Every finding on record at Cedar Manor Nursing & Rehabilitation Center

Based on record review, and interviews during an abbreviated survey (2622924), the facility did not ensure a comprehensive care plan was developed and implemented to maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (1) of three (3) residents reviewed for behaviors. Specifically, there was no documented evidence of a behavior care plan for Resident # 1 who had a diagnosis of dementia with other behavioral disturbances and had multiple nursing progress notes as well as staff interviews that revealed that Resident # 1 refused care and had behaviors.A review of the facility's Resident Assessment and Care Planning Policy last revised 01/25/2025 documented it is the policy of the facility to maintain accurate and current comprehensive assessment and person-centered plan of care for each resident.The facility's Activities of Daily Living Policy dated 5/2025 documented it is the policy of the facility that all residents are assisted with their activities of daily living according to each resident's individual plan of care. admission Minimum Data Set (an assessment tool) dated 08/12/2025 documented that the resident had a Brief Interview of Mental Status score of 10; indicating the resident was moderately cognitively intact with no behaviors present. Resident had no impairments to the upper extremities and one side impairment to the lower extremity. Resident uses a wheelchair for locomotion. Requires supervision with eating and maximum assistance with toileting. Moderate assist with bed mobility and maximum assist with transfers. Frequently incontinent of urine and bowel. Resident is on antipsychotic, antianxiety, antidepressants.Review of all care plans indicated there was no documented evidence of a behavior care plan for Resident #1.A review of a respiratory progress note documented by Respiratory Therapist #1 dated 08/06/2025 at 9:21am documented Incentive Spirometer recommended for lung expansion therapy with goals to increase lung volumes, strengthen the lungs and reduce the rate of pneumonia. Resident refused incentive spirometry and stated they are not feeling well.A review of a respiratory progress note documented by Respiratory Therapist #1 dated 08/07/2025 at 8:29pm documented Resident #1 refused Incentive spirometry therapy.A review of a nursing progress note documented by Registered Nurse #2 dated 09/03/2025 at 10:16pm documented Resident #1 is alert and confused. Family member and resident refused shower.A review of a nursing progress note dated 09/08/2025 at 10:21pm documented Resident #1 refused bedpan but after encouragement used it and went to bed.A review of a nursing progress note documented by Licensed Practical Nurse #4 dated 09/26/2025 at 10:30pm documented Resident #1 refused to be showered this morning, writer intervened by encouraging resident and daughter-in-law was also present who also intervened. Bed bath given.A review of a nursing progress note documented by Registered Nurse #3 dated 09/30/2025 at 9:57pm documented that Resident #1 refused care and stated, I will go home tomorrow resident sat in the front of the bed stated, I going to report you if you touch me. Will continue to monitor resident behavior.During an interview with Certified Nurse Aide #3 at 11/3/2025 at 3:05pm they stated Resident #1 was assigned to them when they were moved from the east wing to the north wing. Resident #1 would always cry that they want to go home, and they did refuse the bedpan.During an interview with Certified Nurse Aide #4 on 11/12/2025 at 10:53am they stated they are familiar with Resident #1 because they worked with Resident #1 on the east wing. Certified Nurse Aide #4 stated the resident will always scream when you attempt to provide care to them, and Resident #1 reports to them that they want to go home. Sometimes when you attempt to provide care to Resident #1, they will scream that they are in pain. Certified Nurse Aide #4 stated sometimes Resident #1 did not want to use the bedpan. If a resident refuses care, there is no way for the certified nurse aide to document this in point click care (an electronical medical record); therefore, they report to the nurse directly when a resident refuses care. Certified Nurse Aide #4 stated that Resident #1 had behaviors where they would yell for staff to get out of the room and refusal of cares.During an interview with the Director of Nursing on 11/17/2025 at 10:06am they stated Resident #1 had behaviors where they would be weepy, cry out and refuse cares. In review Resident #1's care plans with Director of Nursing, they stated they will have to further review the care plans.During a follow up telephone interview with the Director of Nursing on 11/17/2025 at 1:48pm they stated they took the time to review the care plans and spoke to Unit Manager #2 about the care plans. Director of Nursing stated that Resident #1 did not have a behavior care plan in place, and Unit Manager #2 was documenting the behaviors in nursing progress notes. Director of Nursing stated they instructed Unit Manager #2 to initiate a behavior care plan for Resident #1, and they can reference to the nursing notes for the behavior care plan. If a resident was refusing care, then that can be a part of the behavior care plan. 415.11(c)(1)

