality Assurance Meeting held on 11/04/2024 with department heads. Attendance sheet reviewed. On 11/03/2024 Security Guard #1 and #2 terminated. Policy and Procedure for Reception Desk dated 08/31/2023 was revised on 11/11/2024 to reflect on a new button installed at security desk to allow only Security Guards to open the door front door from the inside. A Transaction Receipt dated 11/11/2024 for the locksmith to install the push button for front door was reviewed. On 11/12/2024 Resident #1 was readmitted to the facility without injury. On 11/13/2024 Resident #1 was observed walking toward the entrance and was stop. A wander guard bracelet was applied. A nursing progress note dated 11/13/2024 documented Resident #1 and family received education and verbal consent was given for wander guard. An elopement care plan was implemented on 11/12/2024 for Resident #1. On 11/15/2024 an Elopement Drill was done with staff members. An Audit tool dated 11/18/2024 was developed to monitor compliance with residents at risk for elopement/wandering. The 2nd entrance door will be kept locked. Only Security Guard in the reception area can open the door. Security Guard will ensure residents are not in the space between 1st and 2nd entrance glass door. Residents can only stay in between the 1st and 2nd entrance door if a recreation staff is present. Policy and Procedure dated 08/12/2022 Elopement prevention/Wandering behavior reviewed with no revision. Policy and Procedure for Reception Desk dated 08/31/2023 reviewed with revision on 11/11/2024 to reflect on a new button that was installed at security desk to allow only Security Guards to open the door from the inside. 10 NYCRR 415.12(h)(2)

Based on observation, record review, and interviews during an Abbreviated Survey (NY00323964), the facility did not ensure an allegation of abuse was reported to the New York State Department of health (NYSDOH) within two hours after the allegation was made. This was evident for 1 out of 3 residents (Resident #1) sampled for abuse. Specifically, Resident #1 reported on 09/14/23 at 2:00pm that Certified Nursing Assistant (CNA) #1 was rough and hit Resident #1 with the bed sheet on 09/14/23 on the night shift. The facility did not report the alleged abuse within two hours after the allegation was made. The facility reported the abuse allegation on 09/15/23 at 4:28pm. The findings are: The Policy and Procedure on title Accident and Incident Investigation and Reporting dated 12/19/22, states that it is the responsibility of the Administrator/Director of Nursing Service and or designee to report to the NYS DOH the above listed violations immediately, but no more than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily harm. Resident was admitted to the facility with diagnoses including Cerebellar Stroke Syndrome, Mood Disorder and Vascular Dementia without Behavioral Disturbance. A Nursing Progress Note, by Licensed Practical Nurse (LPN) #1, dated 09/14/23 at 2:00pm, documented that Resident #1 reported to LPN #1 that CNA #1 on the 11:00pm - 7:00am shift, hit Resident #1 with a bed sheet because Resident #1's TV was too loud on 09/14/23. LPN #1 notified the ADON. An Accident/Incident Report, by Assistant Director of Nursing (ADON), dated 9/14/23 documented that Resident #1 was interviewed and stated that CNA #1 from previous shift 11:00 pm- 7:00 am was rough with the sheets during care. On assessment no injury noted, Range of Motion (ROM) within normal limits, and skin intact. CNA #1 was removed from schedule pending investigation. The Assistant Director of Nursing (ADON) Resident #1's roommate who stated that Resident #1 made noises when CNA #1 asked Resident #1 to turn their TV volume down because it was disturbing. The facility concluded that Resident #1 was upset after CNA #1 turned their TV volume down and that abuse, neglect, or mistreatment did not occur. The Webform Submission from the nursing home showed that the facility reported the alleged abuse incident to NYSDOH on 09/15/2023 at 4:28pm. During an interview with the Administrator on 10/18/23 at 10:52am, the Administrator stated that they were not employed at the time of the allegation. The Administrator stated that the window for reporting abuse is two hours after the facility is made aware of the allegation. The Administrator stated that the webform submission from the facility to NYSDOH is dated 09/15/23 at 4:28 pm. 10 NYC RR 415.4 (b)

Based on observation, record review, and interviews during an Abbreviated Survey (NY00323964), the facility did not have evidence that an alleged violation of abuse was thoroughly investigated. This was evident in 1 out of 3 resident (Resident #1) sampled. Specifically, Resident #1 reported to Licensed Practical Nurse (LPN) #1 on 09/14/23 at 2:00pm, that Certified Nursing Assistant (CNA) #1 hit Resident #1 with a bed sheet because the volume on the Television (TV) was too loud. Review of the facility's Accident and Incident Report dated 09/14/23, revealed that the facility did not address and implement interventions regarding Resident #1's TV volume. The findings are: The facility's Policy and procedure titled; Accident and Incident Investigation and Reporting reviewed 09/19/2022, states that the objective is to provide a timely and thorough investigation for all reported occurrences, accidents, incidents, any allegations of abuse, and any reports of suspicion of a crime being committed against a resident. Resident was admitted to the facility with diagnoses including Cerebellar Stroke Syndrome, Mood Disorder and Vascular Dementia without Behavioral Disturbance. A Nursing Progress Note, by Licensed Practical Nurse (LPN) #1, dated 09/14/23 