Every finding on record at Brooklyn United Methodist Church Home

Based on observations, record review, and interviews conducted during an abbreviated survey (NY00360005), the facility did not ensure a resident's designated representative was notified of changes in condition. This was evident in one out of three residents (Resident #2) sampled. Specifically, a Health Status Note dated 11/05/2024 documented Resident #2 complained of left eye pain. An assessment was done and revealed mild swelling to the left eye. The Medical Doctor was informed and an ordered for Diclofenac eye drops. There is no documented evidence that Resident #2's designated representative was notified of the changes in condition. The findings are: The facility policy titled: Family Notification revised 01/2025 documented it is the facility's policy to notify the resident, the representative/designee or guardian whenever there is a transfer, room change and change in the resident's condition. Resident #2 was admitted to the facility with diagnoses including Hypertension and Cerebrovascular Accident (a medical term for a stroke). The Minimum Data Set (an assessment tool), dated 09/26/2024, documented Resident #2 had moderate cognitive impairment. A Health Status note dated 11/05/2024 documented Resident #2 complained of left eye pain, an assessment revealed no eye redness or discharge. Pain at the edge of the left upper eyelid when touched and mild swelling observed. The Medical Doctor was informed and ordered Diclofenac eye drops to the left eye three times daily for seven days. An Attending Physician/Provider note dated 11/06/2024 documented Resident #2 was assessed and observed with mild swelling around their left eye. No evidence of acute infection. Plan was to start eye drops to reduce inflammation and any discomfort. If no improvement in the next twenty-hour to thirty -six hours, oral antibiotics will be started. A Physician's Order dated 11/05/2024 documented instill one drop pf Diclofenac Sodium Ophthalmic Solution 0.1 % in the left eye three times a day for left eye pain for seven days. There was no documented evidence that Resident #2's representative was notified. A Social Service note dated 11/07/2024 documented Resident #2's representative visited and observed that Resident #2's left eye was slightly puffy. The representative stated they were not informed of the resident's condition. During an interview on 03/05/25 at 9:49 AM, Social Worker #2 stated that on 11/07/2024 at 4:43 PM Resident #2's representative approached them into their office and reported that they were not informed about Resident #2's left eye. Social Worker #2 stated the policy is to call the resident's family if there is a change in condition or if the resident is being discharged to the hospital. The Social Worker stated that the policy states that nurse is supposed to call the family if there is a change in condition. During an interview on 03/05/2025 at 3:38 PM, Registered Nurse Supervisor #2 stated they assessed Resident #2 on 11/05/2024 and Resident #2 complained of pain while pointing to their left lower eye. The Medical Doctor was notified and assessed Resident #2. The Registered Nurse Supervisor #2 stated that the Medical Doctor ordered eye drops. Registered Nurse Supervisor #2 stated they do not recall notifying Resident #2's representative, however, Resident #2 was alert and oriented and able to understand their plan of care. Registered Nurse Supervisor #2 stated that the Medical Doctor discussed the plan of care with Resident #2. During a telephone interview on 03/11/2025 at 1:00 PM, the Director of Nursing stated the protocol is to always inform the family of any change in the resident condition, incident, physician's orders, and anything pertaining the resident. The Director of Nursing stated Resident #2 was alert, oriented and the Medical Doctor discussed with them about ordering eye drops to treat the discomfort and swelling and Resident #2 agreed with the Medical Doctor's plan of care. During a telephone interview on 03/11/2025 at 2:38 PM, that Administrator stated it is the facility's protocol to notify the family of resident's change in condition, fall, incident, hospital transfer, etc. the Administrator stated that Resident #2's representative should have been notified of Resident #2's eye condition. 10 NYCRR 415.3(f)(2)(ii)(c)

Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00372860), the facility did not ensure that a resident was free from abuse. This was evident for one (1) out of nine (9) residents (Resident #1) sampled. Specifically, the facility's dining room surveillance video recording dated 02/22/2025 showed at 9:05 AM Certified Nursing Assistant #1 hit Resident #1 on their left upper shoulder (once) with the back of their left hand, then walked out of the dining room, after Resident #1 threw liquid on Certified Nursing Assistant #1 who was standing behind them. Housekeeper #1, who was in the dining room, then walked over to Resident #1 and wheeled the Resident out of the dining room at 9:08 AM. Resident #1 was assessed by Registered Nurse Supervisor #1 with no visible injury, pain, or discomfort. The findings are: The facility's Policy and Procedure titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property was revised on 08/2024. The policy states that each resident will be free from Abuse and will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. Resident #1 was admitted to the facility with diagnoses including Hypertension (high blood pressure) and Schizophrenia (a chronic mental illness characterized by disruptions in thought processes, perceptions, emotions, and social interactions). The Minimum Data Set (an assessment tool) dated 01/09/2025 documented Resident #1 had severe cognitive impairment. The Comprehensive Care Plan titled: At Risk for Victimization dated 02/01/2024 documented Resident #1 was at risk for victimization due to observed verbal aggression and socially inappropriate behavior. The interventions documented to encourage verbalization of feelings and to observe for changes in mood, behavior, and affect. The dining room surveillance video (#1) recording dated 02/22/2025 showed at 9:05AM Certified Nursing Assistant #1 picked up Resident #1's meal tray and exited the dining room. Certified Nursing Assistant #1 returned to the dining room and went up behind Resident #1, used their right hand to tap the right side of Resident #1's wheelchair three times. Resident #1 in turn, picked up a cup and without looking tossed the content (liquid) of the cup behind them. The liquid spilled onto Certified Nursing Assistant #1 and onto the floor. Certified Nursing Assistant #1 hit Resident #1 on their left shoulder (once) with the back of their left hand and walked out of the dining room. Housekeeper #1 who was in the dining room rearranging the dining tables, turned around and saw Resident #1 throw the liquid and Certified Nursing Assistant #1 hit Resident #1 on their left shoulder with the back of their hand. Housekeeper #1 then walked over to Resident #1 and was talking to Resident #1 before escorting the resident out of the dining room. Camera view of the dining room ended. The unit hallway surveillance video (#2) recording dated 02/22/2025 showed at 9:08 AM on 02/22/2025, Housekeeper #1 escorted Resident #1 from the dining room to the nursing station and was observed having a conversation with Licensed Practical #1 (Housekeeper #1 was reporting the incident). Resident #1 was observed at the nursing station and a staff providing supervision. Licensed Practical Nurse #1 observed preparing/administering medication. Licensed Practical Nurse #1 observed having a conversation with Certified Nursing Assistant #1 (Licensed Practical Nurse stated they told Certified Nursing Assistant #1 to stop caring for residents). Certified Nursing Assistant #1 walked away from Licensed Practical Nurse #1 and could be seen on camera carrying linens into a resident room, then went into another resident's room (resident alert and oriented times three) with linens after Licensed Practical Nurse #1 spoke with them. Registered Nurse Supervisor #1 arrived on the unit at 10:14 AM. Certified Nursing Assistant #1 left the unit at 10:25 AM. An Incident Note dated 02/22/2025 by Registered Nurse Supervisor #1 documented at approximately 9:35 AM, Housekeeper #1 reported they witnessed Resident #1 tossed apple juice at Certified Nursing Assistant #1, and Certified Nursing Assistant #1 hit Resident #1 on their left should with the back of their hand. Resident #1 was assessed for any physical or emotional trauma. There were no physical injury or pain reported. The dining room camera was reviewed and showed at approximately 9:05 AM Certified Nursing Assistant #1 hit Resident #1. The facility's investigation dated 02/22/2025 documented at approximately 9:35 AM, Housekeeper #1 reported to Registered Nurse Supervisor #1 that they witnessed Resident #1 tossed back liquid at Certified Nursing Assistant #1. Certified Nursing Assistant #1 then hit Resident #1 on their left shoulder with the back of their hand. Resident #1 was assessed and there was no injury or complaints of pain. The facility concluded that abuse had occurred. Certified Nursing Assistant #1 was suspended and subsequently terminated. Staff were re-in serviced on abuse, neglect, mistreatment, and reporting. During a telephone interview on 03/03/2025 at 11:01 AM, Certified Nursing Assistant #1 stated on 02/22/2025 between 10:15 AM and 10:30 AM (not sure of the time), Resident #1 had completed their breakfast in the dining room. Certified Nursing Assistant #1 stated they were attempting to remove Resident #1's meal tray and the resident became excited and threw water at them. Certified Nursing Assistant #1 stated they did not hit Resident #1, but they rubbed Resident #1 on their back and told the resident not to throw anything at them. Certified Nursing Assistant #1 stated Housekeeper #1 was in the dining room and thought they had hit Resident #1. Certified Nursing Assistant #1 stated they did not react to Resident #1's behavior and walked away to care for another resident. Certified Nursing Assistant #1 stated while they were providing incontinent care to a resident (identified as alert and oriented times three) Licensed Practical Nurse #1 approached them and they showed Licensed Practical Nurse #1 their uniform and explained what Resident #1 had done. During an interview on 03/03/2025 at 9:22 AM Housekeeper #1 stated that on 02/22/2025 between 9:00 AM and 9:15 AM (not sure of the time) they observed Certified Nursing Assistant #1 walked up behind Resident #1 and Resident #1 threw juice at Certified Nursing Assistant #1. Certified Nursing Assistant #1 punched Resident #1 on their back with a closed fist. Housekeeper #1 stated they were standing at approximately 10-15 feet away from Resident #1 and Certified Nursing Assistant #1 when they heard a popping sound. Housekeeper #1 stated Resident #1 reported to them that Certified Nursing Assistant #1 punched them in their back. Housekeeper #1 stated they wheeled Resident #1 to the nurse and informed Licensed Practical Nurse #1. Housekeeper #1 stated they are aware that they should not have wheeled Resident #1 out of the dining room and that they could have used the phone in the dining room to call the nurse. Housekeeper #1 stated they were in-serviced on calling the nurse immediately and provide supervision to protect the resident. During a telephone interview on 03/06/2025 at 12:51 PM, Licensed Practical Nurse #1 stated at approximately 9:15 AM Housekeeper #1 informed them that they witnessed Certified Nursing Assistant #1 hit Resident #1 on their back. Licensed Practical Nurse #1 stated they did not report the incident immediately to Registered Nurse Supervisor #1 because they were in the middle of distributing medication. However, Registered Nurse Supervisor #1 arrived on the unit and was asking for Certified Nursing Assistant #1, as they were getting ready to inform Registered Nurse Supervisor #1 of the incident. Licensed Practical Nurse #1 stated Resident #1 was unable to explain what happened. Licensed Practical Nurse #1 stated they had instructed Certified Nursing Assistant #1 to stop working. Licensed Practical Nurse #1 they received in-service to report any incident t their supervisor immediately, stop the perpetrator from completing their assignment and monitor the resident or victim. During an interview on 03/03/2025 at 4:09 PM Registered Nurse Supervisor #1 stated at 9:30 AM Housekeeper #1 approached them with the Administrator on Duty and reported that they witnessed Certified Nursing Assistant #1 punch Resident #1. Registered Nurse Supervisor #1 stated they joined the Administrator on Duty between 9:45 AM and 9:50 AM and reviewed the surveillance video recording before going to the unit at approximately 10:10 AM because they did not receive a call from Licensed Practical Nurse #1. Registered Nurse Supervisor #1 stated the surveillance video recording showed Certified Nursing Assistant #1 hit Resident #1 on their left upper shoulder with an open hand (palm hitting the shoulder). Registered Nurse Supervisor #1 stated they assessed Resident #1 and there were no injuries and Resident #1 denied pain. Registered Nurse Supervisor #1 stated at approximately 10:20 AM they were on the unit looking for Certified Nursing Assistant #1 and saw them in a room and told them to stop what they were doing and report to the nurse's office. Registered Nurse Supervisor #1 stated they should have gone to the unit before watching the video. During an interview on 03/04/2025 at 8:54 AM Acting Administrator stated on 02/22/2025 at 10:25 AM Registered Nurse Supervisor #1 informed them that they removed Certified Nursing Assistant #1 from the unit. Acting Administrator stated after reviewing the surveillance video recording it was determined that abuse had occurred. Acting Administrator stated the surveillance video recording showed Certified Nursing Assistant #1 hit Resident #1 on the left upper shoulder with the back of their hand. Acting Administrator stated Resident #1 was assessed by Registered Nurse Supervisor #1 and Resident #1 did not complain of discomfort and there were no injuries. Acting Administrator stated that the Social Workers were called into the facility to conduct interviews with all residents on the unit. Acting Administrator stated that the Administrator was notified of the incident at 10:30 AM on 02/22/2025 and an ad hoc meeting was held via phone conference. Acting Administrator stated the Abuse policy was reviewed, and no changes were made. Acting Administrator stated that Certified Nursing Assistant #1 was suspended and later terminated. Acting Administrator stated all staff were reeducated on abuse and reporting and they also had discussions with the staff on how to protect residents from further abuse. During an interview on 03/04/2025 at 11:00 AM, Administrator stated Director of Nursing informed them on 02/22/2025 at 10:30 AM that Certified Nursing Assistant #1 hit Resident #1. Administrator stated they instructed Director of Nursing to remove Certified Nursing Assistant #1 off the unit and start an investigation. Administrator stated a conference was held on 02/22/2025 and in attendance was the Medical Director, Director of Nursing, Acting Administrator and the Administrator on Duty. Administrator stated they discussed the incident, reviewed the Abuse policy and instructed the Social Workers to go to the facility to interview all the residents on the unit. Administrator stated to prevent reoccurrence, all staff were reeducated on abuse and an audit tool was initiated to reinforce reporting. During a telephone interview on 03/11/2025 at 12:47 PM, the Director of Nursing stated they were informed of the incident by Registered Nurse Supervisor #1 on 02/22/2025 at approximately 10:19 AM. The Director of Nursing stated they notified the Administrator, and a meeting was held with the administrative team to discuss the incident. The Director of Nursing stated they instructed Registered Nurse Supervisor #1 to remove Certified Nursing Assistant #1 off the unit. The Director of Nursing stated they watched the surveillance video recording and had concluded that abuse did occur. The Director of Nursing stated they conducted in-services on abuse and reporting to all staff. The Director of Nursing stated that the staff were instructed to report any incident timely and not wait. The Director of Nursing stated to prevent reoccurrence, Certified Nursing Assistant #1 was suspended, abuse police was reviewed, and all staff were re in serviced on abuse and reporting. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the non-compliance and was in substantial compliance for this specific regulatory requirement prior to and during the time of this survey. A Plan of Correction is not required for this citation. The facility took immediate corrective actions and was found to incompliance on 02/24/2025, prior to Surveyors' onsite visit on 03/03/2025. On 02/22/2025, Policy and Procedure on Abuse was reviewed. No revisions were done. On 02/22/2025, facility re-in-serviced all staff members (nursing staff, housekeeping, administrative staff, Occupational/Physical Therapy staff, Security, Activity staff, Dietary staff etc.) on the following: Verbal Abuse, Sexual Abuse, Mental Abuse, Involuntary Seclusion, Mistreatment, Neglect, Misappropriation of Property, Screening, Training, Prevention, Identification, Investigation, Reporting/Response, and Protection. The facility took immediate corrective actions. On 02/22/2025 at 10:25 AM Certified Nursing Assistant #1 was removed from the schedule immediately and subsequently terminated. On 02/22/2025 Resident #1 was assessed with no visible injuries or complaints of pain. On 02/22/2025 - Psychiatrist conducted a virtual evaluation of Resident #1. On 02/22/2025 - Abuse policy reviewed with no changes made. On 02/22/2025 a Quality Assurance and Performance Improvement meeting was held on. Topic: Resident #1 being hit on the back of their left shoulder by Certified Nursing Assistant #1. Attendance sheet with names of attendees obtained. On 02/22/2025 - assessment done on all cognitively impaired residents on the unit. On 02/22/2025 an audit done to identified residents with potential for abuse. On 02/22/2025 - all residents on the unit were interviewed to determine if they had experienced any abuse. 02/22/2025 all residents on CNA #1's assignment was interviewed to ascertain if abuse had occurred. On 02/22/2025 an in-service on Abuse, Mistreatment, Neglect and Misappropriation of Property, Protecting, and Reporting was completed. Target audience: All staff. Certified Nursing Assistants 33/33 in-serviced =100% Licensed Practical Nurses 15/15 in-serviced =100% Registered Nurses 15/15 in-serviced = 100% Dietary, Housekeeping, Rehab, Security, and Administrative staff 100% in-serviced. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interviews conducted during an Abbreviated Survey (NY00372860), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident in one out of nine (9) residents (Resident #1) reviewed. Specifically, the facility's dining room surveillance video recording dated 02/22/2025 showed at 9:05AM Certified Nursing Assistant #1 hit Resident #1 on their left shoulder after Resident #1 picked up a cup and without looking tossed the content (liquid) of the cup behind them (wetting Certified Nursing Assistant #1.) Housekeeper #1 who was in the dining room at the time stated that they heard a popping sound after Certified Nursing Assistant #1 hit Resident #1 on their shoulder. The facility did not report the allegation of abuse within 2 hours to law enforcement. The facility notified law enforcement at 12:08 PM. The findings are: The facility's Policy and Procedure titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property was revised on 08/2024. The policy states the facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility. Resident #1 was admitted to the facility with diagnoses including Hypertension (high blood pressure) and Schizophrenia (a chronic mental illness characterized by disruptions in thought processes, perceptions, emotions, and social interactions). The Minimum Data Set (an assessment tool) dated 01/09/2025 documented Resident #1 had severe cognitive impairment. The dining room surveillance video (#1) recording dated 02/22/2025 showed at 9:05AM Certified Nursing Assistant #1 picked up Resident #1's meal tray and exited the dining room. Certified Nursing Assistant #1 returned to the dining room and went up behind Resident #1, used their right hand to tap the right side of Resident #1's wheelchair three times. Resident #1 in turn, picked up a cup and without looking tossed the content (liquid) of the cup behind them. The liquid spilled onto Certified Nursing Assistant #1 and onto the floor. Certified Nursing Assistant #1 hit Resident #1 on their left shoulder (once) with the back of their left hand and walked out of the dining room. Housekeeper #1 who was in the dining room rearranging the dining tables, turned around and saw Resident #1 throw the liquid and Certified Nursing Assistant #1 hit Resident #1 on their left shoulder with the back of their hand. Housekeeper #1 then walked over to Resident #1 and was talking to Resident #1 before escorting the resident out of the dining room. Camera view of the dining room ended. The facility's investigation dated 02/22/2025 documented at approximately 9:35 AM, Housekeeper #1 reported to Registered Nurse Supervisor #1 that they witnessed Resident #1 tossed back liquid at Certified Nursing Assistant #1. Certified Nursing Assistant #1 then hit Resident #1 on their left shoulder with the back of their hand. Resident #1 was assessed and there was no injury or complaints of pain. The facility concluded that abuse had occurred. Certified Nursing Assistant #1 was suspended and subsequently terminated. During a telephone interview on 03/14/2025 at 9:40 AM the Director of Nursing stated it is the policy of the facility to report abuse within two hours to the law enforcement. The Director of Nursing stated they notified the Department of Health, then the Attorney General, and then law enforcement. The Director of Nursing stated that the report to law enforcement was late. During a telephone interview on 03/14/2025 at 10:48 AM the Administrator stated that the policy states law enforcement should be notified within two hours of being aware of an incident. The Administrator stated that law enforcement was notified at around 12:00 PM because they were gathering information. 10 NYCRR 415.4 (b)(1)(ii)