Based on record review, and interviews during an abbreviated survey (2622924), the facility did not ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (one) out of 3 (three) residents reviewed for activities of daily living. Specifically, Resident #1 had 2 (two) grievances on file for 08/25/2025 and 09/15/2025 related to care. 1) 08/25/2025 Resident #1's Representative found them in the facility smelling of urine and prior to their arrival a family member was there and reported that staff did not change Resident # 1. 2) On 09/15/2025 Resident #1's Representative found them in the day room requesting to go to the bathroom and Certified Nurse Aide #4 refused to put them on the bedpan and stated the resident is a Hoyer and threw the bedpan. On 08/17/2025 the resident was transferred to the hospital with admitting diagnosis of sepsis. On 08/21/2025 documented discharge diagnosis sepsis, community acquired pneumonia, urinary tract infection, acute kidney injury.The facility's Activities of Daily Living Policy dated 5/2025 documented it is the policy of the facility that all residents are assisted with their activities of daily living according to each resident's individual plan of care. Activities of Daily Living are defined as toileting, bathing, personal hygiene/ dressing and grooming, transfer/bed mobility, ambulation/locomotion and eating.Resident #1 is an [AGE] year-old that was admitted to the facility on [DATE] with diagnosis that include but not limited to dementia with other behavior disturbances, displaced fracture of the greater trochanter of the left femur, and chronic kidney disease. An admission Minimum Data Set, dated [DATE] documented that the resident had a Brief interview for mental status score of 10; indicating the resident's cognition was moderately impaired with no behaviors present. Resident had no impairments to the upper extremities and one side impairment to the lower extremity. Resident used a walker for locomotion. Requires supervision with eating and maximum assistance with toileting. Moderate assist with bed mobility and maximum assist with transfers. Frequently incontinent of urine and bowel. Resident is on antipsychotic, antianxiety, antidepressants, and anticoagulantsReview of an activity of daily living care plan dated 8/21/2025 documented Resident #1 requires assist with activities of daily living function due to current primary medical condition.Review of a Urinary Incontinence Care Plan dated 8/8/2025 documented the resident has bladder incontinence related to confusion, impaired mobility. Potential for urinary tract infection with a goal that the resident's risk for septicemia will be minimized/prevented via prompt recognition and treatment of symptoms of urinary tract infection through the review date initiated on 8/8/2025 interventions initiated on 8/8/2025 documented BRIEF USE: The resident uses (incontinent) disposable briefs to maintain dignity, clean peri-area with each incontinence episode, monitor/document for signs and symptoms of urinary tract infection: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.Review of a nursing progress note dated 08/16/2025 at 4:05pm documented Resident #1 was sent to the hospital with provider order, due to change in mental status wherein she was unable to answer questions, pain, drop in oxygen saturation, tachycardia, yellowing of skin, and general malaise. Family made aware of transfer. Review of a nursing progress note dated 08/17/2025 at 03:42am documented Resident #1 admitted to the hospital. Admitting diagnosis Sepsis. Provider and Family aware. A hospital Discharge summary dated [DATE] documented discharge diagnosis sepsis, community acquired pneumonia, urinary tract infection, acute kidney injury.Review of a grievance dated 8/25/2025 documented that the family found the resident smelling of urine on 8/24/2025 when they arrived at 5pm. Prior to their arrival another family member was there on 8/24/2025 from 9:30am-12:30pm and reported to the family member coming in that no cares were provided to Resident #1.Certified Nurse Aide documentation for August 2025 Bowel and Bladder Elimination had omissions in documentation for day shift 7-3pm on 08/05/2025,08/07/2025-08/10/2025, 08/12/2025-08/13/2025,08/15/2025, 08/21/2025, 08/23/2025, 08/28/2025 and 08/29/2025. Evening shift 3-11pm had omissions on 08/05/2025,08/12/2025, 08/13/2025, 08/15/2025, 08/16/2025, 08/22/2025, 08/23/2025, 08/25/2025, 08/27/2025 and 08/29/2025. Night shift 11- 7am had omissions in documentation on 08/07/2025, 08/10/2025 and 08/13/2025, 08/15/2025, 08/22/2025, 08/24/2025, and 08/31/2025.Certified Nurse Aide documentation for August 2025 toilet transfers had omissions in documentation for Day shift 7-3pm on 08/12/2025, 08/13/2025, 08/15/2025, 08/21/2025, 08/23/2025, 08/28/2025, and 08/29/2025. Evening shift 3-11pm had omissions on 08/10/2025, 08/12/2025,08/13/2025, 08/15/2025,08/16/2025, 08/22/2025, 08/23/2025, 08/25/2025, 08/27/2025, and 08/29/2025. Night shift 11- 7am had omissions in documentation on 08/10/2025,08/13/2025,08/15/2025, 08/22/2025, 08/24/2025, 08/31/2025.Certified Nurse Aide documentation for August 2025 toilet hygiene had omissions in documentation for Day shift 7-3pm on 8/12/2025, 08/13/2025, 08/15/2025, 08/21/2025, 08/23/2025,08/28/2025 and 08/29/2025. Evening shift 3-11pm had omissions on 08/10/2025, 08/12/2025,08/13/2025, 08/15/2025,08/16/2025, 08/22/2025, 08/23/2025, 08/25/2025, 08/27/2025, and 08/29/2025. Night shift 11- 7am had omissions in documentation on 08/13/2025,08/15/2025, 08/22/2025, 08/24/2025, 08/31/2025.Review of a grievance dated 9/15/2025 documented on 9/14/2025 family came to visit Resident #1 and found them in the dayroom with other residents and two aides. Family stated the resident wanted to use the bathroom. Certified nurse aide told the family that they could not because the resident was a Hoyer, and the resident threw the bed pan when offered it to the resident; the aide walked away from the family. The Family found the supervisor who instructed the aide to assist with the bedpan and then the resident calmed down after they were assisted on the bedpan.Certified Nurse Aide documentation for September 2025 Bowel and Bladder Elimination had omissions in documentation for day shift 7-3pm on 09/02/2025,09/09/2025-09/15/2025, 09/17/2025-09/20/2025, 09/22/2025, and 09/26/2025-09/30/2025. Evening shift 3-11pm had omissions on 09/07/2025-09/09/2025, 09/14/2025, 09/15/2025, and 09/23/2025. Night shift 11- 7am had omissions in documentation on 09/02/2025, 09/06/2025, 09/07/2025, 09/09/2025, 09/12/2025, 09/13/2025, 09/16/2025, 09/19/2025-09/21/2025, 09/23/2025-09/25/2025,09/27/2025,09/28/2025, 09/30/2025.Certified Nurse Aide documentation for September 2025 toilet transfers had omissions in documentation for Day shift 7-3pm on 09/02/2025, 09/09/2025-09/15/2025, 09/17/2025-09/20/2025, 09/26/2025-09/30/2025 Evening shift 3-11pm had omissions on 09/04/2025, 09/07/2025-09/09/2025, 09/12/2025,09/14/2025, 09/16/2025, 09/23/2025, 09/24/2025. Night shift 11- 7am had omissions in documentation on 09/02/2025, 09/06/2025, 09/07/2025,09/09/2025, 09/12/2025,09/13/2025, 09/16/2025, 09/19/2025-09/25/2025,09/27/2025,09/28/2025,09/30/2025.Certified Nurse Aide documentation for September 2025 toilet hygiene had omissions in documentation for Day shift 7-3pm on 09/02/2025, 09/09/2025-09/15/2025. Evening shift 3-11pm had omissions on 09/04/2025, 09/07/2025-09/09/2025, 09/14/2025 Night shift 11- 7am had omissions in documentation on 09/03/2025, 09/06/2025, 09/07/2025, 09/10/2025, 09/12/2025, 09/13/2025.A Social Services Progress note dated 09/25/2025 at 12:03pm documented a meeting was held with the family and the ombudsman on the phone. Family expressed concerns with toileting schedule, nursing reviewed the schedule, and the family somewhat understood the toileting schedule. Therapy explained transfer and positioning as well. Overall, family continues to want more information, and more time spent with Resident #1. Team suggested they hire a one to one if they want more attention or visit more often in the day.During an interview with Resident #1's Representative 11/3/2025 at 2:46pm stated their issues overall when Resident #1 was admitted they developed a urinary tract infection and was diagnosed with sepsis in the hospital. Resident #1's Representative stated they found Resident #1 in the facility twice soaked in urine. They reported this to Unit Manager #1 who stated the resident does not get VIP treatment. Resident # 1's Representative was stressed about the resident's hygiene, and the care Resident #1 was receiving in the facility. They were concerned for Resident #1 while they were on the rehabilitation unit because they did not care. The lack of empathy from the staff is unbelievable they found Resident #1 screaming for help and they started recording the staff that was sitting there watching the resident and stated it was not Resident #1's time to go to the bathroom because Resident #1 was a Hoyer. During a telephone interview with the Director of Nursing at 11/17/2025 at 10:06am the nurses on the unit can oversee the documentation of certified nurse aides for the side that they work, but the unit managers are responsible for reviewing. Activities of Daily Living can be ensured that they are completed by documentation and visually. If activities of daily living are not being completed, then they will address it with the staff. Director of Nursing stated they did not have a computer in front of them to review the certified nurse aide documentation for 8/2025 and 9/2025. Toileting schedule was added to the documentation but there were issues with the certified nurse aides signing off on it. They spoke with Unit Manger #2 about how to enter the task into Point Click Care correctly. The resident does have behaviors where they are weepy and cry out for help and refuse cares. They will review the documentation and call surveyor back.During a telephone interview with the Director of Nursing on11/17/2025 at 1:48pm they stated they spoke with Unit Manager #2, and they are, and they are following up with staff to find out why they did not document. They will speak with the staff about the importance of documentation. Documentation should be reviewed by the nurse that can run a report, but the manager is the sole keeper and should remind staff to document. Unit Manager #2 was a new manager and was not up to speed with everything and was learning their new role. Director of Nursing stated they do acknowledge that there are omissions in documentation for certified nurse aide documentation for 8/2025 and 9/2025.During an interview with Registered Nurse #2 on 11/26/2025 at 11:42am they stated they oversee the certified nurse aides on their shift, but they do not review the certified nurse aide documentation. Registered Nurse #2 stated they never reviewed the certified nurse aide documentation because they were not directed to do it and that is why they never reviewed the documentation. Registered Nurse #2 stated they check to see if care was provided by assessment, talking to the resident, and visibly seeing the aide provide care. The unit manager is responsible to reviewing the can documentation. Registered Nurse #2 stated every morning the unit manager talks to them to express the importance of documentation. Stated that if the shift ends and the documentation is not complete then you did not do it.During an interview with Certified Aide #6 on 11/26/2025 at 12:19pm they stated they must do the computer documentation for the activities of daily living. Recently administration stated if documentation is not complete it will be a verbal and then a write up in their file. Certified Nurse Aide #6 stated that all the time they cannot document the care because there is too much to do and not enough staff. They try their best to complete the documentation; however, they do leave when their shift ends because the facility is not going to allow them to stay for documentation. They stated that if they need to do three (3) showers and everything else they are burnt out and cannot do the documentation. Unit Manager #2 had come to them about the documentation issue. Unit Manager #2 stated to Certified Nurse Aide #6 that it's important because if they do not complete it, they do not know who had a bowel movement, nutritional status of the resident or refused cares.415.12(a)(3)