at 2:00pm, documented that Resident #1 reported to LPN #1 that CNA #1 on the 11:00pm - 7:00am shift, hit Resident #1 with a bed sheet because Resident #1's TV was too loud on 09/14/23. An Accident/Incident Report, by Assistant Director of Nursing (ADON), dated 09/14/23 documented that Resident #1 was interviewed and stated that CNA #1 from the previous shift 11:00 pm- 7:00 am was rough with the sheets during care. On assessment no injury noted, Range of Motion (ROM) within normal limits, and skin intact. CNA #1 was removed from schedule pending investigation. The ADON interviewed Resident #1's roommate who stated that Resident #1 made noises when CNA #1 asked Resident #1 to turn their TV volume down because it was disturbing. The facility concluded that Resident #1 was upset after CNA #1 turned their TV volume down and that abuse, neglect, or mistreatment did not occur. During an interview on 10/05/23 at 11:15am, CNA #1 stated that they were assigned to Resident #1 on 09/14/23 on the night shift (3:00pm-11:00pm). CNA #1 stated that Resident #1 rang the bell at around 4:45am and CNA #1 went to Resident #1's room. CNA #1 stated that Resident #2 asked CNA #1 to lower the volume on Resident #1's TV because it was too loud, and Resident #2 was unable to sleep. CNA #1 stated that they (CNA #1) asked Resident #1 to lower the volume on the TV with the remote control, but Resident #1 did not want the volume to be lowered. CNA #1 stated that CNA #1 lowered the volume on the TV and Resident #1 became upset and was verbally loud. A subsequent interview on 10/27/23 at 3:40 pm, the Assistant Director of Nursing (ADON) stated that they did not focus or address the volume on Resident #1's TV. The ADON said that no interventions were implemented because it happened only once. The ADON stated that the focus was on the abuse. 10 NYCRR 415.4 (b)

Based on observation, interviews and record reviews conducted during an Abbreviated Survey (NY00323964), the facility failed to ensure that a resident's care plan was reviewed and revised to accurately reflect the status of the resident. This was evident in 1 out of 3 resident (Resident #1) sampled. Specifically, Resident #1 reported on 09/14/23 at 2:00pm that Certified Nursing Assistant (CNA) #1 was rough with them and hit Resident #1 with the bed sheet because the volume on Resident #1's Television (TV) was too loud. Resident #1's care plan was not updated with interventions addressing the volume on the TV. The findings are: The facility Policy and procedure, Care Planning. The purpose and policy, to ensure that resident care and treatment is planned appropriately for resident's needs and condition, impairment, disability, or disease process in a timely, systematic, and comprehensive manner. The care plan is revised when appropriate to reflect the resident's current needs based on evaluation of progress towards goals, response to care and treatment, significant changes in the resident's status and resident preferences/choices. Resident was admitted to the facility with diagnoses including Cerebellar Stroke Syndrome, Mood Disorder and Vascular Dementia without Behavioral Disturbance. The Minimum Data Set (MDS, a resident assessment tool) dated 07/27/23 documented that Resident #1 had cognition was severely impaired. A Nursing Progress Note, by Licensed Practical Nurse (LPN) #1, dated 09/14/23 at 2:00pm, documented that Resident #1 reported to LPN #1 that CNA #1 on the 11:00pm - 7:00am shift, hit Resident #1 with a bed sheet because Resident #1's TV was too loud on 09/14/23. LPN #1 notified the ADON. An Accident/Incident Report, by Assistant Director of Nursing (ADON), dated 9/14/23 documented that Resident #1 was interviewed and stated that CNA #1 from previous shift 11:00 pm- 7:00 am was rough with the sheets during care. On assessment no injury noted, Range of Motion (ROM) within normal limits, and skin intact. CNA #1 was removed from schedule pending investigation. The Assistant Director of Nursing (ADON) Resident #1's roommate who stated that Resident #1 made noises when CNA #1 asked Resident #1 to turn their TV volume down because it was disturbing. The facility concluded that Resident #1 was upset after CNA #1 turned their TV volume down and that abuse, neglect, or mistreatment did not occur. A Care Plan for Risk for Abuse dated 07/21/23 documented interventions to encourage resident to voice concerns to staff regarding their peers, staff to observe during rounds and care, encourage participation in programs of choice and Psych consult pro re nata (prn or as needed). There were no interventions addressing Resident #1's TV volume. During an interview on 10/05/23 at 11:15am, CNA #1 stated that they were assigned to Resident #1 on 09/14/23 on the night shift (3:00pm-11:00pm). CNA #1 stated that Resident #1 rang the bell at around 4:45am and CNA #1 went to Resident #1's room. CNA #1 stated that Resident #2 asked CNA #1 to lower the volume on Resident #1's TV because it was too loud, and Resident #2 was unable to sleep. CNA #1 stated that they (CNA #1) asked Resident #1 to lower the volume on the TV with the remote control, but Resident #1 did not want the volume to be lowered. CNA #1 stated that CNA #1 lowered the volume on the TV and Resident #1 became upset and was verbally loud. During a telephone interview on 10/27/23 at 3:15pm, the Director of Nursing (DON) stated that the care plan for Resident #1 should have been updated with interventions addressing the TV volume issue. 10 NYCRR 415.11 (c)(2)