Based on record review and interviews conducted during a Recertification Survey from 01/02/2025 to 01/10/2025, the facility did not ensure a resident, or their designated representative was provided appropriate notification at the termination of Medicare Part A benefits. This was evident for 3 (Residents #47, #51, and #99) of 3 residents reviewed for Beneficiary Notification. Specifically, the facility did not provide appropriate notification at least two calendar days before Medicare covered services ended as required and did not provide the designated form for notification in the nursing home setting. The findings are: The facility policy titled Advanced Beneficiary Notice of Non-Coverage revised 07/2024, documented that it is the facility policy to provide advance notice to Medicare beneficiaries of expected non coverage of services(denial) under Medicare Part B. Effective January 1,2012. CMS form R-131 will be utilized to provide timely advance notification to residents/ designated representatives. 1. Resident #47 was discharged from Medicare Part A services on 11/01/2024 with 1 day remaining and remained in the facility. The Notice of Medicare Non-coverage Form (CMS Form 10123) was signed by Resident #47 and dated 11/01/2024, the same date of discharge from skilled services. In addition, Resident #47 was provided with the Advance Beneficiary Notice of Non-coverage (CMS-R-131) instead of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 which was also signed and dated 11/01/2024. 2. Resident #51 was discharged from Medicare Part A services on 06/21/2024 with 1 day remaining and remained in the facility. The Notice of Medicare Non-coverage Form (CMS Form 10123) was signed by Resident #51 and dated 06/21/2024, the same date of discharge from skilled services. In addition, Resident #47 was provided with the Advance Beneficiary Notice of Non-coverage (CMS-R-131) instead of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 which was also signed and dated 06/21/2024. 3. Resident #99 was discharged from Medicare Part A services on 07/12/2024 with 4 days remaining and remained in the facility. The Notice of Medicare Non-coverage Form (CMS Form 10123) was signed by the spouse of Resident #99 and dated 07/12/2024, the same date of discharge from skilled services. In addition, Resident #47 was provided with the Advance Beneficiary Notice of Non-coverage (CMS-R-131) instead of the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 which was also signed by the spouse of Resident #99 and dated 07/12/2024. Additional information on the Notice of Medicare Non-coverage Form (CMS Form 10123) documented that notification was provided to Resident #99's spouse but did not document when the notification was made. On 01/08/25 at 03:21 PM, an interview was conducted with the Director of Social Services who stated that they had been providing notices for the past year and the Rehabilitation department provides a schedule of who is coming off therapy and their last day of services. The Director of Social Services also stated that notices are reviewed with resident who will sign it, and if the resident is not able to sign it then it is mailed to the family with a request that they return signed copies. The Director of Social Services further stated that notices are given as soon they receive the information from the Rehabilitation department. The Director of Social Services stated that they were not sure of and could not remember the timeframe in which the notices should be given, whether the notices needed to be given three days or 1 week in advance and could not explain why the notices were not given within this timeframe if they thought this to be the correct timeframe. The Director of Social Services also stated that for Resident #99 the spouse was notified on 07/11/2024 and came in to sign the form on 07/12/2024. The Director of Social Services also stated that the Finance department provided them with the form, and they were not aware that an incorrect form was being used. On 01/08/25 at 04:40 PM, an interview was conducted with the Administrator who stated that they did not have much involvement with the Beneficiary notice process, The Administrator also stated that the process of providing notification involves several departments so the facility tries to give themselves extra time so they thought that their policy references that notices should be provided three days before discharge from skilled services and not two as required. The Administrator further stated they were not aware that notices were not being provided in a timely manner and the incorrect form was being used. 10 NYCRR 415.3(g)(2)(i)

Based on observations and staff interviews during the Recertification survey from 01/02/2025 to 01/10/2025, the facility did not ensure that the residents' environment was maintained in a safe, sanitary, and comfortable manner. Specifically multiple observations were made of ceiling tiles and resident equipment and found to be unsanitary and in disrepair. This was evident for 1 of 3 resident units (Unit 3). The findings are: The facility policy titled Homelike Environment dated 10/02/24 state that residents are provided with a safe clean and comfortable and homelike environment. During multiple observations on the 3rd floor unit from 01/02/2025 to 01/10/2025 the following was observed: 1. ceiling tiles along the unit corridors were noted in disrepair, not firmly affixed to the ceiling, cracked and stained. 2. Corridor borders were noted to not be firmly attached and layered with dirt and dust. 3. room [ROOM NUMBER] B had brownish water-stained ceiling tiles. 4. room [ROOM NUMBER] B had a broken wall bumper behind the head of the bed, the wall tile behind the room sink was layered with dirt and stains, and the sink was chipped. 5. room [ROOM NUMBER] A had a high back wheelchair which was heavily stained with dried encrusted food particles. 6. room [ROOM NUMBER] had a wheelchair with a dusty seat cushion and torn left arm rest. 7. room [ROOM NUMBER] had a high back wheel chair which was layered and encrusted with dirt and dried food particles. 8. In the Dining Room there was a dusty worn piano, stains on the walls, and bent, dusty window blinds. On 01/10/25 at 09:08 AM, Housekeeper #2 was interviewed and stated that they start their shift by first cleaning the dining room area before breakfast. Cleaning includes but not limited to dining room tables, chairs, floors and walls if needed. Housekeeper #2 also stated that rooms are also cleaned and disinfected, and they wipe down the walls if they are dirty. Housekeeper #2 further stated that heavy duty cleaning of rooms is also done which consists of cleaning the walls, bed frame, mattress, floors, from top to bottom. On 01/10/25 at 10:08 AM, the Director of Environmental Services was interviewed and stated that their role is to ensure the safety and wellness of all residents, staff and visitors by maintaining a clean and safe and homelike environment. The Director of Environmental Services also stated that they oversee the performance of their staff and make spot checks to ensure the work is carried out, and when they come across an issue they address the issue at that moment with the staff. The Director of Environmental Services further stated that the wheelchairs are challenging to get washed, however they notify the Director of Nursing of the wheelchairs that are to be power washed, and the night shift nurse will remove the wheelchair and place it outside the room door. Sometimes residents will refuse to have their wheelchairs removed from their room. The Director of Environmental Services stated that they do have an issue with the roof which does leak when it rains, which is way the ceiling tiles are stained, and they do try to replace them. On 01/10/25 at 11:06 AM, the Administrator was interviewed and stated that the cleanliness of the environment is important for the prevention of infection control issues and for the overall well-being of the resident and staff morale. The Administrator also stated that they expect to receive a large grant that is going to enable them to replace all the room furniture, the windows, the roof which leaks when it rains, the air conditioners, ceiling tiles and more. The Administrator further stated that they ordered furniture, but the wrong items were sent and they are in the process of correcting this with the company. 10 NYCRR 415.5(h)(2)