Based on observation, interview, and record review conducted during recertification and abbreviated survey (NY00353725) conducted from 4/6/2025-4/11/2025, the facility did not ensure the residents rights to a safe, clean, comfortable, and homelike environment. Specifically, 1) the facility did not provide adequate amount of bath linens for all the residents; and 2) rooms [ROOM NUMBERS] were observed with displaced base board moldings. The findings include: 1. The policy and procedure titled Linen Policy undated documented Par levels will be maintained according to the facility par-level inventory directory. Par levels will be reviewed and adjusted based on census and resident population. Review of the facility PAR level for linens, undated, documented: - North unit census 52 residents, dayshift 40 towels, evening shift 40 towels. - South unit census of 52 residents dayshift 40 towels, evening shift 40 towels. - East unit census 49 residents dayshift 40 towels, evening shift 40 towels. - Night closet 40 towels for all three units. Review of the invoice dated 2/6/2025 documented an order for 180 bath towels. An observation was made on 4/7/25 at 9:30 AM of the clean linen cart on the South unit. Sheets and gowns were observed but there were no towels for use. During an interview on 4/7/25 at 9:34 AM, Resident #49 stated there were no towels available for use during morning care and had been told to use paper towels or nothing at all. During an interview on 4/7/2025 at 10:00 AM, Resident # 78's family member stated the facility has a limited supply of towels, and sometimes the staff had to use pillowcases and sheets to dry the resident after their shower. During the Resident Council meeting on 4/7/2025 at 10:33 AM, Resident #78 and Resident # 102 stated they had limited towels. They stated staff often used hand towels and sheets to dry residents after showers. During an interview on 4/7/2025 at 3:00 PM, the Administrator stated they ordered more towels. It was an ongoing issue; they had about 12 bundles of towels and would order some more. They stated sometimes the staff hid the supplies or threw them away. During an observation on 4/7/2025 at 3:00 PM in the linen closet in the laundry room, there were eight packs of 12 towels for a total of 96 towels. During an observation and interview on 4/7/2025 at 4:30 PM, the South unit had a census of 52 residents, and five aides were assigned to the unit. Certified Nurse Aide #5 stated each aide was given three towels and they had one resident that needed a shower. The facility did not have enough towels to provide care to all the residents and administration was aware. During an interview on 4/8/2025 at 9:46 AM, Certified Nurse Aide #6 stated they gave two showers and there were no towels left for the rest of the day. The facility did not have enough towels, and the administration was aware of the towel shortage. During an interview on 4/8/2025 at 10:00 AM, the Maintenance Director stated that they did not know the exact number of towels put on the carts and they had enough supplies. They stated the Supervisors had the keys to the laundry if more supplies were needed. They also stated sometimes they did not get back the same number of towels sent to the unit. During an interview on 4/8/2025 at 3:36 PM, Laundry Worker #4 stated they were supposed to send up 40 towels to each unit every shift and 20 towels on nights, but there were not enough. They put 20 towels on the carts for every shift. Sometimes, they only put 5 or 6 towels on the carts because that was what was available. During an observation and interview on 4/8/2025 at 4:00 PM, the South unit had a census of 52 residents, and five aides were assigned to the unit. Certified Nurse Aide #1 stated each aide had five towels for the shift and it was still not enough. During an interview on 4/10/25 at 2:48 PM, Certified Nurse Aide #28 stated when they did not have towels, they used whatever they had left on the cart for residents. This included using sheets and old blankets to dry residents. They stated the facility was aware of the shortage, but nothing was done. 50766 2. During an observation 04/06/25 at 05:20 PM of room [ROOM NUMBER], the base board tiling was observed to be displaced from wall between radiator and wall and resting on the floor between the window and resident bed. During an observation on 04/07/25 at 12:33 PM of room [ROOM NUMBER], the wall in the center of front of room had a repaired hole in the wall, which was not repainted, and the base board tiling was observed lying on the ground, not re-attached to the wall. During an interview and observation on 04/11/25 at 9:35 AM with Director of Maintenance, room [ROOM NUMBER] was observed with baseboard tile displaced off of the wall in between radiator and back wall of room, under the window. The Director of Maintenance stated they were not made aware the baseboard was loose. room [ROOM NUMBER] was observed with baseboard in the front middle of room, between the two resident areas not attached to wall and lying on the floor. They stated they were not aware of the repair needed to room [ROOM NUMBER] and did not receive a request, verbal or work order from unit staff. They stated repairs needed on units were provided to maintenance staff by receiving work orders or verbal reports from staff or residents. During an interview on 04/11/25 at 9:49 AM, the Assistant Director of Nursing stated they were not aware of environmental concerns in rooms [ROOM NUMBERS]. They stated that work repair requests were submitted electronically. If an urgent request was needed, the front desk would be called, and they would relay the request to maintenance. They stated that unit staff should relay environmental concerns to the nurse and/or manager and a work order request submitted. The Assistant Director of Nursing provided a work order request dated 3/28/25 for room [ROOM NUMBER] which documented the resident stated they were still missing TV channels and there was a hole in wall that was being worked on, and no one had come back to fix it/repaint etc. 10 NYCRR 415.5(h-i)(1-3)