Based on observation, interview, and record review during an abbreviated survey (NY00314841), the facility failed to develop a baseline care plan within 48 hours of a resident's admission. This was evident in 1 of 3 residents sampled (Resident #1. Specifically, a Baseline Care Plan was initiated for Resident #1 but was not completed within 48 hours of admission, and Resident #1 was not provided with a written summary of their baseline care plan. The findings are: The facility policy titled The Interdisciplinary Baseline Plan of Care with last review date of 01/30/2023 states that all newly admitted residents will have a Baseline Care Plan initiated and completed within 48 hours of admission. Upon completion, Nursing will review and provide a copy of the Baseline Care Plan to the resident/representative. Nursing will document in the progress note that the resident/representative was provided with education regarding the Baseline Plan of Care, and offered a copy of same, that the resident/representative goals of care were reviewed. Resident #1 was admitted to the facility with diagnoses including Osteomyelitis, Cellulitis of the Right Foot (RF), and Diabetic Foot Infection. The Minimum Data Set with an assessment reference date of 04/11/2023 documented that Resident #1 has a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. Review of Resident #1's medical record revealed that an Interdisciplinary Team (IDT) Baseline Plan of Care form was initiated on 04/04/2023 however, the form was not completed. There was no documented evidence in the electronic medical record (EMR) that Resident #1 was provided with a written copy of the resident's baseline care plan. During an interview on 04/20/2023 at 9:15 am, Resident #1 stated that they were admitted to the facility for antibiotic administration and wound care. Resident #1 stated that they were not provided a copy of their Baseline Care Plan. During an interview on 06/29/2023 at 2:40 pm, Registered Nurse Supervisor (RNS) #2 stated that the IDT was responsible for completing the Baseline Care Plan on the Resident's admission. RNS #2 stated that they are not sure why a Baseline Care Plan was not completed for Resident #1. RNS #2 said that the nursing supervisor on duty is responsible for providing a copy to the Baseline Care Plan to Resident #1 or their representative. During an interview on 06/29/2023 at 2:57 pm, the Director of Nursing (DON) stated that the nursing supervisors are supposed to review the new admission care plan and make sure that a Baseline Care Plan is completed within 48 hours from the time the resident is admitted , and a copy provided to the resident or their representative. 10 NYCRR 415.11 (c)

Based on observation, interview, and record review conducted during an abbreviated survey (NY00314841), the facility failed to ensure that the services provided or arranged by the facility as outlined by the comprehensive care plan, met professional standards of quality. This was evident in 1 of 3 residents (Resident #1) sampled for quality of care/treatment. Specifically, Resident #1 Physician's Order documented Vancomycin Trough STAT (medical term for immediately or at once) dated 04/05/2023 and Vancomycin Trough One-Time dated 04/06/2023. The lab results dated 04/06/2023 and 04/07/2023, revealed that the Vancomycin Trough was done, but there was no documented evidence that the trough levels were reviewed by nursing or a medical staff. The findings are: The facility policy titled Laboratory Tests dated 10/11/2020 states that the results of diagnostic testing will be reviewed by the Nursing and Medical Staff and changes will be made to the resident plan of care as indicated. Resident #1 was admitted to the facility with diagnoses including Osteomyelitis, Cellulitis of Right Foot, and Diabetic Foot Infection. The Minimum Data Set with an assessment reference date of 04/11/2023 documented that Resident #1 has a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. A care plan for Antibiotic / Peripherally Inserted Central Catheter (PICC) line was initiated on 04/04/2023. The care plan documented that Resident #1 requires intravenous (IV) antibiotic. The facility interventions include to monitor labs as ordered and review with MD, and to review peak and trough levels as ordered. A Physician's Order dated 04/05/2023, for Resident #1, documented Vancomycin Trough STAT, and Vancomycin, Trough One-Time dated 04/06/2023. A Laboratory Result dated 04/06/2023 at 4:49 am, revealed that Vancomycin Trough level was collected. The result documented <5.00 L (reference range 10.0-20.0). The result was reported to the facility on [DATE] at 07:00 pm. A Laboratory Result dated 04/07/2023 at 8:16 am, revealed that Vancomycin Trough level was collected. The result documented 7.8 L. The result was reported to the facility on [DATE] at 7:00 pm. There was no documented evidence that the trough levels were reviewed by nursing or a medical staff. Therefore, no interventions were implemented. During an interview on 04/20/2023 at 6:05 pm, Registered Nurse Supervisor #1 (RNS #1) stated that they worked on 04/06/2023 on the 3:00pm-11:00pm shift and was not aware of the Vancomycin trough results. RNS #1 said that the lab usually calls them with abnormal lab results and fax the results to the nursing office. RNS #1 stated that they did not receive a call and did not receive a fax with Resident #1's Vancomycin trough level. During an interview on 04/20/2023 at 6:30 pm, RNS #2 stated that they worked on 04/06/2023 on the 7;00am-3:00pm shift and do not recall receiving a call or fax from the lab with Resident #1's Vancomycin trough level. RNS #2 stated that they did not follow-up with the laboratory about the results of the STAT order. During an interview on 04/21/2023 at 2:49 pm, RNS #3 stated that they worked on 04/05/2023 and entered the order