Based on observations and interviews conducted during the Recertification survey from 01/02/2025 to 01/10/2025 the facility did not ensure a safe functional environment for residents, staff, and public. This was evident for the staff bathroom and nursing station on 1 (Unit 3) of 3 Units. The finding is: The facility policy titled Homelike Environment dated 10/02/24 stated that residents are provided with a safe, sanitary and orderly environment. During multiple observations on the 3rd floor unit from 01/02/2025 to 01/10/2025 the following was observed: 1. The Staff bathroom adjacent to the Tub Room had a loose and wobbly toilet seat. 2. in the Nurse's Station: a. the Plexi glass was covered with dust, dirt and streaks. b. two swivel chairs were layered with dirt and dust. c. the call bell console was layered with dust and dirt d. there was an accumulation of dirt and dust on the floors underneath the desk e. the computer screen monitors and phones were layered with dust. On 01/10/25 at 09:40 AM, Housekeeper #2 was interviewed and stated that only the floors in the Nurse's station are cleaned and not the station itself. Housekeeper #2 also stated that they do not want to move anything and that the nurse is usually sitting at the nurse station, and they believe that they wipe down their own equipment. Housekeeper #2 further stated that they mostly wipe down the outer counter top of the nurse station. On 01/10/25 at 10:08 AM, the Director of Environmental Services stated that they make rounds to ensure that staff are performing their duties. The Director of Environmental Services also stated that housekeeping staff is supposed to clean the nurse's station, and they can speak with the unit nurse about the areas that they could clean. The Director of Environmental Services further stated that the nurses also wipe their station to keep it free from dust. 10 NYCRR 415.29

Based on observation, and interviews conducted during the Recertification survey from 01/02/2025 to 01/10/2025, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident for 1 (Resident #76) of 1 resident reviewed for Pressure Ulcer out of a sample of 27 residents. Specifically, Licensed Practical Nurse #2 failed to practice appropriate infection control and placing the barrier on a visibly soiled overbed table and did practice appropriate hand hygiene and glove changes during wound care. The findings are: The facility policy titled Wound Care effective date 07/2024 and last reviewed 08/08/2024 stated that the purpose is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors as well as to provide guidelines for the care of wounds to promote healing. The policy also stated under the heading Steps in the Procedure: 1. Use disposable cloth (paper cloth is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange supplies so they can be easily reached. Resident #76 was admitted with diagnoses that included Pressure Ulcer Left Hip, unstageable and Pressure Ulcer Sacral Region, Stage 4. The Annual Minimum Data Set assessment dated [DATE] documented that Resident #76 had short and long-term memory problems, severely impaired cognitive skills for decision-making. The Annual Minimum Data Set assessment also documented that Resident #76 required dependent assistance for transfers, was always incontinent of bowel and bladder, and had two stage 4 pressure ulcers that were present upon admission. The Physician Orders dated 12/20/2024 documented cleanse Left Hip wound with Dakin's solution (1/4 strength) to left hip topically and pat dry. Apply Calcium Alginate, cover with Opti foam dressing two times a day for Stage 4 pressure ulcer of left hip, and cleanse sacral wound with Dakin's (1/4/ strength) solution and pat dry. Apply calcium alginate and cover with Opti foam dressing two times a day for Stage 4 pressure ulcer of sacral area. The Advantage Surgical and Wound Care Progress Note dated 12/30/2024 documented Stage 4 measuring 7cm x 7cm x1cm with undermining at 6:00 ends at 9:00 distance 1.5cm Moderate sero-sanguineous drainage, no odor, 90% granulation 10% slough. Periwound skin does not exhibit signs of infection. The progress note also documented a Left Hip Stage 4 wound measuring 3.5 x 2 x 1 with undermining noted at 9:00 and ends at 12:00 maximum distance. On 01/07/25 at 10:36 AM, a wound care observation for Resident #76 was conducted with Licensed Practical Nurse #2 who was assisted by Certified Nurse Assistant #2. Licensed Practical Nurse #2 washed hands, donned a gown, mask, and gloves, then placed a sterile drape on a visibly soiled overbed table. Licensed Practical Nurse #2 did not clean the overbed table before placing a sterile drape on the visibly soiled overbed table. A white Styrofoam tray was then placed on top of the barrier, solutions were placed at side of barrier, an unwrapped scissor was used to open the Opti foam and Calcium alginate packaging and then used to cut the Calcium alginate film which was then placed on the tray along with a bulk pack of gauze pads. Licensed Practical Nurse #2 washed their hands, donned gloves and removed the soiled dressing from Resident #76's left hip. Licensed Practical Nurse #2 removed the soiled gloves and donned a clean pair of gloves without performing hand hygiene and then placed several gauze pads onto the Styrofoam tray and proceeded to moisten gauze with Dakins solution. Licensed Practical Nurse #2 then used a dabbing motion to clean wound before cleaning in a circular motion. Licensed Practical Nurse #2 patted the wound dry with gauze picked up from the tray, changed gloves without performing hand hygiene, applied the Calcium Alginate and bordered gauze, and then removed a pen from their pocket which they used to date the dressing, returned the pen to their pocket, removed gloves and washed hands. Licensed Practical Nurse #2 performed the exact same procedure when cleaning the wound to the sacrum, with the same breaches in infection control and hand hygiene observed. On 01/08/25 at 11:13 AM, an interview was conducted with Licensed Practical Nurse #2 who stated they were a little bit under the weather and not as organized as they usually are. Licensed Practical Nurse #2 then described the procedure of wound care as follows: wash my hands, gather supplies, cover table with a clean towel drape, then place supplies on a clean surface, then wash hands. Put on Personal Protective Equipment, remove old dressing, wash my hands, then put on clean gloves, clean area with Dakin's, cover with Calcium alginate, then apply bordered gauze. Licensed Practical Nurse #2 further stated that they perform hand hygiene before they start the procedure, after removing the old dressing and after they have applied the new dressing. Licensed Practical Nurse #2 stated that when gloves are removed, hands should be washed then and also when the wound is cleaned and before the dressing is put on, but they did not always do this today while doing the wound care. Licensed Practical Nurse #2 also stated that they had instructed the Home Health Aide to clean the overbed table before the dressing change and assumed it had been done. Licensed Practical Nurse #2 stated that they were informed that the tray was provided for them to do wound care today, but usually they just use the drape sheet and place supplies directly on to it. Licensed Practical Nurse #2 stated they received training on wound care some time ago and that a refresher training from time to time would be good. On 01/10/25 at 11:12 AM, an interview with Registered Nurse Supervisor #1 who stated that if nurses observe complications or a change in the wound, they assess the wound and notify the doctor. Registered Nurse Supervisor #1 also stated that they do not do the actual wound care and does not make observations of what the Licensed nurses are doing during wound care as they are the only supervisor in the building. On 01/10/25 at 11:30 AM, an interview was conducted with the Assistant Director of Nursing, who is also the Infection Preventionist, stated that they are the wound care nurse and assess residents on admission who are at risk for developing wounds. The Infection Preventionist described the process for wound care as follows: set up side table which should be cleaned first, place sterile drape, then supplies and treatments are placed on drape. Gauze is separated for normal saline and for treatments, scissors are taken from the treatment cart in a sealed package, wash hands, don gloves and remove dressing have bag close for garbage, wash hands put new gloves on and do treatment, cleanse wound with normal saline from cleanest to dirty, apply treatment and cover. The Infection Preventionist also stated that hand hygiene is done before contact, and when gloves come in contact with contaminated areas. The Infection Preventionist further stated that periodically observations of wound care are done, but it is not something that is done routinely or documented. The Infection Preventionist stated that they do competencies on wound care. The Infection Preventionist stated that use of Styrofoam trays during wound care is not encouraged, and hand hygiene is to be performed whenever gloves are removed. On 01/10/25 at 11:49 AM, an interview was conducted with the Director of Nursing Services who stated that the Infection Preventionist is in charge of wound care and wound care competencies are done by the Assistant Director of Nursing or themselves or a Registered Nurse will do observations in between. The Director of Nursing Services also stated they were not if the observations were documented anywhere. 10 NYCRR 415.19(b)(4)

Based on observations and interviews conducted during the Recertification survey from 01/02/2025 to 01/10/2025, the facility did not ensure that survey result reports for the 3 preceding years were readily available to residents and visitors upon request. Specifically, upon review of the survey binder, only survey results for the year 2023 were included in the survey binder. In addition, notice of the availability of the survey results reports was not posted in areas of the facility that are prominent and accessible to the public. The findings are: On 01/06/2025 at 10:05 AM, during the Resident Council meeting nine of nine residents verbalized that they did not know where the Department of Survey results were posted in the facility. Six of nine residents had a Brief Interview for Mental Status (BIMS) score as follows: The BIMS test presents a scoring scale that guides the interpretation: 0 to 7 points indicates severe cognitive impairment, 8 to 12 points indicates moderate cognitive impairment, 13 to 15 points indicates cognitive intactness. Resident 44 with BIMS score of 15/15 Resident 117 with BIMS score of 15/15 Resident 36 with BIMS score of 13/15 Resident 61 with BIMS score of 12/15 Resident 45 with BMS score of 12/15 Resident 32 with BMS score of 14/15 On 01/08/2025 at 09:20 AM, the survey binder was observed by the reception area and contained Recertification survey results for 09/18/2023 only. During multiple observations during the survey, notice of the availability of the survey results was not observed on Units 2, 3 and 4. On 01/08/25 at 10:41 AM, the Director of Activities was interviewed and stated that residents are reminded about the availability of survey results and are told where to find the survey binder by the security desk during Resident Council meetings every month. The Director of Activities also stated that they did not currently have postings about the availability of survey results on all of the units. On 01/08/25 at 03:15 PM, the Administrator was interviewed and stated that historically the survey binder has been maintained by the Security desk and there is a sign posted there. The Administrator also stated that they were not aware that notice of the availability of the survey results were supposed to be posted in prominent areas throughout the building. The facility Administrator further stated that they were not aware that the three preceding years surveys and complaint investigation results should be made available to the residents and public. 10 NYCRR 415.3(d)(1)(v)

Based on observations and interviews during the Recertification survey from 01/02/2025 to 01/10/25, the facility did not ensure that total number of nursing staff and actual nursing staffing hours are posted in a prominent place readily accessible to the residents and visitors. The findings are: The facility's policy titled Staffing Policy dated 03/02/2020 last reviewed 07/2024 stated that the facility will post daily for each shift number of personnel responsible for providing direct care for residents. The policy also stated that within two hours of the beginning of the shift, the number of licenses Nurses such as Licensed Practical Nurses, Registered Nurses and Certified Nursing Assistants directly responsible for resident care will be posted in a prominent location accessible to residents and visitors and a clear readable format. During the Recertification survey from 01/02/25 to 01/08/2025, staffing postings for nursing staff documenting projected hours for day, evening and night shifts were observed on a bulletin board on the left side of the hallway which was not accessible to all residents and visitors. The Staffing postings dated 09/01/2024 to 01/08/2025 documented projected hours for the day, evening and night shift for each day. On 01/08/25 at 11:05 AM, the Staffing Coordinator was interviewed and stated that in order to develop the staffing postings, they look at how many licensed and unlicensed nursing staff are needed per shift as per the Staffing Par level. The Staffing Coordinator also stated that staffing is posted every day at 7 AM for all three shifts. The Staffing Coordinator further stated they have been posting the staffing for all shifts every day at 7 AM for twenty years. On 01/08/25 at 11:27 AM, the Director of Nursing Services was interviewed and stated that the facility policy is to post staffing for all three shifts every morning on the bulletin board, which is located next to the time clock on the first floor. The Director of Nursing that they were not aware that the posting needed to reflect actual staffing and be visible to residents and visitors. On 01/08/25 at 03:24 PM, the Administrator was interviewed and stated that they were not aware that actual nursing staffing hours and actual number of nursing staff needed to be posted before every shift. The Administrator also stated that most of the time the projected staffing posted is accurate, and their policy is to post at the beginning of the day. 10 NYCRR 415.13