Based on observation, record review, and interview conducted during the recertification and abbreviated surveys (NY00364873) from 4/06/2025 to 4/11/2025, the facility did not ensure that each resident who was unable to perform activities of daily living received the necessary care and services to maintain grooming and personal hygiene for three of five dependent residents (Residents #387, # 124, and # 56) reviewed for Activities of Daily Living. Specifically, 1) there was inconsistent documentation that Resident #387 who required assistance with bowel and urinary incontinence had there brief changed every 3 to 4 hours, 2.) Resident #124 was observed with long, dirty fingernails and 3) Resident # 56 stated they had not received a shower or had their hair washed since they were admitted to the facility. The findings include: The undated policy and procedure titled Activities of Daily Living documented all residents are assisted with their activities of daily living. The unit nurses are responsible for creating schedules for showering a minimum of twice per week, allowing for resident preference. In addition, the unit nurses should create shift assignments for each certified nurse aide. 1) Resident # 387 had diagnoses including cerebral infarction, anemia, and hypertension The Quarterly Minimum Data Set (resident assessment tool) dated 11/06/2024 documented Resident #387 was cognitively intact, required minimal to maximum assistance with their activities of daily living and had urinary and bowel incontinence. The comprehensive care plan revised 04/28/2024 titled Bladder Incontinence included brief changes every 3 to 4 hours and as required. Wash, rinse, dry the perineum, and change clothing as needed after incontinence episodes. The certified nurse aide care guide for Resident # 387 revealed documentation that Resident #387 used incontinence briefs and was to be changed every 3 to 4 hours, and as needed. The 11/2024 certified nurse aide record showed no documented evidence that incontinence care was provided during the day shift from 11/2/2024-11/30/2024 and during the night shift from 11/3/2024-11/26/2024. The 12/2024 certified nurse aide record revealed no documented evidence that incontinence care was provided during the day shift from 12/2/2025-12/5/2025 and during the night shift from 12/2/2025-12/5/2025. During a telephone interview on 04/8/2025 at 12:17 PM Resident # 387's family member stated the resident was left in their waste for hours. They stated they requested that the resident be changed but were told by staff that they were short-staffed. During an interview on 04/8/2025 at 1:01 PM, Certified Nurse Aide # 17 stated when cares were provided it should be documented in the Kiosk. They stated when there were new residents, they would get information from nursing as to which cares should be provided to the resident. During an interview on 04/08/2025 at 1:14 PM, Licensed Practical Nurse # 3 stated when documentation for the resident's care was left blank, it could mean the care was done but was not documented. They stated the nurse manager or nurse supervisor were supposed to follow-up with the certified nurse aides to make sure they completed all their resident care documentation in the Kiosk. During an interview on 04/8/2025 at 1:25 PM, Registered Nurse Unit Manager # 16 stated personal hygiene should be documented every shift. They stated if there was no documentation it was due to either the certified nurse aides were too busy or forgot to document. They stated all certified nurse aides were educated and that there should be documentation for all cares provided to residents before staff left at the end of their shift. 2) Resident #124 was admitted to the facility with diagnoses including diabetes mellitus, Alzheimer's disease, and Parkinsonism. The Minimum Data Set, dated dated dated [DATE] documented Resident #124 had intact cognition and needed substantial/maximal assistance from staff with shower/bathing. The comprehensive care plan titled Activities of Daily Living dated 11/8/24, documented substantial/maximal assistance from staff with shower/bathing, supervision or touching assistance from staff with personal hygiene. During interview and observation on 4/6/25 at 5:59 PM and 4/8/25 at 12:55 PM Resident #124 was in bed. Resident #124's 1st, 2nd, and 3rd fingernails on both hands were long and had dark brown matter under each of the nails. Resident #124 stated they would like to take care of their long dirty fingernails, but they could not Resident #124 stated they had asked staff to clean and groom their fingernails but were told by staff they were to busy. During an interview on 4/8/25 at 1:54 PM Certified Nurse Aide #8 stated fingernail grooming was the certified nurse aides responsibility, and should be done during showers or baths. Certified Nurse Aide #8 stated when they showered Resident #124 on 4/7/25, they observed long fingernails, but because of lack of time they only washed the resident's fingernails. Certified Nurse Aide #8 stated they only file nails. During an interview and observation on 4/8/25 at 3:09 PM Registered Nurse Manager #2 stated clipping or filling residents' fingernails were responsibilities of certified nurse aides. Registered Nurse Manager #2 stated nurses could also clip or file residents' fingernails. Registered Nurse Manager #2 looked at Resident #124 fingernails and stated they were long/dirty, and should have been groomed. They stated no staff reported to them that Resident #124 had long fingernails. 3) Resident #56 diagnoses included multiple sclerosis, iron deficiency anemia, muscle wasting and atrophy unspecified lower leg. The Quarterly Minimum Data Set, dated dated dated [DATE] documented Resident #56 was cognitively intact, required substantial/maximal assistance with showering/bathing and was dependent on others for transfers. The physician order dated 12/31/24 documented transfer via mechanical lift with two (2) staff assist. The care plan dated 6/11/24 titled Activities of Daily Living, documented the resident required assistance with activities of daily living and functional, substantial/maximal assistance with showering/bathing and was transferred by mechanical lift with two (2) persons. During an interview on 04/07/25 at 12:42 PM Resident #56 stated they had not received a shower or had their hair washed since admission on 6/8/24 and only received bed baths. They stated they had requested various certified nurse aides to provide them a shower instead of bed bed bath but were told they could not receive a shower because they are unable to stand up. During an interview and observation on 04/09/25 at 11:44 AM Registered Nurse Manager #31 stated Resident #56 was on the schedule for a shower on Mondays and Thursdays during the 3 PM-11 PM shift and were not aware that Resident #56 was not showered and only received bed baths. A review of the resident care plan with Registered Nurse #31 did not indicate a reason why Resident #56 could not receive a shower or have hair washed. They stated unit had a bariatric shower available in unit shower room. Bariatric chair was observed with Unit Manager Registered Nurse #31 and was intact. They stated Resident #56 is a two-person assist for transfers and can be accommodated for showers on the unit. During an interview on 4/9/25 at 11:56 AM Licensed Practical Nurse #23 stated they were not aware if Resident #56 was to receive a shower or just bed baths. They stated they never observed Resident #56 being showered. They further stated they were not sure why showering and hair washing had not been completed. During a telephone interview on 04/11/25 at 01:39 PM Certified Nurse Aide #32 stated Resident #56 had requested showers and was on the shower schedule two times a week. They stated they were concerned the resident may fall and chose not to shower Resident #56 because the bariatric shower chair leg adjustment did not always work well. They stated they reported their concern to the nurses and unit manager. They stated the maintenance department repaired the bariatric shower chair in the past but they were concerned the chair would fault again, therefore they only offered Resident #56 bed baths. 10 NYCRR 415.12(a)(2) 49255 50766