for a STAT Vancomycin Trough level. RNS #3 stated that the laboratory either call or fax the results for STAT orders. RNS #3 stated that they did not receive any results on 04/05/2023 and endorsed to the next shift to follow up. RNS #3 stated that they worked on 04/07/2023 on the 7:00am-3:00pm and the 3:00pm-11:00pm shifts and did not receive any of the Vancomycin trough results. During an interview on 04/21/2023 at 8:37 am, Medical Doctor (MD) #1 stated that they ordered Vancomycin trough levels a few times for Resident #1 and was not able to review the results because no one told them that the results came in. MD #1 said that laboratory results can be found in Sigma, but the trough levels did not show up. MD #1 stated that they called the nurse on the unit, does not recall the nurse's name, but the nurse said that the results were not showing in Sigma. MD #1 stated that they do not have access to the Laboratory website. During an interview on 04/20/2023 at 12:30 pm, the Assistant Director of Nursing (ADON) said that the laboratory results interphases with Sigma, and if it does not show up, the laboratory has a website that can be accessed by the RNS. The ADON also stated that they receive laboratory results through fax and most of the time, the laboratory will make a phone call and send a fax for STAT orders and abnormal results. During an interview on 04/21/2023 at 9:00 am, the Director of Nursing (DON) said that laboratory results can be found in Sigma and can also be accessed through the laboratory website. The DON stated that it is the nurses and the nursing supervisor's responsibility to follow up with the results and relay the result to the MD. The DON added that the MD also has the responsibility to follow up with the result on their own by looking it up on Sigma. 10 NYCRR 415.11(c)(3)(i)

Based on observation, interview, and record review conducted during an abbreviated survey (NY00314841), the facility failed to ensure that a resident receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was evident in 1 of 3 residents (Resident #1) reviewed for quality of care and treatment. Specifically, Resident #1 has a physician's order for Vancomycin 1gm (gram)/250ml (milliliter) in 0.9% Sodium Chloride intravenous (IV) infuse 1 gm by IV route every 8 hours. Review of the electronic Medical Administration Record (eMAR) revealed that Resident #1 missed 2 dosages of Vancomycin. Additionally, Resident #1 has a physician's order dated 04/07/2023 for Peripherally Inserted Central Catheter (PICC) line dressing change every 72 hours. Review of the electronic Treatment Administration Record (eTAR) showed that the PICC line dressing change was not done until 04/13/2023. The findings are: The facility policy on Medication Administration using the eMAR with last review date of 01/2023 states that nurses administering medications and treatments will document correctly on the eMAR reflecting that the medication/treatment was administered. For refusal of medication, the nurse will click on not administered and document reason. Medical Doctor (MD) must be notified of drug refusal, and a note must be written which includes the medication, the physician notified, and intervention given by the physician. The facility policy on Intravenous Therapy with effective date of 08/31/2022 states that the order for care and management of intravenous catheter site will be placed in the treatment order group. This order will include dressing changes every 7 days and as needed if damaged or soiled for midlines and centrally placed catheters. Resident #1 was admitted to the facility with diagnoses of Osteomyelitis, Cellulitis of Right Foot, and Diabetic Foot Infection. The Minimum Data Set with an assessment reference date of 04/11/2023 documented that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. A care plan for Antibiotic / PICC line was initiated on 04/04/2023. The care plan documented that Resident #1 required intravenous IV antibiotic. The interventions included monitoring labs as ordered and review with the Medical Doctor (MD). Monitoring for side effects of antibiotic and reporting to the MD. Monitoring of the PICC line site for signs and symptoms of infection every shift and report findings. A Physician's Order dated 04/06/2023 documented Vancomycin 1gm/250ml in 0.9% Sodium Chloride IV, infuse 1gm by IV route every 8 hours at 6:00 am, 2:00 pm, and 10:00 pm. The eMAR showed that Resident #1 was not administered Vancomycin IV on 04/14/2023 at 2:00 pm and on 04/15/2023 at 2:00 pm. A Nursing Note dated 04/15/2023 at 6:13 pm documented that Resident #1 left the facility at 4:20 pm with a family member. There was no documented evidence that the MD was notified of the missed dosages of Vancomycin and no interventions were implemented. A Physician's Order dated 04/07/2023 documented an order for PICC line sterile dressing change every 72 hours. An electronic Treatment Administration Record (eTAR) showed that the PICC line dressing change was not performed until 04/13/2023. During an interview on 04/20/2023 at 1:02 pm, Registered Nurse #1 (RN #1) stated that Resident #1 has an order for Vancomycin every 8 hours at 6:00 am, 2:00pm, and 10:00 pm. RN #1 stated that Resident #1 missed their 2:00pm Vancomycin dose on 04/14/2023 because Resident #1 was in rehab therapy. RN #1 also said that Resident #1 missed the 2:00pm dose on 04/15/2023 because Resident #1 refused due to the Resident going out on pass. RN #1 said that they did not write a progress note about the missed dosages and that they did not notify the MD. RN #1 also stated that they did not change Resident #1's PICC line dressing on 04/07/2023, 04/10/2023, and 04/16/2023 