Based on observation, record review, and interviews during an abbreviated survey (Case # NY00334732), the facility failed to ensure that a resident, identified as an elopement risk received adequate supervision to prevent elopement from the facility. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, on 03/01/2024, Resident #1, who had severely impaired cognition and had a wander alert device in place since 02/29/2024 at 10:01 pm, left the building undetected at 11:49 am. Facility staff became aware that Resident #1 was missing from the unit on 03/01/2024 at approximately 12:20 pm. Resident #1 was located by Resident #1's relative on 03/01/2024 and notified the facility at 5:30 pm that Resident #1 was at the hospital and would be returning to the facility. On 03/01/2024 at 10:05 pm, Resident #1 returned to the facility. This resulted in Immediate Jeopardy Past Noncompliance with the potential for serious harm to 24 residents' who were at risk for elopement. The findings include: The facility's Elopement Prevention Policy dated 04/2023 documented that the facility shall ensure a safe and secure environment for those residents who are at risk for elopement by maintaining devices and equipment fully operational and functional. On admission, the Social Worker will take a digital photo of resident and distribute to security after ascertaining from resident's family if resident had ever wandered away from home. Interdisciplinary team will develop an individualized behavioral management care plan. Unit staff will be counseled on importance of responding immediately to door alarms and monitoring resident location. Security will ensure that gates are always closed and test exit door batteries, alarms, wander guard strips, and resident personal alerts, and report malfunctions to maintenance. The facility's Policy titled Wander Alert Device Response dated 01/2024, documented that the security guard on duty shall respond to a wander alert device alarm that is triggered. The security guard shall notify their supervisor or nursing supervisor and remain with the resident at risk until their supervisor or the nursing supervisor responds to the call. All personnel shall be responsible for responding to a wander alert device alarm that is activated. If a resident at risk for elopement is in the vicinity of the wander alarm, close enough to activate it, the staff member will respond to the alarm and notify their supervisor and attempt to redirect the resident. Resident #1 was admitted to the facility from the hospital on 02/29/2024 at 8:55 pm with diagnoses of Dementia (memory Loss) and Altered Mental Status. Wandering risk assessment dated [DATE], documented that Resident #1 was at high risk for wandering and a wander alert device was applied to Resident #1's right wrist. A care plan for elopement was initiated on 03/01/2024 at 07:45 am. Facility interventions included a visual hourly monitoring and apply wander alert device, and redirect Resident #1 as needed. The Visual Monitoring Sheet dated 03/01/2024 from 12:00 am-11:00 am showed that Resident #1 was monitored every hour and was last seen on the unit at 11:00 am. Nurse's Note dated 03/01/2024 at 2:48 pm documented that Registered Nurse Supervisor #1 was alerted by the staff at 12:20 pm that Resident #1 could not be found on the unit. Registered Nurse Supervisor #1 last saw Resident #1 sitting on the couch by the nursing station at 09:29 am. The unit was searched, and Resident #1 could not be located. The Director of Nursing, the police, family, and Medical Doctor were informed. The facility's investigation dated 03/02/2024, documented that Resident #1 eloped from the facility due to human failure. Resident #1 was new to the facility and took the elevator and blended in with other visitors. Surveyor #1 together with the Acting Administrator reviewed the facility surveillance camera footage on 03/04/2024 at 9:31 am. On 03/01/2024, Camera #2 showed Resident #1 entered the elevator with two visitors and Certified Nursing Assistant #1 at approximately at 11:48 am. The video recording showed Certified Nursing Assistant #1 tapping on something on the elevator panel. According to the Acting Administrator, Certified Nursing Assistant #1 entered the code to disengage the Wander Alert Alarm System. Camera #1 in the lobby at 11:49:52 am, showed Resident #1 exiting the main entrance exit door in the lobby, while Security Guard #1 was disarming the wander alert alarm system. The camera outside of the building showed Resident #1 walking out of the parking lot onto the street at 11:50:16 am. During an interview on 03/04/2024 at 4:34 pm, Certified Nursing Assistant #1 stated that they were on the elevator, and they entered the code to disarm the Wander Alert Device Alarm System without knowing that one of the three people who entered the elevator was a Resident. During an interview on 03/04/2024 at 3:58 pm, Security Guard #1 stated that they were not aware that Resident #1 was a new Resident to the facility and was at risk for elopement or wandering. Security Guard #1 stated that they disarmed the Wander Alert Alarm System for the visitors to exit the facility. Security Guard #1 stated that they did not check why the Wander Alert Device Alarm System was activated before disarming the alarm to unlock the second door for the people to exit the facility. Security Guard #1 stated that they have been working at the facility for nine years and they are trained on the elopement protocol and do not know why they did not check to see if Resident #1 was a resident. Security Guard #1 stated that they made the mistake of disarming the egress and letting the visitors and Resident #1 out of the building. During an interview on 03/04/2024 at 4:58 pm, the Director of Nursing stated that the elopement was human error. The Director of Nursing also stated that Resident #1 was a newly admitted Resident and that the Resident blended with the visitors and left the facility. During an interview on 03/05/2024 at 10:36 am, the Administrator stated that they were informed newly admitted Resident #1 had eloped from the facility. The Administrator stated that they looked at the camera footage and it showed that Resident #1 left the facility with the visitors. Administrator #1 stated that when the alarm is activated, the main exit door to the street is locked, and an audible alarm is heard until the code is entered on the panel. Administrator #1 stated that the door remains locked until the code is entered on the panel. The audible alarm disengages, and the main exit door (to the street) opens. During an interview on 03/06/2024 at 1:24 pm, Medical Director #1 stated that they were made aware of the incident by the Director of Nursing. Resident #1 had a wander alert device in place and that was the protocol. Resident #1 had memory loss and was wandering. Medical Director #1 stated that they attended the safety committee meeting the same day the incident occurred via zoom and they do not believe the incident occurred because of a medical concern. The incident happened because of a gap in the facility, which was corrected. The Immediate Jeopardy was determined to have begun on 03/01/2024. The Administrator was informed of the Immediate Jeopardy and provided with the Past Noncompliance Immediate Jeopardy Template on 03/06/2024 at 5:30 pm. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to and during the time of this survey. A Plan of Correction is not required for this citation. The facility took immediate corrective actions and was found to be in substantial compliance on 03/03/2024 at 9:00 am prior to the Surveyor's onsite visit on 03/04/2024 at 9:00 am. On 03/01/2024 Quality Assurance Committee meeting was held post incident: Attendees include Administrator, Director of Nursing, Infection Control person, Medical Director, Director of Social Services. Policy/Procedure on Elopement revised on 03/01/2024 to add that the Registered Nurse Supervisor will take a digital photograph of the resident(s) and distribute to security and nursing respectively. Alternately, Security will have the responsibility. Resident #1's care plan was updated on 03/02/2024 to reflect visual monitoring every fifteen minutes due to elopement. Facility started in-servicing staff on 03/01/2024, ongoing. Lesson Plan: Responding to the Wander Alert/Triggered Alarm. Not to deactivate alarm until resident is redirected by nursing. Facility has 88 staff 97% in-serviced. 3 security guards - 100% in-serviced 13 out of 16 Nurses - 81% in-serviced 30 Certified Nursing Assistants 100% in-serviced Director of Nursing will continue to in-service the remaining 20% of nursing staff as they report to work. 10 NYCRR 415.12(h)(2)

Based on observations and staff interviews conducted during the recertification survey from 9/10/23 to 9/18/23, the facility did not ensure the daily nurse staffing information was posted in a prominent place readily accessible to residents and visitors. This was evident for the total census of 113 residents. Specifically, the daily staffing information was observed posted on the wall near the staff time clock, not in a prominent place readily accessible to residents and visitors. The findings are: The facility policy and procedure titled Posting Direct Care Daily Staffing Numbers reviewed 4/20/23 documented the facility will post daily for each shift, the number of nursing personnel responsible for providing direct care to residents. On 9/10/23 at 9:51 AM, observation of the facility's daily staffing was made on the main floor and revealed that daily staffing dated 8/23/23 was posted on the wall near the staff time clock, not visible to residents and visitors. On 9/10/23 at 11:52 AM, the observation of unit 3 revealed there was no daily staffing observed posted on the unit. On 9/11/23 at 10:03 AM, observations of unit 2 and unit 4 revealed there were no daily staffing posted on unit 2 and unit 4. During an interview on 9/10/23 at 2:30 PM, the Director of Nursing Services (DNS) stated that the staff responsible for the daily staff posting was currently off for the day but will follow up to ensure that the information is updated when they return to work. However, the DNS acknowledged that the daily staffing information was not up to date and should have been updated to reflect daily staffing information. During an interview on 9/14/23 at 12:17 PM, the Nursing Office Manager (NOM) stated that daily staffing is updated/posted on the wall next to the staff time clock and are not posted on the residents' units. The NOM stated that they were not aware that the daily staffing needed to be readily accessible for residents/visitors. The NOM further stated the daily staffing information may not be up to date especially during the weekends and when the NOM is off. 415.13

Based on observation, interview, and record review conducted during the recertification survey from 9/10/2023 to 9/18/2023, the facility did not ensure the residents had a right to organize and participate in resident groups in the facility. This was evident during Resident Council wit Resident #64, #95, #39, #118, #53, #56, and #16. Specifically, the facility did not take reasonable steps to organize and assist residents with meeting regularly as a Resident Council. The findings are: The facility policy titled Resident Council Rights in Nursing Homes dated 3/2/2023 documented the facility must provide a resident council with private space for meetings and make residents aware of upcoming meetings. On 09/11/2023 at 11:48 AM, a Resident Council meeting was held with Resident #64, the President of Resident Council, and Resident #64, and Resident #95, #39, #118, #53, #56, and #16. All residents in attendance stated the facility does not assist with scheduling and organizing Resident Council meetings that residents could regularly attend without staff present. The Resident Council has not gathered since the COVID-19 pandemic and Resident #64 stated they were elected to their position as President by the staff and not the residents. The Patient Roster - Moving Resident Council meeting minutes dated 7/3/2023, 8/25/2023, and 9/1/2023 documented residents were met with individually according to room number, were informed of positive COVID-19 cases, and were encouraged to attend activities according to preference and activity calendar. On 09/10/2023 at 03:45 PM, the Director of Social Work (DSW) was interviewed and stated the facility had Resident Council meetings prior to the COVID-19 pandemic. The facility now uses a Moving Resident Council where the DSW will meet individually with residents in their room to discuss COVID-19 cases. Residents are referred to the activities calendar and encouraged to engage in activities they enjoy and to wear masks. Residents are encouraged to go outside and to minimize the risk of spreading infection. There is an area for residents to gather for activities. The DSW meets with residents whenever there is a new COVID-19 case. If there are no COVID-19 cases to report to residents, the Moving Resident Council takes place monthly. On 09/18/2023 at 02:19 PM, the Administrator was interviewed and stated the DSW is responsible for organizing the Resident Council. The Administrator stated they were aware the DSW was using a Moving Resident Council stemmed from the COVID-19 pandemic and is used to provide banking information and COVID-19 case information to residents. The residents have an opportunity to communicate their concerns. The purpose of Resident Council is for residents to communicate their life in the facility and meet as a group without staff present. Residents currently have group activities but are kept separate as much as possible to prevent the spread of infection. The DSW tried to keep the residents safely distanced. The Administrator stated they did not discuss keeping residents at a safe distance for Resident Council with the DSW. 415.5(c)(1-5)