Based on resident, family and staff interviews, and record review conducted during a recertification survey, the facility did not ensure that sufficient staff was available to meet the needs of all residents. Specifically, actual staffing levels were repeatedly below facility assessed minimum levels on the following dates (3/8/25, 3/9/25, 3/10/25, 3/22/25, 3/23/25, 4/3/25, 4/5/25 and 4/9/25). The findings include: The July 2024 Facility Assessment documented the minimum staffing for Certified Nurse Aides for all 3 units was 14 certified nurse aides for the 7 AM- 3 PM shift, 12 certified nurse aides for the 3 PM- 11 PM shift and 7 certified nurse aides for the 11 PM to 7 AM shift. The 3/8/25 staffing sheet for the 7 AM-3 PM shift documented a total of 9 Certified Nurse Aides for all three units when the minimum requirement was 14. The 3/9/25 staffing sheet for the 7 AM-3 PM shift documented a total of 10 Certified Nurse Aides for all three units when the minimum requirement was 14. The 3/10/25 staffing sheet for the 7 AM-3 PM shift documented a total of 11 Certified Nurse Aides for all three units when the minimum requirement was 14. The 3/22/25 staffing sheet for the 7 AM-3 PM shift documented a total of 12 Certified Nurse Aides for all three units when the minimum requirement was 14. The 3/22/25 staffing sheet for the 11 PM- 7 AM shift documented a total of 6 Certified Nurse Aides for all three units when the minimum requirement was 7. The 3/23/25 staffing sheet for the 7 AM-3 PM shift documented a total of 12 Certified Nurse Aides for all three units when the minimum requirement was 14. The 4/3/25 staffing sheet for the 3 PM- 11 PM shift documented a total of 11 Certified Nurse Aides for all three units when the minimum requirement was 12. The 4/5/25 staffing sheet for the 7 AM-3 PM shift documented a total of 11 Certified Nurse Aides for all three units when the minimum requirement was 14. The 4/9/25 staffing sheet for the 11 PM- 7 AM shift documented a total of 5 Certified Nurse Aides for all three units when the minimum requirement was 7. On 4/10/25 02:51 PM, during an interview, Certified Nurse Aide #34 stated they worked the 3 PM-11 PM shift on the east wing and most of the time they picked up extra work by staying for another shift. They stated short staffing usually happened on the weekend. Certified Nurse Aide #34 stated the facility used an agency but the agency staff did not usually show up. Certified Nurse Aide #34 stated when they were short staffed during 7 AM - 3 PM shift, residents' showers might be skipped. On 4/10/25 at 4:10 PM, during an interview with the Staffing Coordinator, they stated the minimum staffing for the 7 AM- 3 PM shift was 5 Certified Nurse Aides per unit or 15 Certified Nurse Aides total for all 3 units. The Staffing Coordinator stated that if they had a call out, they tried to get another staff member to fill the shift but it was not always easy. They stated they walked around facility and asked Certified Nurse Aides that were working if they could pick up the next shift. The Staffing Coordinator stated they often used an agency and would confirm the shift with the agency, and later would find out the agency staff did not show up. The Staffing Coordinator stated they felt it was mostly short staffed on the weekends. On 4/11/25 at 9:15 AM, during an interview the Director of Nursing stated the staffing level was 4-5 certified nurse aides per unit and there were days they went below the minimum staffing and used the nursing supervisors to chip in. The Director of Nursing stated it was a strain on staff when they had 2-3 extra residents to care for. The Director of Nursing stated they did not feel short staffing was specific to nights or weekends and felt it could just be related to a regular call out. The Director of Nursing stated when agency staff were scheduled, they often did not show up. [10 NYCRR 415.13(a)(1)(i-iii)]

Based on observation, record review and interview conducted during the recertification survey from 4/6/25 to 4/11/25, the facility did not ensure infection control prevention practices were maintained to prevent the development and transmission of communicable diseases and infection for all residents. Specifically, the facility did not provide documentation of screening, administration or declination and education provided for 10 of 10 staff (Certified Nurse Aides #8 and #25, Laundry Aide #20, Housekeeping Aide #21, Licensed Practical Nurses #3, #23, #24, Registered Nurses #22 and #27 and Food Service Worker #26), reviewed for COVID-19 vaccinations. The findings are: During the recertification survey, the facility was asked to provide documentation that COVID-19 vaccination was offered, education was provided, and staff had the opportunity to consent or decline the vaccine for Certified Nurse Aides #8 and #25, Laundry Aide #20, Housekeeping Aide #21, Licensed Practical Nurses #3, #23, #24, Registered Nurses #22 and #27, and Food Service Worker #26, but none was provided. During an interview on 04/10/25 at 1:10 PM, the Director of Nursing stated they were the Infection Preventionist and had a lot of refusals from staff for the vaccine as well as lack of interest. They stated they did not have declinations for the COVID vaccine on a spreadsheet but stated it was important to do so to keep records straight. The Director of Nursing stated it was a big job to keep track of all of the vaccines and was working to get help with the task. During an interview on 4/10/25 at 2:49 PM with Certified Nurse Aide #28 they stated the facility had not offered any COVID vaccination that they could remember and had not received any education about it. During an interview on 4/10/25 at 2:49 PM, Certified Nurse Aide #29 they stated they had not been offered a COVID vaccine and there had not been any information provided to them about the vaccine. 10NYCRR 415.19 (a)(1-3)

51902 Based on observation and interview during the recertification survey from 4/6/2025 to 4/11/2025, the facility did not ensure each resident was treated with respect and dignity. This was evident for 2 residents (Resident #79 and Resident #18) during dining observations. Specifically, 1) Certified Nurse Aides #13 and #18, Occupational Therapist #15 and Home Health Aide were observed standing over Resident #79 while assisting the resident with meals. 2) Resident #18 was fed by staff standing during the meal. Findings include: The undated facility policy, Promoting/Maintaining Resident Dignity documented it is the policy of Cedar Manor Nursing and Rehabilitation to treat each resident with respect and dignity. 1) Resident #79 had diagnoses of Alzheimer's disease, protein calorie malnutrition, and dysphagia (difficulty swallowing). The Minimum Data Set, dated dated dated [DATE] documented the resident had severely impaired cognition and was dependent on staff for feeding. During an observation on 4/6/25 at 5:45 PM, Resident #79 was in bed and Certified Nurse Aide #18 was standing over them feeding them dinner. When interviewed during the observation, Certified Nurse Aide #18 stated they did not sit to assist Resident #79 with meals because it was not comfortable. A chair was observed on the opposite side of the bed. During an observation on 4/7/25 at 12:38 PM, Resident #79 was in bed and Certified Nurse Aide #13 was standing over them feeding them lunch. When interviewed during the observation, Certified Nurse Aide #13 stated they did not sit to assist Resident #79 with meals because they needed a taller chair to feed them. During an observation on 4/9/25 at 12:50 PM, Resident #79 was in bed and Occupational Therapist #15 was standing and feeding Resident #79 lunch. When interviewed during the observation, Occupational Therapist #15 stated they were standing while feeding resident for a referral to assess for self-feeding. During an interview on 4/10/25 at 11:49 AM Unit Manager #2 stated staff should be sitting when assisting residents with meals and therapy was present for a consult for positioning. 2) Resident #18 was admitted to the facility with diagnoses including cerebrovascular accident, functional quadriplegia and contracture of right hand. The 1/7/25 Quarterly Minimum Data Set (a resident assessment tool) documented Resident #18 had severely impaired cognition and was dependent on staff with all activities of daily living. During an observation on 04/06/25 at 5:53 PM Resident #18 was laying down in bed and Certified Nurse Aide #7 was standing over the resident while assisting them with eating their meal. During an interview on 04/26/25 at 5:56 PM Certified Nurse Aide #7 stated that Resident #18 ate 75% of their dinner. Certified Nurse Aide #7 stated they knew they should sit next to residents when assisting them with eating, rather than standing over them. Certified Nurse Aide stated that they chose to stand over the resident because they had a knee pain and if they sat down it would be very painful to stand up. 10 NYCRR 415.3