because they could not obtain the supply for the PICC line dressing. RN #1 stated that they did not ask anyone for the supply. RN #1 said that they were able to obtain supplies on 04/16/2023 and that the PICC line dressing change was done on 04/17/2023. During an interview on 04/20/2023 at 6:30 pm, Registered Nurse Supervisor #2 (RNS #2) stated they were not made aware that Resident #1 missed 2 dosages of Vancomycin. RNS #2 said that PICC line dressing change kits are always available in the unit. RNS #2 stated that RN #1 did not approach them on where to get supplies for the PICC line dressing change. During an interview on 04/21/2023 at 8:37 am, MD #1 stated that they were not notified that Resident #1 missed two doses of Vancomycin. During an interview on 04/21/2023 at 9:00 am, the Director of Nursing (DON) said that the nurse should have notified the MD that Resident #1 missed their Vancomycin and that the nurse should have documented the reasons in the progress notes. During a follow up interview on 06/29/2023 at 2:57 pm, the DON stated that they have a medical supply personnel who makes sure that units are properly stocked and if RN #1 was unable to locate the PICC line supply, they should have picked up the phone and call medical supply personnel. The DON said that they would have delivered the PICC line supply. 10 NYCRR 415.12

Based on observation, interview, and record review conducted during an abbreviated survey (NY00314841), the facility failed to address an irregularity identified during Drug Regimen Review (DRR) to minimize or prevent adverse consequences. This was evident in 1 of 3 residents (Resident #1) reviewed for quality of care and treatment. Specifically, Resident #1's DRR dated 04/04/2023 documented that the Vancomycin order is without a future end date. The facility did not review and update the Physician's Order to reflect a future end date. Resident #1 was receiving Vancomycin 500 milligrams (mg) intravenous (IV) solution, infuse 500 mg by IV route 3 times per day without a future end date. The findings are: The Policy on Drug Regimen Review with last reviewed date of 03/2023 states that the attending Physician or licensed designee shall respond to the Drug Regimen Review in a timely manner. Any identified irregularities must be reported to the Director of Nursing (DON) and/or Nursing Supervisor for immediate follow-up and action by the Attending Physician and/or licensed designee. The Policy on Medication Administration using the Electronic Medication Administration Record (eMAR) with last review date of 01/2023 states that all orders pertaining to a resident care will be accurately entered into the Sigma care system. The nurse will fill in the required fields on the order screen; these include an end date for medications that are ordered for a specific amount of time. Resident #1 was admitted to the facility with diagnoses including Osteomyelitis, Cellulitis of Right Foot, and Diabetic Foot Infection. A Physician's Order dated 04/04/2023 at 3:58 pm documented Vancomycin 500 mg IV solution, infuse 500 mg by IV route 3 times per day. There was no future end date on the order. A Drug Regimen Review dated 04/04/2023 documented that Vancomycin 500 mg IV TID (three times daily) is without future end date. The recommendation documented in the DRR was to place a stop date/parameter on antibiotic to evaluate efficacy and continuation of treatment. The DRR also documented that the DRR findings were reported to the provider, the Director of Nursing, and the Medical Director. The provider response section of the DRR, completed by MD #1, documented that the MD agreed with the recommendations of the pharmacist. The nurse response section on the DRR form was not completed. A Physician's Order dated 04/06/2023, revealed that the initial order was discontinued, and a new order was entered on 04/06/2023 for Vancomycin 1gm (gram)/250ml (milliliter) in 0.9% Sodium Chloride intravenous, infuse 1gm by IV route every 8 hours. There was no future end date on the new order. During an interview on 04/20/2023 at 12:30 pm, the Assistant Director of Nursing (ADON) stated that they entered the order for Vancomycin for Resident #1 on 04/06/2023 but forgot to put a stop date on the order. The ADON said that the stop date should have been 05/01/2023. During an interview on 04/21/2023 at 8:37 am, MD #1 stated that they reviewed the DRR and signed for it in the electronic medical record (EMR). MD #1 also said that they instructed a nurse to put an end date on the Vancomycin order. The MD could not recall remember the nurse's name. During an interview on 04/21/2023 at 9:00 am, the Director of Nursing (DON) stated that the Vancomycin should have a stop date and the nurse who entered the order should have written a stop date. The DON stated that the pharmacy consultant does the drug regimen review electronically and document their findings on Sigma (electronic medical record software). The DON stated that the nursing supervisors are responsible for reviewing the DRR and making sure that the recommendations are carried out based on the providers response. 10 NYCRR 415.18(c)(2)