Based on observation, interview, and record review conducted during the recertification survey from 9/10/2023 to 9/18/2023, the facility did not ensure residents were provided with the contact information for the State Long Term Care Ombudsman (SLTCO). This was evident in the lobby and 1 (3rd Floor) of 3 units. Specifically, the posted telephone number for the SLTCO was incorrect in the lobby and on the 3rd Floor. The findings are: On 09/11/2023 at 11:48 AM, a Resident Council meeting was held with Resident #64, the President of Resident Council, and Resident #95, #39, #118, #53, #56, and #16. Resident #53 and #39 stated the SLTCO contact information posted throughout the facility was incorrect and they attempted to contact the SLTCO but were unable to do so. On 9/11/2023 at 1:55 PM, the SLTCO poster including the contact telephone number was observed in the main lobby and 3rd Floor bulletin boards. A phone call was attempted using the telephone number listed and no contact was made with the SLTCO office. The phone number listed was not the currently published contact number for the local SLTCO office. On 09/18/2023 at 02:35 PM, the Director of Social Work (DSW) was interviewed and stated they were responsible for posting the SLTCO information throughout the facility. The DSW did not recall the last time they checked the telephone contact information and were unaware the SLTCO phone number was incorrect. The SLTCO contact number is posted because residents have a right to call the SLTCO if they have concerns regarding their stay at the facility. 415.3(1)(c)(1)(vi)

Based on observation, interview, and record review conducted during the recertification and complaint (NY00310185), the facility did not ensure the residents' right to a safe, clean, comfortable environment. This was evident for the outdoor patio and 3 of 3 resident floors (2nd, 3rd, and 4th). Specifically, 1) the outdoor patio was observed with paper cups, gloves, and cigarette butts on the ground and overgrown shrubs, trees, and grass; 2) the 2nd floor was observed with sticky dirty furniture, sticky floors stained black at the baseboards, broken dressers, peeling paint, sagging unhooked privacy curtains, a bed frame in disrepair, missing mirror, urine odor, and a stained faucet with a loose handle in resident rooms and dirty air conditioning (AC) units in the dayroom; 3) the 3rd floor was observed with a broken AC unit, dirty windowsills, broken floor and wall tiles, a leaking rust colored sink, urine odor, and a hole in the wall of resident rooms; and 4) the 4th floor was observed with mismatched peeling paint and cracked plaster in a sink of resident rooms. The findings are: 1) On 9/10/2023 at 9:30 AM and 9/11/2023 at 11:00 AM, the outside patio and resident smoking area were observed with overgrown bushes and shrubs protruding through the perimeter fence and onto the patio by several feet. There were weeds protruding through the fence and cracks in the patio. Garbage and debris including paper drinking cups, snack bags, and plastic gloves, were strewn throughout the patio. Several cigarette butts were on the floor next to the ashtrays. 40686 2) From 09/10/2023 at 09:34 AM to 09/12/2023 at 11:11 AM, observations of the following were made on the 2nd Floor: - 204B had peeling paint on the wall above their bed - 210 had a sticky floor and 2 dressers with broken drawers - 210B had a privacy curtain hanging around the bed that was missing several hooks and sagged - 207 had an overbed table that was stained with a sticky substance - 221 had a strong urine smell emanating from the room into the hallway, sticky floors, a privacy curtain for the shared bathroom that was missing several hooks and sagged, and a water stain on the ceiling over the sink - 221B had a dresser with a broken top drawer - 212 had water pitchers in a wash basin on the floor of the shared bathroom, the floor was sticky, paper towels were shoved in between the bathroom light and the ceiling, and a shared rusty stained sink with a loose hot water handle separated and hanging down from the ceramic - 217A had sticky floors stained with a black grime near all baseboards and behind the room door - 214 had a missing mirror over the shared sink with metal prongs protruding from the wall where the mirror previously hung - 214A had a bed frame missing the wooden footboard and a dresser with a missing top drawer - 2 air conditioning (AC) units in the floor dayroom were dusty and had grime and debris around the knobs and grates on top of the unit and all windows had a film buildup on the glass portion and a layer of dirt and dust on the sills - 1 dresser in a hallway alcove stained with a sticky substance and with a broken top drawer that was missing the front panel - 1 shower room near the floor dayroom that was wet, slippery, had underwear hanging from the grab bar next to the toilet, and had a puddle of water on the floor surrounding the toilet There was no documented evidence the above-mentioned observations were listed in the Maintenance Logbook from 7/17/2023 to 9/11/2023. On 09/15/2023 at 10:46 AM, Housekeeper #2 (HK) was interviewed and stated they are currently assigned to the 2nd Floor and their daily cleaning routine for the unit involves mopping with bleach, cleaning the floor and tables in the dayroom, and emptying the garbage. HK #2 cleans anything dirty they see. They also wipe down the windowsills but never cleaned the glass panes of the windows. A resident in 201 uses the shower room near the dayroom as their own personal bathroom and is there several times throughout the day and wets the floor and washes their clothes in the sink leaving puddles of water on the shower room floor. There is always a urine smell in the shower room and HK #2 cleans it with bleach. HK #2 stated they clean that shower room approximately 4 times a day. HK #2 mopped the unit this morning but the black grime along the baseboards does not come off with mopping. The floors need to be buffed to take off the black grime. HK #2 last buffed the unit this past Saturday. 37787 3) On 9/12/2023 at 12:20 PM, 9/13/2023 at 12:05 PM, and 9/15/2023 at 11:28 AM, the following was observed on the 3rd Floor: - room [ROOM NUMBER] had a heavy urine smell - room [ROOM NUMBER] had a heavy urine smell, the AC unit rusty and stained brown, and there were broken tiles under the shared sink - room [ROOM NUMBER] had a windowsill rusted and stained brown - room [ROOM NUMBER] had dirty, dusty, brown, rusty windowsills and wall tiles by the shared sink that were coming off the wall - room [ROOM NUMBER] had a heavy urine smell, broken floor tiles by the shared sink, and a large hole in the wall between the window and the bed -room [ROOM NUMBER] had tiles coming off the wall by the shared sink, a constantly running sink faucet that could not be turned off by hand, and a sink that was stained brown with rust -The floor dayroom windowsill on the right side of the room was broken dislodged from the track On 9/15/2023 at 11:34 AM, the Maintenance Worker (MW) was interviewed and stated they check the Maintenance Logbook on every unit every morning. Staff also call the MW directly if there are concerns. Sometimes, the MW stated they might miss something. The MWs do rounds every day but there are only 3 MWs assigned for the whole building. On 9/15/23, at 12:01 PM, Housekeeper #1 was interviewed and stated they are assigned to the 3rd Floor and the floor dayroom, pantry, garbage, all resident rooms, and hallways are cleaned daily. The urine smell comes from residents' dirty clothes. They will speak to their supervisor regarding how to address the urine smell. On 9/18/23 at 12:10 PM, Licensed Practical Nurse (LPN) #4 was interviewed and stated they report issues on the 3rd Floor to Housekeeping and Maintenance. The MW comes to look at the Logbook but do not do anything. 44472 4) On 09/15/2023 at 01:54 PM, Resident #22 from room [ROOM NUMBER] was interviewed and stated the AC unit in their room is very dirty and has cracks in the plaster where the AC unit connects to the wall. Resident #22 stated that looking at the condition of the AC unit makes them sick. The dirt flies all over the room. They told the Housekeeper (HK), but the HK only cleans the floor. They informed the Maintenance Worker (MW), but the MW never returned to fix it. On 09/14/2023 at 12:16 PM, the following observations were made on the 4th Floor: - room [ROOM NUMBER] had white spackled paint on walls and numerous [NAME] on the shared sink - room [ROOM NUMBER] had an AC unit covered in dirt and debris with cracks in the plaster connecting the unit to the wall - room [ROOM NUMBER] had dirt and debris on the AC unit and peeling paint on the walls - top of radiator with dried up cracked compound cement all over top of radiator, dirty - room [ROOM NUMBER] had plaster covering the wall tiles near the shared sink - room [ROOM NUMBER] had plaster covering the wall tiles near the shared sink - room [ROOM NUMBER] had white spackle on the walls and debris on the AC unit - room [ROOM NUMBER] had white spackle on the walls and debris on the AC unit - The floor dayroom had a dirty, dusty floor, peeling paint, and dirt and debris accumulated on the AC units. There was no documented evidence in the 4th Floor Maintenance Logbook that any of the above-mentioned environmental concerns were reported from 2/8/2023 to 9/10/2023. On 09/14/2023 at 03:19 PM and 09/15/2023 at 11:15 AM, Director of Housekeeping and Maintenance (DHM was interviewed stated there is a Maintenance Logbook on each unit that the Maintenance Worker (MW) is responsible for checking. The DHM acknowledged some walls have spackle because they have not finished repainting areas of the facility. Some AC units do have dust, debris, and cracks in the plaster surrounding them. The Housekeeper (HK) is responsible for cleaning the windows and the windowsills. There are 3 rooms a day on each unit that have the floors buffed and completely cleaned. The DHM checks the 3 buffed and cleaned rooms after the HK is done. There is flooding in the 2nd Floor shower room because of a resident that washes their clothes in there. The outside area of the facility gets cleaned every other day. There is garbage that gets built up from the streets because there are people that dump garbage from the neighboring buildings onto the facility property. As soon as the facility cleans outside, the neighbors dump more garbage. A lawn service comes monthly and as needed to take care of the shrubs and grass that need to be cut. The DHM makes rounds on each of the units and makes note of broken furniture. The HK also informs the DHM of any broken furniture they observe on the unit and the DHM checks the Maintenance Logbook daily. The DHM stated they did not notice the resident in 214A was missing the footboard to their bed when they last made their rounds. That is something that staff should have recorded in the Logbook. The mirror in 214A was cracked and had to be removed last week. The DHM plans to replace the mirror and had to order it. The hallways get buffed every other day and as needed. The DHM stated they buff one day but because of the residents, the floors will be dirty the next day. HK staff also try to scrape the edges of the floors by the baseboards when they buff the floors. On 9/18/2023 at 11:00 AM, the Administrator was interviewed and stated they are aware of the areas in the facility that need cleaning and repair. They will try to repair all those findings and will have an audit of what else needs to be done . 415.5(h)(2)

Based on observation, interviews, and record review conducted during the recertification and abbreviated survey (NY00302016 and NY00318527) from 9/10/2023 to 9/18/2023, the facility did not ensure all alleged violations involving abuse were reported within 2 hours, or events not involving abuse were reported within 24 hours to the New York State Department of Health (NYSDOH). This was evident for 1 (Resident #92) of 3 residents reviewed for abuse and 1 (Resident #79) of 2 residents reviewed for accidents out of 27 total sampled residents. Specifically, 1) Resident #92 reported a Certified Nursing Assistant (CNA) pushed them in the chin and the facility did not report the allegation to the NYSDOH within 2 hours, and 2) the facility did not report Resident #79 was found on the floor in their room with left arm redness and sheering within 24 hours. The findings are: The facility's policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property dated 4/20/23 documented the resident will be free from Abuse that include verbal, mental, sexual, or physical abuse, corporal punishments, or involuntary seclusion. 1) Resident #92 was admitted to the facility with diagnosis of Schizophrenia and Scoliosis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #92 had intact cognition. The facility's investigative report initiated 9/9/22 at 2:30 PM documented Resident #92 reported to the Director of Nursing (DNS) that the Certified Nursing Assistant (CNA) from the night shift pushed Resident #92 in the chin during provision of care. The Aspen Complaint Tracking System documented the facility reported the incident involving Resident #92 to NYSDOH on 9/10/22 at 2:00 PM, more than 2 hours after the occurrence. On 9/18/23 at 1:30 PM, the DNS stated the investigation of this incident involving Resident #92 was initiated immediately on 9/9/22 when it was reported to the DNS and was completed on the following day. The DNS acknowledged that alleged incident was not reported to NYSDOH within 2 hours and was submitted on 9/10/22 at 2:00 PM. 40686 2) Resident #79 had diagnoses of bipolar disorder and Alzheimer's disease. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #79 was cognitively impaired. On 09/14/2023 at 12:30 PM, the complainant was interviewed via telephone and stated they received a call on 6/19/2023 from the facility to inform them Resident #79 was found on the floor and had fallen out of bed. Resident #79 was in pain and had left arm swelling and scratches. The undated Accident Incident (AI) Report documented Resident #79 was found on their floor mat at bedside at 6:45 AM on 6/18/2023. A Registered Nurse (RN) assessment was done and Resident #79 had blanchable redness and sheering to the left upper arm. Left shoulder and humerus X-ray were done and were negative for fracture. An undated Investigation documented Resident #79 had an incident on 6/19/2023 that caused left upper arm redness and sheering. On 6/20/2023, staff reported to the Assistant Director of Nursing (ADON) that the Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) used a hoyer lifter to transfer Resident #79 back to bed from the floor mat next to their bedside. Resident #79's left upper arm may have rubbed against the Hoyer lift straps or against a metal part of the bed. Room was changed closer to the nursing station and Resident #79 was provided with a floor bed. The Investigation was unsigned and the Director of Nursing's name was typed at the bottom. Medical Doctor Note dated 6/20/2023 documented Resident #79 had an unavoidable mechanical fall. The facility reported the incident on 6/21/2023 to the NYSDOH, more than 24 hours after occurrence. On 09/18/2023 at 12:55 PM, the Director of Nursing (DNS) was interviewed and stated Resident #79's incident happened over the weekend on the night shift. The ADON received the call about the incident and the DNS was not notified until Monday, 6/19/2023. The incident was not reported to the NYSDOH within the regulatory guidelines because the facility did not determine abuse occurred. The DNS decided to report the incident when the Resident #79's wife became very upset and the DNS wanted to report the incident to the NYSDOH before the wife reported it. 415.4(b)(1)(i)