Based on interviews and record reviews conducted during a recertification survey it was determined that for 1 of 14 residents (Resident #102) during a resident council meeting, the facility did not ensure each resident was free from misappropriation of resident property. Specifically, the facility did not safeguard packages when delivered to the facility for Resident #102 who reported a missing package 11/15/24 and was not reimbursed until 4/8/25. The findings are: The undated policy titled Missing Resident Property documented missing resident property is defined as the loss or unauthorized use or removal of personal property regardless of the monetary value of the item(s). Resident #102 was admitted to the facility with diagnoses including Spinal Stenosis, Pain and Major Depressive Disorder. The Comprehensive Minimum Data Set Assessment, dated 11/26/24, and the Quarterly MDS dated [DATE] documented Resident #102 had intact cognition. On 4/07/25 at 10:33 AM, during a resident council meeting, Resident #102 reported they were missing a package for about 6 months. They stated when they initially inquired about the package, they were told it was signed for. Later, the resident was told the package was never received. The resident stated they were not reimbursed for the missing package. The Missing Property form dated 11/15/24 documented resident reported a missing package and that the Maintenance Director searched the front desk and storage units and did not find the package. It further documented it was signed by the Administrator and was not dated. A sticky note attached to the missing property form documented Resident #102 was reimbursed $40 cash and signed by Resident #102 on 4/8/25. During an interview on 4/08/25 at 12:58 PM, Director of Social Work stated they asked Resident #102 how the Resident Council meeting went and found out then that Resident #102 reported their missing package was never found and it had been about 6 months. The Director of Social Work stated they resolved the issue by reimbursing the resident $40 cash today. Director of Social Work stated they knew it had been a long time since it was reported in November and had no explanation as to why there was a delay in the resolution. 10NYCRR 415.4(b)

Based on observation, record review and interview conducted during a recertification 4/6/25-4/11/25, the facility did not ensure that necessary assistance and care were provided to carry out activities of daily living for 1 of 10 Residents (Resident #81) reviewed for activities of daily living. Specifically, Resident #81 was not showered twice a week as per unit showering schedule. Findings include: Resident #81 had diagnoses including peripheral vascular angioplasty status with implants and graphs, chronic obstructive pulmonary disease and schizoaffective disorder, bipolar type. The admission Minimum Data Set (a resident assessment tool) dated 3/10/25 documented Resident #81 was cognitively intact, did not reject cares and required partial/moderate assistance with showering. A Physician order dated 3/12/25 documented Resident #81 ambulated with assist of 1 using a rolling walker. An activities of daily living care plan, revised 3/6/25, documented Resident #81 required assistance with activities of daily living functions due to decreased/impaired mobility and required partial/moderate assistance with showering/bathing. A unit shower schedule documented Resident #81's shower days were Tuesdays and Fridays during the 3 PM -11 PM shift. A review of the certified nurse aide accountability documented shower/bathe self partial/moderate assistance was last completed Wednesday, 3/19/25 at 21:36PM. During interviews and observations on 04/07/25 at 9:34 AM, 4/8/25 at 11:39AM and 4/9/25 at 10:47 AM, Resident #81 stated they were not showered twice a week and they had not received a shower in a week. They stated the facility staff does not ask them to shower. Resident was observed wearing two hospital gowns on all three observations. Resident #81 stated they were not offered a shower on scheduled date, 4/8/25. They also stated that an aide presented to their room on 4/9/25 and informed them that their shower days were Tuesday and Fridays during the evening shift (3pm-11pm). Resident #81 stated they assumed they would have to wait until Friday and did not ask for a shower. During an interview on 4/09/25 at 11:12 AM Certified Nurse Aide #33 stated they offered to assist Resident #81 with dressing and hygiene earlier in shift and resident refused. They stated Resident #81 had not changed hospital gowns or washed up over last three days and refused cares. Certified Nurse Aide #33 stated they do not believe the resident was showered on 4/8/25 during 3pm-11pm shift (scheduled day) because Resident #81 had not changed gowns for three (3) days. They stated they reported to the nurse on the unit today that Resident #81 had been wearing the same gowns for three (3) days and had not washed. During an interview on 4/09/25 at 11:18 AM Licensed Practical Nurse #23 stated they were not aware of the last time Resident #81 received a shower or changed gowns. They stated they were aware Resident #81 refused to dress and bathe at times. They stated they could not recall if they documented refusals of care in the facility electronic medical record or if they reported to Unit Manager Nurse. During an interview on 04/09/25 at 11:22 AM, Unit Manager Registered Nurse #31 stated they have not received report from unit nurse staff that Resident #81 refused cares and/or did not receive showers during scheduled shower times or change gowns. After a review of the certified nurse aide accountability records with Unit Manager Registered Nurse #31, they were not able to determine when the last time Resident #81 received a shower. Nursing progress notes were also reviewed, and they were unable to locate refusal of care documentation or a refusal of cares care plan for Resident #81. They stated that if they were notified Resident #81 was not showering or changing clothes, they would have met with Resident to provide encouragement, reached out to family and made physician aware and entered new orders, if applicable. They also stated they would have met with the unit team and involved social work if necessary. During an interview on 04/10/25 at 11:32 AM Resident #81 stated physical therapy staff presented to their room earlier in day and assisted them in dressing until a certified nurse aide arrived to completed task. Resident #81 stated they independently bathed that morning in bathroom. 10 NYCRR 415.12(a)(3)

Based on observation, interview, and record review conducted during the Recertification Survey from 4/6/25-4/11/25, the facility did not ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 resident (Resident #92) reviewed for Respiratory Care. Specifically, 1) Resident #92 was observed multiple times receiving oxygen at 5 liters and 3 liters via nasal cannula with a physician order for 2 liters. Resident #92 was also observed with an empty portable oxygen tank while resident sleeping with nasal cannula in place. The findings included: A facility policy (reviewed 1/25) titled, Respiratory Therapy Administration and Equipment, documented: verify that there is a physician's order/review the physician's orders for oxygen administration. Resident #92 diagnoses included chronic obstructive pulmonary disease, asthma and diabetes. A 5-day re-entry Minimum Data Set (assessment tool) dated 3/20/25 documented Resident #92 was cognitively intact, had shortness of breath when lying flat and received oxygen therapy. A Physician order dated 3/27/25 documented to administer oxygen therapy via nasal cannula at 2 liters/ minute continuous every shift for chronic obstructive pulmonary disease. A care plan (updated 3/13/25) documented the resident had asthma, chronic obstructive pulmonary disease, and acute / chronic respiratory failure with hypoxia. Interventions included oxygen via nasal cannula as ordered. During an observation on 04/06/25 at 6:56 PM, Resident #92 was in bed sleeping with nasal cannula in place. The oxygen concentrator was observed running at 5 liters/minutes. During a brief interview on 04/07/25 at 12:47 PM, Resident #92 was sitting at bedside with the nasal cannula in place. The oxygen concentrator was observed running at 5 liters/minute. Resident #92 stated they did not know what the setting for the oxygen administration should be. During an observation and interview on 04/08/25 at 8:53 AM, with Registered Nurse #19, Resident #92 was sleeping in bed with the nasal cannula in place. The nasal cannula was connected to a portable oxygen tank, set at 3 liters/minute and empty. Registered Nurse #19 transferred the cannula tubing to another portable tank and set administration at 3 liters/minute. When asked what the physician order was for the oxygen, Registered Nurse #19 stated they believed it was for 2 liters/minute. Registered Nurse #19 reset the portable oxygen tank to administer oxygen at 2 liters/minute. 10 NYCRR 415.12