Based on observation, interview, and record review conducted during an abbreviated survey (NY00314841), the facility failed to maintain clinical records including treatment/medication administration, in accordance with accepted professional standards and practices, that are complete, and accurately reflect a resident's treatment and condition. This was evident in 1 of 3 residents (Resident #1) reviewed for quality of care and treatment. Specifically, Resident #1's Physician's Order dated 04/04/2023 documented Cleanse Right Lateral foot with Normal Saline Solution (NSS) and apply Wet to Dry dressing daily. Review of the electronic Treatment Administration Record (eTAR) revealed that the order for the treatment was not transcribed on the eTAR, and the treatments were not signed for. The findings are: The facility policy on Medication Administration using the eMAR with last review date of 01/2023 states that all orders pertaining to resident care will be accurately entered into the Sigma care system. The nurses administering medications and treatments will document correctly on the eMAR reflecting that the medication/treatment was administered. A Physician's Order dated 04/04/2023 documented, cleanse right lateral foot with Normal Saline Solution (NSS) and apply wet to dry dressing daily. Review of the eTAR revealed that the order for the treatment was not transcribed on the eTAR. During an interview on 04/20/2023 at 9:15 am, Resident #1 stated that the nurses perform daily dressing change on their right foot wound. During an interview on 04/20/2023 at 12:45 pm, Licensed Practical Nurse #1 (LPN #1) stated that they signed the eTAR for Resident #1's wound care. LPN #1 was unable to locate their signature in eTAR. During an interview on 04/20/2023 at 2:07 pm, LPN #2 stated that Resident #1 had an order for treatment to the right foot wound in Sigma (an electronic medical record software). LPN #2 said that they performed dressing change to Resident #1's right foot on 04/19/2023 and signed for it on the eTAR. LPN #2 was unable to locate their signature in eTAR. During an interview on 04/21/2023 at 5:16 pm, the Wound Care Coordinator (WCC) stated that Resident #1 had surgery on their right lateral foot and had an order for wet to dry dressing change. The WCC stated that they entered the order for daily wet to dry dressing on 04/04/2023 but that they forgot put in a schedule; as a result, the order was not transcribed to the eTAR for the nurses to sign. During an interview on 04/20/2023 at 12:30 pm, the Assistant Director of Nursing (ADON) stated that treatment orders should have a schedule entered in the physician's order so it would automatically transcribe to the eTAR. The ADON attempted to locate the treatment order on the eTAR but was unable to locate it. 10 NYCRR 415.22(a) (1-4)

Based on observation, record review, and interviews conducted during the Recertification survey from 5/9/23 to 5/16/23, the facility did not ensure person-centered care plans (CCP) was developed and implemented to meet resident needs. This was evident for 3 (Resident #190, #86, and #47) of 38 total sampled residents. Specifically, 1) a CCP related to wandering and elopement was not developed for Resident #190, 2) a CCP related to seizure disorder was not developed for Resident #86, and 3) a CCP related to behavior was not developed for Resident #47. The findings are: The facility policy titled CCP dated 2/2023 documented the Comprehensive Care Plan will include measurable objectives and timeframes, to meet a resident medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment. 1) Resident #190 had diagnoses of psychotic disorder and anxiety disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #190 had moderately impaired cognition. On 05/11/23 at 03:57 PM, 05/12/23 at 08:50 AM, 05/15/23 at 2:20 PM, and 5/16/23 at 11:09 AM Resident #190 was observed with a Wander Elopement Device (WED) applied to their right ankle and was on 1:1 staff observation. The Physician's order dated 02/27/2023 documented Resident #190 have their WED monitored and checked for placement every shift. The Medication Administration Record (MAR) for May 2023 documented Resident #190 had their WED placement checked according to Physician's order. Nursing note dated 5/15/2023 documented Resident #190 continues on 1:1 monitoring and WED is functional. No aggressive behavior noted. There was no documented evidence a CCP related to wandering or elopement was developed to include Resident #190's WED use. On 05/15/23 at 12:09 PM, an interview was conducted with License Practical Nurse (LPN) #4 who stated Resident #190 had a WED to their right ankle, wanders, and has made several attempts to elope by going to the elevator. On 05/15/23 at 10:05 AM, an interview was conducted with LPN #6 who stated they are responsible for completing CCPs related to wandering and elopement. LPN #6 did not have time to complete the CCPs for Resident #190 because they assist with medication administration. Resident #190 does wander and has attempted to elope. 2) Resident # 86 had diagnoses of diabetes and seizure disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] Resident #86 was cognitively intact and had a diagnosis of seizure disorder. Physician order dated 5/8/2023 documented order for Resident #86 to receive Levetiracetam 750 mg 2 tablets (1500 mg) by oral route every 12 hours for seizure disorder. Nursing note dated 5/13/2023 documented Resident #86 had a diagnosis of seizure disorder. There was no documented evidence a CCP related to seizure disorder was developed and implemented to address Resident #86's diagnosis seizure disorder. On 05/15/23 at 09:18 AM, an interview was conducted with Licensed Practical Nurse (LPN) #3 who stated Resident #86 is on Keppra and has a diagnosis of seizure disorder. 45988 3) Resident #47 had diagnoses of dementia and Parkinson's disease. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #47 had severe cognitive impairments. Behavior notes dated 11/11/22, 11/17/22, and 11/23/22 documented Resident #47 had recurring disruptive behaviors such as screaming, rolling out of bed onto a mat on the floor, and being physically aggressive with staff. A psychiatry consult dated 12/20/22 documented staff reported Resident #47 was agitated, often disrobing, restless and combative during care. On evaluation, Resident #47 was irritable, hostile, disorganized and unable to respond to interview questions. A nursing note dated 3/1/23 documented Resident #47 was very combative, cursing, hitting, and spitting at staff. Resident #47 also attempted to hit and pinch staff when they attempted to redirect the resident. Behavior notes dated 3/20/23, 3/22/23 and 3/23/23 documented Resident #47 continued exhibiting disruptive behaviors such as disturbing roommate's sleep with noise, becoming verbally and physically abusive towards staff when redirected, kicking, spitting, shouting, rolling off the bed onto a mat and then crawling on the floor. A psychiatry consult dated 4/18/23 documented Resident #47 was noted with increased bizarre behaviors and extreme agitation. A CCP related to dementia, effective 04/07/2023, documented a goal that Resident #47 will maintain a level of cognitive function within the next 90 days. Interventions included anticipate needs and provide care, introduce self with each visit, monitor for changes and report to physician, and provide reality orientation each shift. There was no documented evidence a CCP related to inappropriate behavior was developed and implemented for Resident #47. On 05/16/23 at 9:06 AM, the Certified Nursing Assistant (CNA) #4 was interviewed and stated Resident #47 becomes aggressive during care, screams, and hits staff. On 05/16/23 at 09:42 AM, Licensed Practical Nurse (LPN) #8 was interviewed and stated Resident #47 exhibits behaviors such as screaming, having outbursts, and being disruptive. CCPs are initiated by the Registered Nurses (RN) upon admission and if there are new issues. On 5/16/23 at 11:09 AM, LPN #3 was interviewed and stated the RNs initiate the CCPs and the nursing staff work together to update the CCPs every 90 days. On 05/16/23 at 12:21 PM, the RN supervisor was interviewed and stated the RNs initiate the CCPs and the LPNs update the CCPs. Resident #47 does not have a CCP for behavior in place and this should have been done. On 05/16/23 02:47 PM, the Director of Nursing Services (DNS) was interviewed and stated the RN Supervisors initiate the CCPs. At times, there is not always a RN Supervisor on duty. The DNS gave no specific reason for CCPs not being initiated completed, and or reviewed and revised. 415.11(c)(1)

Based on observations, record review, and staff interviews conducted during the Recertification survey (T37011), the facility did not ensure safe food storage was practiced. This was evident during the Kitchen Observation facility task. Specifically, (1) expired honey thickened orange juice and enteral feeding bottles were observed in the dry food storage area. (2) the emergency food storage area was observed with expired thickened orange juice and multiple bottles and boxes of expired enteral feeding. The findings are: The facility policy titled Standard Operating Procedure Receiving/FIFO Policy, revised [DATE], documented use first in, first out (FIFO) inventory rotation of products in all storage areas to assure that oldest dated products in all storage areas to assure that oldest dated products are used first, products with easiest date use by or expiration date and stored in front of product with later dates . The facility Dietary Competency Rotation documented food items must be dated upon receiving and stock must be rotated First in, first out. Food items with older receiving dates will be placed in front or on top of newly dated delivery. All dates on food items should be checked before use in order for proper rotation FIFO. Check all food items on a regular basis for expiration date. During the initial tour of the kitchen and dry food storage on [DATE], from 09:29 AM to 11:01 AM, the following expired items were observed: Two boxes of 24 count 4-ounce (oz.) cups of honey thickened orange juice with a use by date of [DATE]. Twelve 50.7 fluid (fl) oz. bottles of Glucerna 1.2 (enteral feeding) with a use by date of [DATE] were on the shelf in the dry storage room. During an observation of the emergency food storage on [DATE] from 03:28 PM to 03:45PM, the following expired items were observed: One box of 48 count 4 oz cups of honey thickened orange juice with a best by date [DATE], one bottle of Glucerna 1.2 with a use by date of [DATE], two bottles of Glucerna 1.2 enteral feeding with use by date of [DATE], one 33.8 fl oz bottle of Glucerna with carb steady with a use before date of [DATE], two 33.8 fl oz bottles of Glucerna 1.2 enteral feeding with a use by of [DATE], four bottles of Nepro 1.8 calorie enteral feeding with a use by date of [DATE], six 33.8 fl oz bottles of Two Cal HN enteral feeding with a use by date of [DATE], five 33.8 fl oz bottles of Nepro carb steady 1.8 calorie enteral feeding with a use by date of [DATE], 1 box containing six 50.7 fl oz- bottles of Glucerna 1.5 with use by date of [DATE], twelve 33.8 fl oz bottles of Glucerna 1.2 enteral feeding with a use by date [DATE], 5 bottles of enteral feeding with use by date of [DATE]. 