Based on record reviews, and staff interviews during the recertification and abbreviated (NY00318546 and NY00318527) survey from 9/10/2023 to 9/18/2023, the facility did not ensure all alleged violations of abuse were thoroughly investigated. This was evident for 2 (Resident #171 and #79) of 27 total sampled residents. Specifically, 1) Resident #171 was observed with a bump and redness to their forehead that was not thoroughly investigated, and 2) staff statements were not obtained to rule out abuse when Resident #79 was found on the floor. The findings are: The facility policy titled Accident/Incident (AI) Report dated 3/9/2023 documented promptly submit completed statements from all Certified Nursing Assistants (CNA) related to the AI to the Nursing Supervisor within the tour of duty. 1) Resident #171 had diagnoses of Psychotic Disturbance, Mood Disturbance and Anxiety. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #171 had severely impaired cognition. On 9/14/2023 at 5:28 PM, the complainant was interviewed and stated they received a phone call from the facility on 6/17/23 and were asked whether Resident #171 had a history of falling. The complainant stated they reported to the facility that Resident #171 did not have a history of falling. The facility reported to the complainant during the phone call that Resident #171 had redness and swelling to their forehead. The Nursing Note (NN) dated 6/17/23 documented that the facility called the complainant to report swelling and redness to Resident #171's forehead. The NN documented the complainant reported receiving a call from the clinic Resident #171 visited 3 days prior and during this call, the clinic reported to the complainant that Resident #171 fell during their visit. The NN dated 6/17/23 documented Resident #171 had swelling between the forehead and was unable to verbalize how the injury occurred. NN dated 6/20/2023 documented upon investigation, Resident #171 noted with redness and a bump. The medical Doctor was made aware and complainant called. Resident #171 was confused and wanders and could not relate what transpired. There is no cause to believe abuse occurred. There is no documented evidence staff statements were obtained and thorough investigation was conducted to rule out abuse for Resident #171. On 9/15/2023 at 11:09 AM, the Home Health Aide (HHA) who accompanied Resident #171 to their clinic appointment was interviewed and stated Resident #171 did not have any falls or incidents while at their clinic appointment. Resident #171 did not return to the facility with a bump or redness to their forehead. On 9/12/2023 at 2:25 PM, the Licensed Practical Nurse (LPN) #4 was interviewed and stated Resident #171 was observed with a bump and redness on their forehead. LPN #4 made the Nursing Supervisor, Registered Nurse (RN) #4, aware. On 9/15/23 at 10:35 AM, RN #4 was interviewed and stated the CNA reported to them Resident #171 had a bump and redness to their forehead. RN #4 assessed Resident #171 and informed the Assistant Director of Nursing (ADON) and the complainant. RN #4 stated the complainant reported being informed by the clinic that Resident #171 fell during their visit. The complainant also reported to RN #4 that the clinic did not inform them of any redness or swelling to the resident's forehead and that something must have happened at the facility. On 9/14/2023 at 6:13 PM, the (ADON) was interviewed and stated RN #4 informed them that the complainant called 911 and had Resident #171 transferred to the hospital due to forehead bump and redness. The ADON attempted to speak with the complainant but they refused. The ADON started their investigation by calling RN #4 and concluded Resident #171 fell while at the clinic. Resident #171 wanders but the ADON did not determine that their injury was of unknown origin because the complainant reported a fall in the clinic. Staff noted the bump and did not witness any fall. The ADON immediately reported the incident to administration. On 9/18/2023 at 10:29 AM, the Director of Nursing (DNS) was interviewed and stated they attempted to call the clinic to find out whether Resident #171 fell during their appointment but no one was there. The DNS did not follow up with the clinic to investigate the origin of Resident #171's forehead bump. 40686 2) Resident #79 had diagnoses of bipolar disorder and Alzheimer's disease. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #79 was cognitively impaired. On 09/14/2023 at 12:30 PM, an interview was conducted with the complainant who stated they came to visit Resident #79 on 6/19/2023 after the facility staff reported to them that Resident #79 was found on the floor early that morning. The complainant observed large deep red scratches on the resident's left arm. The scratches appeared to have already started healing but were draining pus and the complainant reported to the Director of Nursing (DNS) that the scratches appeared to have come from a incident when Residnt #79 was found on the floor the previous week, 6/11/2023. Resident #79 was in a lot of pain. The complainant requested the DNS address Resident #79's injuries and incidents and stated the DNS replied they did not want to take bread out of any staff member's mouth. The complainant responded to the DNS that if someone did this to Resident #79, they need to be held accountable. Nursing Note (NN) dated 6/11/2023 documented Resident #79 was found on the floor next to their bed and unable to verbalize what occurred. Resident #79 was assessed and had a skin tear to their left knee. NN dated 6/12/2023 documented Resident #79 was found on the floor, Medical Doctor (MD) made aware, and first aid treatment provided for skin tear to the left knee. The incident was unavoidable and there is no cause to believe neglect, mistreatment, or abuse occurred. The plan included rehab evaluation, neuro check, hourly monitoring, and fall precautions. The AI Investigation Form dated 6/11/2023 documented the Licensed Practical Nurse (LPN) observed Resident #79 lying on the floor with a skin tear to their left knee. The Nursing Supervisor was made aware. The CNA Statement dated 6/11/2023 documented CNA #7 was making rounds at 6 AM when they observed Resident #79 on the floor next to their bed. Nursing Staffing Sheets dated 6/11/2023 documented CNA #7 and CNA #8 worked on Resident #79's floor on the 11 PM to 7 AM shift. There is no documented evidence a thorough investigation to rule out abuse was conducted and statements were gathered by all staff members present on the unit when Resident #79 was found on the floor on 6/11/2023. On 09/18/2023 at 12:55 PM, the Director of Nursing (DNS) was interviewed and stated Resident #79 has behaviors of and episodes of falling. The AI investigations are used to rule out abuse. The DNS gathers staff interviews as part of the investigation. The DNS stated Resient #79 was found on the floor so they must have fallen because Resident #79 was alone in the room. Resident #79's first fall occurred on 6/11/2023 and, the DNS stated only 1 CNA statement was included in the AI report so only 1 CNA must have been working contact shift. The DNS stated they did not check the staffing sheet. After review of the Staffing Sheets for 6/11/2023, the DNS stated CNA #8 was working when Resident #79 fell on [DATE] and their statement was not gathered as part of the investigation. The DNS stated this is not an adequate investigation. 415.4(b)(2)

Based on observations, interviews, and record review conducted during the recertification survey, the facility did not ensure that a Comprehensive Care Plan (CCP) was developed and implemented. This was evident for 5 of 27 sampled residents (Resident #s 60, 109, 110, 66, and 27). Specifically, Resident #60 had no CCP for Glaucoma. Resident #66 and #109 had no CCP developed to address dental issues. Resident #110 had no CCP developed to address the care needs of Latent Syphilis. Resident #27 had no CCP to address pain. The findings include but are not limited to: The facility policy and procedure title Comprehensive Care Plan last updated on 4/20/23 stated that an individualized comprehensive care plan will be developed and implemented for each resident. The policy further stated that the care plan will be maintained within the medical record of each resident in the facility. The care plan will be developed by an interdisciplinary team of health care professional as appropriate to the need of each resident. 1) Resident #60 was admitted to the facility on [DATE] with the diagnoses of Cerebral Infarction, Glaucoma, and Hypertension. The Quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident #60 has severely impaired cognition. The MDS further documented that the Resident required limited assist of one person for bed mobility and toilet use. Extensive assist of one for transfer and personal hygiene. Supervision and one assist for dressing and supervision and set up for eating. The Physician's Orders renewed on 9/13/23 documented that Resident #60 received Latanoprost solution 0.005% one drop to both eyes at bedtime for Glaucoma. The order has been active since 2/28/2022 There was no documented evidence that a comprehensive care plan related to vision care was developed for the Resident. 2) Resident #109 was admitted to the facility on [DATE] with the diagnoses of Systolic Congestive Heart Failure, type II Diabetes Mellitus, and Hypertension. The Admission Minimum Data Set (MDS) dated [DATE] documented that Resident #109 has moderately impaired cognition. The MDS further documented that the resident is extensive and one assist for bed mobility, transfer, Dressing, toilet use and personal hygiene. Supervision with one assist for eating. On observation, Resident was noted with missing teeth from upper and lower parts of the mouth. The dental consultation dated 3/15/23 stated that the Resident lost some natural teeth and broken teeth are noted. Broken teeth are asymptomatic, no work at this time. There was no documented evidence that a comprehensive care plan related to dental care was developed for the Resident. 3) Resident #110 was admitted to the facility on [DATE] with a diagnosis of Latent Syphilis The Admission Minimum Data Set (MDS) dated [DATE] documented that Resident #110 has severely impaired cognition. The MDS further documented that the Resident is supervision with one assist for bed mobility, Extensive of 2 assists for transfer, dressing, toilet use and personal hygiene. Limited and 1 assist for eating. During an interview with the psychiatrist on 9/15/2023 at 3:53 PM, he stated that Latent Syphilis triggers if not treated goes to the secondary stage which affects the skin. Then psychosis in the tertiary stage which affects the brain. The Resident can become very aggressive and can also develop depression There was no evidence that a comprehensive care plan related to Latent Syphilis was developed for the Resident. 10 NYCRR 415.11(c)(1) 44472 45351