Based on observation, record review, and interview during the recertification survey from 4/6/2025 to 4/11/2025, the facility did not ensure residents who required dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) received services consistent with professional standards of practice for 1 of 1 resident (Resident #439) reviewed for Dialysis. Specifically, there was no documented evidence of consistent assessment and oversight before, during and after dialysis treatment for Resident #439 who received hemodialysis treatments at a community-based dialysis center. The findings included: A facility policy titled Dialysis Policy and Procedure Manual (revised 12/1/24) documented: when resident returns from hemodialysis, nurse checks the communication book for any issues needing to be addressed. Documents in progress notes resident's condition upon return from dialysis. Resident #439 diagnoses included end stage renal disease, chronic obstructive pulmonary disease and type 2 diabetes with proliferative diabetic retinopathy. A 5-day re-entry Minimum Data Set (a resident assessment tool) dated 3/4/25 documented Resident #439 was cognitively intact and received hemodialysis. A Physician Order dated 3/4/25 documented dialysis center every Monday, Wednesday and Friday at 11:15 AM. A care plan (revised 2/28/25) titled, Dialysis, documented the resident needed dialysis related to end stage renal disease. Interventions included to encourage the resident to go for the scheduled dialysis appointments; to monitor vital signs as ordered and record; and to notify the physician of significant abnormalities. A review of nurse progress notes from 2/25/25 to 4/10/25 did not have a post-dialysis assessment nurse notes for the following dates: 3/10/25, 3/12/25, 3/14/25, 3/15/25, 3/17/25, 3/21/25, 3/22/25, 3/26/25, 3/31/25, 4/2/25, 4/4/25, 4/7/25 and 4/9/25. A review of the Medication Administration and Treatment Administration records from 2/25-4/25 did not include dialysis schedule/attendance. During a review of Resident #439's Dialysis Communication Book on 04/08/25 at 12:34 PM, with the Unit Manager Registered Nurse #31, the following dates were observed with missing pre and/or post dialysis vital signs documentation: 3/10/25, 3/14/25, 3/15/25, 3/19/25, 3/22/25, 3/26/25, 3/28/25, 3/31/25, 4/2/25, 4/4/25, 4/7/25, and 4/9/25. When interviewed, Unit Manager Registered Nurse #31 stated the Dialysis Communication Book should have been reviewed by nurse on duty when the resident returned from dialysis. They stated nurses should review vital signs and observe for recommendations/communication from dialysis center after each dialysis visit. During an interview of 04/09/25 at 11:06 AM, Registered Nurse #30 stated Resident #439 currently attended dialysis Monday, Wednesday and Fridays. Resident #439 left the facility about 10 AM and returned during the 3-11 PM shift. They stated they administered medications prescribed for dialysis days and took vital signs. They stated they took Resident #439's vital signs pre-dialysis on 4/9/25 and entered results into facility electronic medical record and did not document in Dialysis Communication Book. They stated they provided Resident #439 with the Dialysis Communication Book on 4/9/25 before leaving for appointment. During an observation of Resident #439's Dialysis Communication Book and interview with Assistant Director of Nursing on 04/10/25 at 12:04 PM, they stated there was missing or incomplete documentation in the Dialysis Communication Book for numerous dates in March and April 2025. The Assistant Director of Nursing stated they were not aware there was incomplete or missing documentation of vitals pre and post dialysis appointments. They would need to investigate with staff. During an interview on 04/10/25 at 12:09 PM, Resident #439 stated they were at dialysis on 4/9/25 and were given the black and white book (communication book) by facility staff. The book was on their chair table at dialysis. They were not aware of any documentation that may have or not have been entered into the book. They stated they did not open the book; they just transport it to and from dialysis appointments. 10NYCRR 415.12(k)

Based on record review and interview during a recertification survey from 4/6/25 to 4/11/25, the facility did not ensure each resident's drug regimen was free from unnecessary medication, use for one (1) of five (5) residents (Resident #49) reviewed for unnecessary medications. Specifically, for Resident #49 Hydromorphone 2 mg every 4 hours as needed for pain of four - six was administered two times from March 1 2025-April 6 2025 for pain below four and Hydromorphone 4 mg every four hours for pain of seven -ten was administered four times from March 1 2025 - April 6 2025 for pain below seven. On 3/8/25 at 1:25 PM, 4/1/25 at 09:23 PM and 4/6/25 at 5:43 PM Hydromorphone 2 mg and 4 mg were administered together without a physician order. The findings include: Resident # 49 had diagnosis including Lupus, hypertension, morbid obesity. The care plan titled Pain initiated on 7/5/2024 documented administer pain medications as per orders. The quarterly Minimum Data Set (an assessment tool) dated 1/7/2025 documented Resident #49 was cognitively intact and received anti-anxiety medication and opioids. The physician order dated 2/24/2025 documented Hydromorphone 2 mg, give 1 tablet every four hours for pain scale of four-six and Hydromorphone 4 mg, give one tablet by mouth every four hours for pain scale seven-ten. The policy and procedure titled Medication Administration revised 3/3/2025 documented provide accurate administration and documentation of medication by a licensed nurse. The March 2025 Medication Administration Record documented Resident #49 received Hydromorphone 2 mg with a documented pain scale of one on 3/12/2025 at 5:42 and on 3/8/25 at 1:25 PM both Hydromorphone 2 mg and Hydromorphone 4 mg were administered together for a pain scale of ten. The physician note dated 3/11/25 documented Resident #49 had a non-healing surgical wound to the lower back and chronic pain. The April 2025 Medication Administration Record documented Resident #49 received 2 mg Hydromorphone 2 mg on 4/1/2925 at 9:23 PM for pain of zero and Hydromorphone 4 mg on 4/1/2025 at 9:23 PM for pain of zero and on 4/1/2025 at 9:23 PM and 4/6/2025 at 5:43 PM both Hydromorphone 2 mg and Hydromorphone 4 mg were administered together for pain scale of # 5. There was no documented evidence in the medical record of a physician order for the administration of Hydromorphone 2 mg and Hydromorphone 4 mg to be administered at the same time. During an interview on 4/8/2025 at 3:30 PM Licensed Practical Nurse #3 stated the resident was receiving Hydromorphone as a pretreatment medication and that may be why the dose did not match the pain scale. They stated nurses should carefully look at and follow the physician orders. They stated If there was a question about the medication dosage the nurses should call the physician. During an interview on 4/09/2025 at 2:56 PM the Director of Nursing stated the nurses always needed to follow the physician order. They stated staff were not following the protocol of right dose, right reason and were listening/doing what the resident wanted rather than following the physician order. During an interview on 4/10/2025 at 5:35 PM the Medical Director stated nurses did not think about matching the pain scale when there was a dressing change. They stated this has been an issue and they were working on a better system to suit the resident and staff. 10 NYCRR 415.12(l)(1)