1 bottle of Glucerna 1.2 calorie enteral feeding with use by date of [DATE], twelve 50.7 fl oz bottles of Glucerna 1.2 enteral feeding with use by date of [DATE], 1 bottle of Jevity 1.2 enteral feeding with use by date of [DATE], 3 bottles of Glucerna 1.2 enteral feeding with use by date of [DATE], 1 bottle of Glucerna with carb steady 1.5 cal with use before date of [DATE], 32 bottles of 33.8 fluid ounce Jevity 1.2 enteral feeding with use by date of [DATE], 2 boxes containing 8 bottles of Jevity 1.2 enteral feeding with use by date of [DATE], 2 bottles of Jevity 1.2 enteral feeding with use by date of [DATE], 1 bottle of 1 Glucerna 1.2 enteral feeding with use by date of [DATE], six 33.8 fl oz bottles of Glucerna 1.5 carb steady enteral feeding with use by date of [DATE], 1 box of eight bottles of Jevity 1.5 enteral feeding with use by date of [DATE], 1 box of 8 bottles of Jevity 1.2 enteral feeding with use by date of [DATE], 1 bottle of Jevity 1.2 enteral feeding with use by date of [DATE]. On [DATE] at 11:07 AM, the Dietary Associate was interviewed and stated that they look at items on the shelf daily and when they restock items. They use First In First Out (FIFO). When the enteral feedings are delivered on Wednesday, they try to rotate them. They removed expired items last month from shelves. Thickened juice- comes in on Tuesdays. They write the date and rotate items to bring forward items on the shelf. They have noticed items close to expiration. They are not supposed to use expired items, which is why items are rotated. Residents cannot be given expired foods. On [DATE] at 11:1 4 AM, an interview was conducted with the Food Service Supervisor who stated when items are received, they look to see if the storeroom person rotated items on the shelf. Items should be rotated using First in First Out for utilization to prevent using foods with mold and bacteria to prevent foodborne illness. When food is delivered on Tuesday, storeroom person does random checks to make sure there is no expired food. On [DATE] at 2:55 PM, the Dietary Associate was interviewed and stated the emergency food was last stocked in [DATE], and items were rotated. The looked at the expiration dates and used FIFO. Expired items are brought to management's attention. Any expired items in the room were discarded in [DATE]. The Acting Food Service Director was present when the storeroom was stocked. On [DATE] at 03:00 PM, the Food Service Supervisor (FSS) was interviewed and stated they have not looked at the emergency food stock for expiration dates and only checked the dry storage area. On [DATE] at 03:01 PM, the acting Food Service Director was interviewed and stated they periodically check expiration dates. Every 6 months they rotate the old stock, and they rotate when new stock is ordered. Some items came in [DATE]. When items are within 1 month of expiration/use by date, we put it in use. Once in a while, there are expired items. Expired items are not good for residents and should not be consumed as they are a health hazard. There is no system to track expired items. They check boxes, and they take old ones out and put new ones in. 415.14 (h)

Based on observation, record review, and interviews conducted during a Recertification Survey from 5/9/23 to 5/16/23, the facility did not ensure a safe, clean, comfortable, and homelike environment for residents. This was evident for 1 (Unit 7) of 6 units observed. Specifically, Resident #67 and Resident #47 had wheelchairs that were in disrepair. The findings are: The facility policy titled Wheelchair Cleaning and Repair dated 9/2018 documented all resident wheelchairs will be maintained clean and in good working order. Resident #67 had diagnoses of non-Alzheimer's dementia and seizure disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #67 had severe cognitive impairment and used a wheelchair. Multiple observations of Resident #67 were made between 05/09/23 at 10:03 AM and 05/12/23 at 11:07 AM of the resident on the Unit 7 in their wheelchair. The armrest pad on the right side was missing and had been filled with gauze and medical tape. The plastic mold where the armrest pad usually sits was still attached to the chair, but the pad was missing, leaving a void and a raised edge that was partially covered by the gauze. On 05/11/23 at 12:08 PM, Resident #67 was interviewed and stated the armrest had been broken for a while and that they avoid using it because it is sharp and they could get cut. Resident #47 had diagnoses of dementia and Parkinson's disease. The MDS assessment dated [DATE] documented Resident #47 had severe cognitive impairments and used a wheelchair. On 05/11/23 at 10:46 AM, 05/12/23 at 10:09 AM, and 05/16/23 at 09:03 AM, Resident #47 was observed in the Unit 7 dining room, sitting in their wheelchair. There was no armrest on the right side of the wheelchair. Gauze and medical tape had been attached to create a padding. The tape was falling off and dirty. The Maintenance Logbook for Unit 7 did not document requests to repair the armrest for Resident #67 and #47. On 05/12/23 at 10:50 AM, Certified Nursing Assistant (CNA) #3 was interviewed and stated that if they notice something not working properly, they report it to the nurse. There is a logbook for environmental issues on the floor. The environmental department people come every day and look in the book and fix the issues. There is a dedicated person who cleans and fixes the wheelchairs. On 05/12/23 at 11:20 AM, Licensed Practical Nurse (LPN) #8 was interviewed and stated that if they see something broken, they report to a supervisor, who will get the appropriate person to fix the issue. For wheelchairs, LPN #8 calls the Rehab Department. LPN #8 was not sure of the status of Resident #67's or Resident #47's wheelchairs. On 05/16/23 at 10:51 AM, the Maintenance Worker (MW) was interviewed and stated the wheelchair mechanic was not at the facility or available for an interview. If there is an issue with a wheelchair and the mechanic is not in, other maintenance workers take a look and try to fix it. If they cannot fix it, they report it to the Director. There is a Maintenance Logbook on each unit that should be used to log any repair request. 415.5(h)(2)