Based on observations, interviews and record review conducted during the recertification survey from 9/10/23 to 9/18/23, the facility did not ensure resident's Comprehensive Care Plan (CCP) were reviewed, revised, and implemented after each assessment. This was evident for 1 of 2 residents reviewed for Pain Management (Resident #87) and 1 (Resident #79) of 2 residents reviewed for Accidents out of 27 total sampled residents. Specifically, 1) CCPs related to Pain Management/Therapy were not reviewed and revised quarterly to reflect current pain management regimen for Resident #87, and 2) the CCP related to Resident #79's risk for falls was not reviewed and revised to reflect updated interventions after the resident had an incident on 6/19/2023. The findings are: The facility policy titled CCP dated 4/20/2023 documented CCPs are reviewed and revised quarterly and as needed. 1) Resident #87 was admitted to the facility with diagnosis of Schizophrenia, Osteoarthritis and Diabetes Mellitus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented resident is cognitively intact, receiving schedule pain medication regimen. On 9/10/23 at 1:20 PM, Resident #87 stated they have arthritic pain to their left hip and have been getting Gabapentin and Tramadol for pain medication. Resident #87 complained of ongoing pain to staff, but resident was told that medication can't be changed to stronger medication/dosage. Resident #87 stated they are not asking for stronger medication but something to relieve their ongoing pain. The physician order initiated 2/28/22 documented Resident #87 to receive Gabapentin 100 mg capsule TID for pain in left hip. The physician order initiated 2/28/22 documented Resident #87 to receive Tramadol 50 mg tablet every 8 hours for chronic pain for osteoarthritis. The CCP titled Communication problem related to pain revised 5/29/23 documented to monitor/document for physical/nonverbal indicators of discomfort, distress and follow up as needed. The CCP titled Pain medication therapy Tramadol revised 5/29/23 documented to review efficacy of the pain medication and to assess whether pain intensity acceptable to resident. There was no documented evidence that the pain management/therapy was discussed with Resident #87 or that CCP related to pain management/therapy were revised quarterly after the MDS assessment on 8/10/23. On 9/15/23 at 12:25 PM, the Assistant Director of Nursing (ADON) stated CCP is initiated upon admission, then updated quarterly and as needed. ADON stated Resident #87's care plans related to pain management/therapy were last revised on 5/29/23 and should have been revised quarterly on 8/30/23. ADON does not know why the CCP were not updated for Resident #87. On 9/15/23 at 1:33 PM, Director of Nursing (DON) stated Resident #87 was admitted to the facility on pain medication and was on pain management therapy. DON stated they were not aware that Resident #87 had any pain related issues. DON stated they were invited to the recent care plan meeting, but resident refused to attend the meeting as per attendance record on 8/31/23. DON stated they were not aware that care plans related to pain management/therapy were last revised 5/29/23. 40686 2) Resident #79 had diagnoses of bipolar disorder and Alzheimer's disease. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #79 was severely cognitively impaired and had a fall since their prior assessment that did not result in injury. Resident #79 required extensive assistance of 2 people for walking in their room and for transfers. The Comprehensive Care Plan (CCP) related to Resident #79's high risk for falls initiated 3/20/2022 documented the resident had gait problems, confusion, and psychoactive drug use. Interventions documented maintain a safe environment with the bed in a low position, ensure proper footwear, and physical therapy evaluation and treatment as needed. The CCP was revised goal was revised on 6/12/2023 and documented Resident #79 will be free of falls. The interventions were not revised since 3/20/2022. The AI Investigation dated 10/19/2022 documented Resident #79 had an unwitnessed fall in the dayroom after they got up from their chair suddenly and fell before a Certified Nursing Assistant could get to them. There was a bump on the resident's forehead, no predisposing factors, no physiological factors, no situational factors, and no witnesses. Resident #79 sustained a right elbow abrasion. The plan included staff to monitor, frequent visual checks, and standard fall and safety precautions. The Licensed Practical Nurse (LPN) documented in their statement that the therapist reported to them that they saw Resident #79 on the floor in the dayroom. The Fall Risk assessment dated [DATE] documented Resident #79 scored a 15 with 10 being a score that indicates the resident is at high risk for falls. The Medical Doctor Order (MDO) dated 6/7/2023 documented monitor Resident #79 hourly for safety. The CCP related to risk for fall post-fall initiated 6/11/2023 documented Resident #79 receive assistance with transfers, maintain a safe environment, education of resident re: use of mobility devices, ensure bed is in the lowest position, ensure call light is available,alert provide in the event of a fall, and evaluate resident's environment to identify factors known to increase falls. Nursing Note (NN) dated 6/11/2023 documented Resident #79 was found on the floor next to their bed and unable to verbalize what occurred. Resident #79 was assessed and had a skin tear to their left knee. The AI Investigation Form dated 6/11/2023 documented the Licensed Practical Nurse (LPN) observed Resident #79 lying on the floor with a skin tear to their left knee. The Nursing Supervisor was made aware. The CNA Statement dated 6/11/2023 documented CNA #7 was making rounds at 6 AM when they observed Resident #79 on the floor next to their bed. Nursing Staffing Sheets dated 6/11/2023 documented CNA #7 and CNA #8 worked on Resident #79's floor on the 11 PM to 7 AM shift. NN dated 6/12/2023 documented Resident #79 was found on the floor, Medical Doctor (MD) made aware, and first aid treatment provided for skin tear to the left knee. The incident was unavoidable and there is no cause to believe neglect, mistreatment, or abuse occurred. The plan included rehab evaluation, neuro check, hourly monitoring, and fall precautions. An undated Investigation documented Resident #79 had an incident on 6/19/2023 that caused left upper arm redness and sheering. On 6/20/2023, staff reported to the Assistant Director of Nursing (ADON) that the Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) used a hoyer lifter to transfer Resident #79 back to bed from the floor mat next to their bedside. Resident #79's left upper arm may have rubbed against the Hoyer lift straps or against a metal part of the bed. Room was changed closer to the nursing station and Resident #79 was provided with a floor bed. The Investigation was unsigned and the Director of Nursing's name was typed at the bottom. On 09/14/23 at 05:07 PM, Registered Nurse (RN) #2 was interviewed and stated they are responsible for updating Resident #79's CCPs related to falls and thought they were updated after each fall. Resident's room was changed closer to the nursing station and they went from a low bed to a very low bed. 415.11(c)(2)(i-iii)

Based on observation, interview, and record review conducted during the recertification and complaint (NY00318527) survey from 9/10/2023 to 9/18/2023, the facility did not ensure residents remained free of accidents and hazards. This was evident for 1 (Resident #79) of 2 residents reviewed for Accidents and the 1 (2nd Floor) of 3 resident units. Specifically, 1) Resident #79 was not adequately assessed for fall risk following each fall, did not have a CCP related to fall risk with adequate interventions that was reviewed upon each fall, and did not receive supervision to prevent further falls; and 2) there were observations of a 2nd floor window in the floor dayroom that can fully open, an eyewash station without an eyewash device in place, a dental office with an x-ray machine and drill that remained unlocked, and a wet shower room floor without a wet floor sign. The findings are: 1) Resident #79 had diagnoses of bipolar disorder and Alzheimer's disease. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #79 was severely cognitively impaired and had a fall since their prior assessment that did not result in injury. Resident #79 required extensive assistance of 2 people for walking in their room and for transfers. On 09/14/2023 at 12:30 PM, an interview was conducted with the complainant who stated they came to visit Resident #79 on 6/19/2023 after the facility staff reported to them that Resident #79 was found on the floor early that morning. The complainant observed large deep red scratches on the resident's left arm. The scratches appeared to have already started healing but were draining pus and the complainant reported to the Director of Nursing (DNS) that the scratches appeared to have come from an incident when Resident #79 was found on the floor the previous week, 6/11/2023. The Comprehensive Care Plan (CCP) related to Resident #79's high risk for falls initiated 3/20/2022 documented the resident had gait problems, confusion, and psychoactive drug use. Interventions documented maintain a safe environment with the bed in a low position, ensure proper footwear, and physical therapy evaluation and treatment as needed. The CCP was revised goal was revised on 6/12/2023 and documented Resident #79 will be free of falls. The interventions were not revised since 3/20/2022. The AI Investigation dated 10/19/2022 documented Resident #79 had an unwitnessed fall in the dayroom after they got up from their chair suddenly and fell before a Certified Nursing Assistant could get to them. There was a bump on the resident's forehead, no predisposing factors, no physiological factors, no situational factors, and no witnesses. Resident #79 sustained a right elbow abrasion. The plan included staff to monitor, frequent visual checks, and standard fall and safety precautions. The Licensed Practical Nurse (LPN) documented in their statement that the therapist reported to them that they saw Resident #79 on the floor in the dayroom. The Fall Risk assessment dated [DATE] documented Resident #79 scored a 15 with 10 being a score that indicates the resident is at high risk for falls. The Medical Doctor Order (MDO) dated 6/7/2023 documented monitor Resident #79 hourly for safety. The CCP related to risk for fall post-fall initiated 6/11/2023 documented Resident #79 receive assistance with transfers, maintain a safe environment, education of resident re: use of mobility devices, ensure bed is in the lowest position, ensure call light is available, alert provide in the event of a fall, and evaluate resident's environment to identify factors known to increase falls. Nursing Note (NN) dated 6/11/2023 documented Resident #79 was found on the floor next to their bed and unable to verbalize what occurred. Resident #79 was assessed and had a skin tear to their left knee. The AI Investigation Form dated 6/11/2023 documented the Licensed Practical Nurse (LPN) observed Resident #79 lying on the floor with a skin tear to their left knee. The Nursing Supervisor was made aware. The CNA Statement dated 6/11/2023 documented CNA #7 was making rounds at 6 AM when they observed Resident #79 on the floor next to their bed. Nursing Staffing Sheets dated 6/11/2023 documented CNA #7 and CNA #8 worked on Resident #79's floor on the 11 PM to 7 AM shift. NN dated 6/12/2023 documented Resident #79 was found on the floor, Medical Doctor (MD) made aware, and first aid treatment provided for skin tear to the left knee. The incident was unavoidable and there is no cause to believe neglect, mistreatment, or abuse occurred. The plan included rehab evaluation, neuro check, hourly monitoring, and fall precautions. An undated Investigation documented Resident #79 had an incident on 6/19/2023 that caused left upper arm redness and sheering. On 6/20/2023, staff reported to the Assistant Director of Nursing (ADON) that the Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) used a Hoyer lifter to transfer Resident #79 back to bed from the floor mat next to their bedside. Resident #79's left upper arm may have rubbed against the Hoyer lift straps or against a metal part of the bed. Room was changed closer to the nursing station and Resident #79 was provided with a floor bed. The Investigation was unsigned, and the Director of Nursing's name was typed at the bottom. Medical Doctor Note dated 6/20/2023 documented Resident #79 had an unavoidable mechanical fall. The CNA Accountability for June 2023 documented 142 of 432 opportunities to observe Resident #79 for hourly monitoring for safety and fall precautions were left blank and were not documented. The Fall Risk assessment dated [DATE] documented Resident #79 scored a 23 and was at a higher risk for falls than the previous assessment dated [DATE]. There was no documented evidence Resident #79 was assessed for the risks and benefits of fall mats prior to use when deemed a fall risk. There was no documented evidence Resident #79 received hourly supervision in accordance with MDO to prevent falls on 6/12/2023 and 6/19/2023. There was no documented evidence Resident #79's CCPs related to falls were reviewed and revised to include interventions to address multiple falls on 10/19/22, 6/12/23, and 6/19/23. On 09/18/23 at 09:49 AM, CNA #7 was interviewed and stated they were assigned to Resident #79 on 6/12/2023 and 6/19/2023 when the resident was found on the floor in their room. The unit works short staffed often on the weekends and CNA #7 does the best they can to address resident needs but there are times you cannot get to all residents to provide activity of daily living care. Some residents wander and must be monitored. CNA #7 makes rounds and checks in on confused residents to ensure they are safe and in bed and not on the floor. CNA #7 stated the CNA Accountability informs them of resident care needs. Resident #79 had 2 incidents of being found on the floor in their room. Resident #79 was not considered a fall risk prior to the 2 incidents in 6/2023. After reporting the first fall to the LPN, the CNA was told Resident #79 needed a low bed. After the 2nd fall, Resident #79's bed was changed to a floor bed and the floor mats were changed from worn mats to brand new floor mats. Resident #79 was found on the floor mat on the 2nd fall. Resident #79 was confused and wandered on the unit after getting dressed in the morning and would normally sit in the floor dayroom. Resident #79 was still able to ambulate after the first fall on 6/12/23. Fall and safety precautions were in place, and this means the CNA ensures there is no clutter on the floor for the resident to trip over and that Resident #79 is monitored for a change in balance. If the resident is unsteady, they need to be placed in a wheelchair. Sometimes Resident #79 attempted to get up from the wheelchair on their unassisted. Resident #79 was placed on hourly checks. CNA #7 normally performed the hourly checks. Resident #79 was on the list of residents to get out of bed and dressed early in the morning. Sometimes, CNA #7 required the assistance of a 2nd CNA because the resident had a behavior of screaming. On 6/19/2023, CNA #7 last saw Resident #79 in bed at 5:45 AM, alert and shaking. When CNA #7 came back to give Resident #79 care, the resident was on the floor mat. CNA #7 informed the LPN assigned to the unit and the LPN directed CNA #7 to get a Hoyer lifter to transfer Resident #79 back to bed before the RN came to the unit to assess the resident. On 09/15/23 at 12:38 PM, LPN #6 was interviewed, and stated Resident #79 had a low bed in place due to their high risk for falls. Resident #79 was not receiving any special supervision and had floor mats in place. LPN #6 was not present for either of Resident #79's falls in 6/2023. Resident #79's room was changed to be closer to the nursing station after the fall on 6/12/2023. Hourly supervision is documented separately. On 09/18/23 at 11:06 AM, the RN Permittee was interviewed, and stated Resident #79 was known as a fall risk that frequently placed themselves on the floor. This was not documented in Resident #79's medical record, but the CNAs informed the RN Permittee of the resident's behavior. Resident #79 was on fall and safety precautions prior to their fall on 6/19/2023. The bed was already in the lowest position and floor mats were already in place. The appropriateness of floor mats is determined by the Director of Nursing (DNS). Rehab assesses the resident also. It is not one person's decision to place floor mats in a resident's room. The CNA is responsible for monitoring residents hourly to ensure they are still in bed. There is a supervision logbook that is checked by the LPNs. On 09/14/23 at 05:07 PM, RN #2 was interviewed and stated Resident #79's low bed was changed to a very low bed after their first fall on 6/12/2023. On 09/18/23 at 12:55 PM, the DNS was interviewed and stated Resident #79's incidents of being found on the floor were investigated. Resident had floor mats on the floor after the first fall on 6/12/2023 and they were still in place when the resident fell on [DATE]. Nursing uses their judgment to determine the appropriateness of floor mats for a resident at risk for falls. Floor mats are not appropriate for a resident who can walk. Resident #79 was unable to walk so floor mats were used as an intervention. It should be listed on under the nursing task list. The AI investigation on 6/12/2023 was not adequate as it did not contain all the statements from staff that were working that shift. could be an error. 2) On 09/10/23 at 11:52 AM, the shower room close to the floor dayroom on the east side of the unit was slippery without visible spills and did not have a wet floor sign. AN Eyewash Station sign was posted on the door and no eyewash station was observed in the shower room. A Supervisor's Office door was unlocked, and the room contained a drill attached to a desk and an x-ray machine. East Wing High side of 2nd floor unit. Shower room with slippery floor. No visible spills. At 3:13 PM, the shower room was still slippery, and a large puddle of water had accumulated under the toilet and no wet floor sign was in place. The Supervisor's Office was still unlocked. At 3:24 PM, the floor dayroom was observed with a window on the left side of the room that opened all the way and had a large enough opening for a person to fit through. On 09/12/23 at 11:11 AM, the shower room on the east side by the floor dayroom had a large puddle of water under the toilet and no wet floor sign. On 09/12/23 at 11:31 AM, the Maintenance Worker (MW) was interviewed and, after observing the window that can open all the way in the dayroom, stated each floor is equipped with a window that can open all the way in case of an emergency for the fire department to access the facility. Nursing should know if there are any residents to monitor that might attempt to open the window and could fall out. The Supervisors Office is a dentist office and the x-ray machine contained inside is functional. Nursing is responsible for ensuring the room is locked. On 09/15/23 at 10:46 AM, Housekeeper (HK) #2 was interviewed and stated they must clean the shower room [ROOM NUMBER] times a day because there is a resident on the unit that uses it like their personal bathroom and splashes water on the floor. HK #2 was unaware that the shower room was also an eyewash station and did not observe an eyewash station in the room. On 09/15/23 at 11:15 AM, the Director of Housekeeping and Maintenance (DHM) was interviewed and stated the 2nd floor window in the dayroom should not open all the way and was fixed after pointed out to the MW to ensure there is a stopper in place. Each floor does not have a window that can open all the way. The DHM stated the Maintenance Department does check the windows to ensure they cannot open but not often. A resident on the 2nd floor causes floods in the shower room because they wash their clothing in the sink. Staff redirect the resident, but the resident's behavior continues. The eyewash station piece is in the Maintenance office downstairs because the resident removed the eyewash station when they use the sink. The DHM is looking into ordering individual bottles of eyewash to equip each floor with. At 11:46 AM, the DHM observed the open unlocked Supervisors Office and stated the Dentist, the DHM, and the owner have a key to this door. It is supposed to remain locked unless in use by the dentist. It may have been opened by staff to clean it but then should be locked again after. 415.12(h)(1)

Based on observation, record review, and staff interviews conducted during the recertification and complaints (NY00307070, NY00318546, survey from 9/10/23 through 9/18/23, the facility did not ensure there was sufficient staff available to meet residents' needs considering the number, acuity and diagnose of the facility's resident population as determined by the Facility Assessment. Specifically, 1) the facility reported short staffing on weekends confirmed by a review of the Daily Staffing and the Payroll Based Journal (PBJ) Staffing Data Report, 2) Resident #171 was discovered with an injury of unknown origin on a day when the unit was short of Certified Nursing Assistants (CNA), and 3) Resident #121 reported not receiving care on a day when the facility was short of CNAs on their unit. The findings include but are not limited to: The Facility Staffing policy reviewed 4/20/23 documented that each nursing unit will have adequate staff to safely and effectively complete resident care on a daily basis. The Facility Assessment tool revised 1/24/23 documented facility is licensed to care for 120 residents with 3 nursing units and with average daily census ranges from 117. Staffing Plan is to ensure sufficient staff to meet the needs of the residents at any given time. 1. PBJ Staffing Data Report and Daily Staffing Sheet The PBJ Staffing Data Report dated Fiscal Year (FY) Quarter 2 2023 (January 1- March 31) documented the facility triggered for the metric of excessively low weekend staffing. A review of Daily Staffing sheets from 8/6/23 to 9/10/23 revealed following weekend dates did not meet the minimum number required on following weekend dates: 8/06/23 Day shift - 9 CNAs (3 short) 8/12/23 Night shift -5 CNAs (1 short) Day shift - 10 CNAs (2 short) Evening shift - 7 CNAs (2 short) 8/13/23 Night shift -5 CNAs (1 short) Day shift - 9 CNAs (3 short) Evening shift - 8 CNAs (1 short) 8/19/23 Night shift -5 CNAs (1 short) Day shift - 10 CNAs (2 short) 8/20/23 Night shift -4 CNAs (2 short) Day shift - 11 CNAs (1 short) 8/26/23 Night shift -5 CNAs (1 short) Day shift - 10 CNAs (2 short) Evening shift - 7 CNAs (2 short) 8/27/23 Night shift -3 CNAs (3 short) Day shift - 8 CNAs (4 short) Evening shift - 7 CNAs (2 short) 9/02/23 Night shift -4 CNAs (2 short) Day shift - 10 CNAs (2 short) Evening shift - 8 CNAs (1 short) 9/03/23 Night shift - 5 CNAs (1 short) Day shift - 10 CNAs (2 short) 9/09/23 Night shift -5 CNAs (1 short) Day shift - 9 CNAs (3 short) 9/10/23 Night shift -5 CNAs (1 short) Day shift - 9 CNAs (3 short) The number of CNAs needed for Night shift, were not met for 10 out of the 11 weekend days, Day shift were not met for 11 out of the 11 weekend days and Evening shift, were not met for 5 out of the 11 weekend days. The facility utilized Home Health Aides(HHAs) to assist on the units. 37787 2) Resident #171 was admitted to the facility on [DATE] with diagnoses which included Psychotic Disturbance, Mood Disturbance and Anxiety. The Admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #171 had severely impaired cognition. The MDS further stated that the Resident is extensive and one assist for bed mobility and dressing. Extensive and 2 assists for transfer and toilet use. On 9/14/2023 at 5:28 PM, the complainant was interviewed and stated that they don't get enough staff at night to watch the Residents. On 9/12/2023, CNA #6 was interviewed and stated that on that day, 6/18/23 , the unit was working short, The 3rd floor had 2 CNAs with the regular charge nurse. CNA #6 further stated that when entered the Resident's room, the Resident was observed with a bump on the forehead and the nurse in charge was immediately notified. On 9/12/23 at 2;25 PM, the LPN #4 was interviewed and stated that a bump with redness was observed on the Resident's forehead and staff did not know how it happened and Resident was unable to express themselves. 44472 3) Resident #121 has a diagnosis of End Stage Renal failure, Morbid obesity. Minimum Data Set (MDS) dated [DATE] documents resident #121 needs extensive to total assistance of staff to complete Activities of daily Living (ADL) Resident # 121 stated the unit have only one CNA on 12/5/2022 and 4/20/2023 and bells were unanswered. The unit have 39 residents. Staffing schedule was reviewed and revealed that for both dates Resident #121 reported, it was documented that on the night shift only one CNA was assigned to unit for 39 residents. Facility Assessment documents that 2 CNAS must be scheduled to work for 39 residents for the night shift. On 09/14/23 at 04:41 PM CNA # 5 was interviewed and stated on 12/5/22 on 11-7 shift only one CNA worked to care for 39 residents, understaffing happened mostly on weekends on all shift, staff leaves the facility because there is no incentives. 40686 On 09/18/23 at 09:49 AM, CNA #7 was interviewed and stated they have worked in the facility for 9 years, always works the night shift and usually works the weekends. Since the COVID pandemic, the facility often works short staffed of CNAs. The 4th Floor has a census of 40 residents and there are 2 CNAs scheduled to provide activity of daily living care to residents, monitor wanderers, and get residents for dialysis in the morning. There are many times, CNA #7 must work alone as the only CNA on the unit to provide care for all 40 residents. CNA #7 does the best they can to cover all resident needs but there are times they cannot get to all residents. It is a lot of responsibility even when staffed with 2 CNAs. In month, the unit will work short-staffed of CNAs an average of 3 times. If the other CNA scheduled to work is on vacation or calls out, the facility does not replace them. CNA #7 stated it gets frustrating and is an ongoing problem even though staff have communicated their concerns with staffing to the Administration and Human Resources. CNA #7 stated they feel burnt out and overworked. CNA #7 requested a personal day several a week in advance for a funeral and was told by the Director of Nursing that they will not grant the day off because they will not be able to find a replacement. Human Resources tells the staff they are putting more work on the other CNAs if they take vacation or call out. CNA #7 had to call out on the personal day they requested because they could not miss the funeral for their family member. CNA #7 was informed when they returned to work that the other CNA scheduled to work on the day CNA #7 took as a personal day ended up having to work alone. If a resident requires 2 people to assist with care or transfers, the LPNs try to help if they have time, otherwise the residents must wait until the day shift comes to work or the CNA will try to request for a CNA from another unit to help. The facility employs Home Health Aides (HHA) to work on the unit instead of more CNAs. HHAs cannot provide direct care to residents so they cannot assist with activities of daily living and do not have access to the medical record so they cannot assist with completing necessary documentation. Administration does give overtime easily so when CNA #7 is asked to cover other CNAs shifts, it is a fight to get paid for the extra time. When care cannot be provided to the residents, the residents start to break down. On 09/15/23 at 10:50 AM LPN # 4 was interviewed stated the unit is almost full capacity every day and gives medications to about 37 to 39 residents and also do the treatment also. The RN supervisor is only one for the whole building. The unit have sometimes 3 CNAS for 37 or 4 CNAS sometimes. If the unit have 3 CNAs in the day shift it is difficult because we have a lot of total care residents. On 09/18/23 at 11:06 AM, the RN Permittee was interviewed and stated they have worked in the facility per diem as an LPN. The unit they manage has worked short of staff approximately 5 times on the night shift. The facility tries to get coverage, but they cannot usually get anyone to cover. On 09/15/23 at 09:45 AM RN# 4 was interviewed stated worked full time in the facility and most of the residents complaint of short staffing, they get upset if the call bell are not answered timely. They tried to reason out to residents that they will attend to them as soon as they're done with whatever they're doing with one resident. On 9/14/23 at 12:31 PM and On 9/15/23 at 1:45 PM, an was conducted with the Staffing Coordinator who stated weekend staffing is very hard to fill in if somebody calls in sick. CNA is harder to replace than an LPN. If they failed to get a replacement, they notify the RN supervisor, and the supervisor continues to look for a replacement. If still the RN supervisor cannot replace a CNA, then that CNA must work by themselves with the help of the nurse on the unit. They make the Director of Nursing (DON) aware that they cannot get a replacement for sick calls and the RN is trying also to get a replacement. The Staffing Coordinator stated that staffing has been challenging for the last year and a half, especially the weekends. They have been continuously reaching out to 9 different staffing agencies, posting on Indeed to recruit more CNAs. Currently they are hiring 1 part time and 2 full time CNA positions for Night shift, 2 part time and 1 full time CNA positions for Day shift, and 1 part time CNA position for Evening shift. It's difficult to find staff to cover the call outs on the weekend. On 9/14/2023 at 6:13 PM, The Assistant Director of Nursing (ADON) was interviewed and stated that Resident wanders around days and night. For the staffing in the facility, it is supposed to be 2 CNAs at night on each floor, 3 CNAs in the evening and 4 CNAs during the day. There are days they worked short during the week and the weekend. Mostly, there is a pattern for staff to call out over the weekend. Specially in the weekend, it is hard to find replacement. If they are working short, depend on the shift, the night shift can end up with 1 CNA, evening shift with 2 CNAs and day shift with 3 CNAs. Staffing is a big problem in the facility. On 09/18/23 at 2PM the Director of Nursing was interviewed and stated they are aware of short staffing and are actively hiring staff, however new hires do not stay long enough, they leave for reason they do not know. On 9/18/23 at 12:12 PM, Administrator stated they are assigning staff sufficiently on a daily basis, but it is a problem finding coverage for all the call outs. There are not enough staff to cover all the call outs. They have been posting in indeed and through word of mouth. Administrator stated that only one resident came to him to complain about staffing issues. He stated staffing issue started during COVID because staff got sick, never came back, and have retired. The positions were never fully replaced. It has been about last 6 months that the call outs gotten worse especially weekend staff. 415.13(a)(1) (i-iii)