Based on observation, interview, and record review during the recertification survey conducted 4/6/25 to 4/11/25, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional principles for 2 medication carts (East and South units) and the East unit medication room. Specifically, 1) the East Unit medication cart was left unlocked and unattended in the hallway while the nurse was in the medication room [ROOM NUMBER]) on the South Unit, a blister pack of Metformin 500 mg (13 pills) was left unattended on a medication cart while the nurse went into a resident room to administer medications and 3) the East Unit medication room had an expired medication and biologicals. The findings include: The policy titled, Medication Storage, last reviewed 1/25 documented medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents and is in accordance with the Department of Health guidelines. All medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel as defined by facility policy. During an observation on 4/6/25 at 6:56 PM on the East unit, the medication cart was unlocked and unattended by nursing staff. Visitors were observed in hallways walking by the cart. During an interview on 4/6/25 at 6:59 PM Registered Nurse #35 stated they walked away from the cart to look for medications in the medication room and left the cart unlocked. They stated they were not supposed to and should not have done that. 2) During medication administration observation on 4/9/25 at 10:33 AM, Licensed Practical Nurse #24 was observed at the medication cart with a blister pack containing 13 Metformin tablets on the top of the medication cart. Licensed Practical Nurse #24 left the Metformin unattended on the top of the medication cart and proceeded to enter a resident room to administer medications. During an interview with Licensed Practical Nurse #24 on 4/9/25 at 10:37 AM they stated the blister pack containing Metformin was for a discharged resident and did not belong on top of the medication cart. Licensed Practical Nurse #24 stated if medications were left unattended, anyone could take the medication off the medication cart. They stated they should not have left the medication unattended. During an interview with the Assistant Director of Nursing on 4/9/25 at 12:29 PM they stated they were at the medication cart and saw the Metformin unattended by the nurse and removed it from the cart because it should not have left there. They stated medications are not to be left out on the cart unattended. 3) The policy titled Guidelines for Storage of Medications last revised 1/2025 documented expired, discontinued and/or contaminated medications will be removed from the medication storage area and disposed of in accordance with the facility policy. During observation on 4/8/25 at 11:51 AM of the East Unit Medication Storage room the following expired medication and biologicals were found: -Aspira Drainage Kit expired 11/2024 -Aspira Drainage Kit expired 1/22/2025 -Allergy Relief Tablets expired 2/2025 -Disposable Inner Canula expired 2/2024 During interview on 4/08/25 at 11:58 AM Registered Nurse #31 stated every nurse that used the medication room should check for expired medications or biologicals. Registered Nurse #31 stated they were responsible for monitoring the medication room and had no explanation as to why the expired products were not removed. Registered Nurse #31 further stated the Assistant Director of Nursing was also responsible for monitoring the medication rooms and for checking that the removal of expired products was being done. During interview on 4/08/25 at 12:14 PM the Assistant Director of Nursing stated the night nursing supervisor was responsible for checking medication rooms for expired medications and biologicals and sending discharged resident medications back to the pharmacy. The Assistant Director of Nursing stated they had no audit tools or documentation to ensure medication storage rooms were checked routinely for expired medications and biologicals. The Assistant Director of Nursing stated if kept in the medication room, expired medications and/or biologicals may be used accidentally. 10 NYCRR 415.18 (d) 45478

Based on observation and interview conducted during a recertification survey, the facility did not ensure that waste was disposed in a dumpster that was free of leaks and the dumpster area was maintained in a clean condition. Specifically, garbage debris was observed around the bottom perimeter of dumpster. The findings are: The undated policy titled Maintain Dumpster and Loading Dock Areas documented when emptying trash, Environmental and Dietary will pick up any spillage and close lids. It further documented that the Environmental manager will follow up after each trash run to ensure compliance. An observation of the kitchen area was conducted on 04/06/2025 at 4:47 PM. The Food Service Director (FSD) accompanied the surveyor to inspect the dumpster and the surrounding area. Garbage debris on the ground surrounding the dumpster. The Food Service Director stated the dumpster was emptied daily when they came to pick up garbage. Food Service Director stated when garbage company dumped the garbage into the truck, items often fell on to the ground and the garbage company did not pick them up. The Food Service Director stated they usually had staff clean up the debris around the dumpster daily and they had no excuse for debris on the ground. The Food Service Director stated that the dietary and environmental department were responsible for keeping the area clean. On 4/06/2025 at 4:57 PM, during an interview with the Environmental Manager and Administrator they observed the dumpster with debris on the ground. The Environmental Manager stated that happened when the garbage company collected the garbage. When they put the dumpster on the truck some of the garbage would spill onto ground, and they had to clean up the remaining garbage on the ground after the garbage truck left. The Environmental Manager stated they usually had the evening staff handle it since the garbage truck came during the day. The Administrator stated they believed the last time it was cleaned was the day before. 415.14(h)

Based on record review and interview during the recertification survey 4/6/25 to 4/11/25, the facility did not ensure that an ongoing review of antibiotic use protocols and a system to monitor antibiotic use was completed for 2 of 2 residents reviewed for antibiotic stewardship. Specifically, for Residents #78 and #190, the facility was unable to provide an infection/antibiotic tracking report as requested on 4/10/25 that ensured their antibiotic program was implemented to monitor antibiotic use protocols when an antibiotic was prescribed to a resident. The findings are: The facility policy titled Antibiotic Stewardship Program revised 2022 documented it is the policy of Cedar Manor Nursing and Rehabilitation Center to comply with evidenced based guidelines or best practices regarding antibiotic prescribing and to promote rational and appropriate antibiotic therapy while improving clinical outcomes while minimizing unintentional side effects of antibiotic use, including toxicity and emergence of resistant organisms. Resident #78 had diagnoses including Type II Diabetes Mellitus, dysphagia, and gout. The physician's order dated 3/14/24 documented Amoxicillin Potassium Clavulanate 875mg-125mg (antibiotic) tablet by mouth every 12 hours for bacterial infection of scalp for 7 days. The Medication Administration Record documented the medication was administered from 3/14/25 to 3/19/25 for a total of 9 doses. The physician's order dated 3/19/25 documented a second order for Amoxicillin Potassium Clavulanate 875mg-125mg (antibiotic) tablet by mouth every 12 hours for bacterial infection for 7 days and was discontinued on 3/26/25 for a total of 14 doses. The Medication Administration Record documented the resident received 14 doses from 3/19/25 to 3/26/25. There was no documentation in the resident's record why the original Amoxicillin Potassium Clavulanate was discontinued and then resumed for an additional 7 days. Resident #190 had diagnoses including Type II Diabetes Mellitus, hypothyroid, and dysphagia. The physician's order dated 4/2/25 documented Amoxicillin 875mg-125mg (antibiotic) 1 tablet every 12 hours for bacterial infection of both ears for 10 days. The Medication Administration Record documented the resident received all 20 doses and the medication was completed on 4/12/25. The facility's Line List of Antibiotics and Infections for residents who were prescribed antibiotics was reviewed on 4/10/25 at 11:43 AM. There was no documented evidence of Resident #78 or Resident #190's antibiotic use. During an interview on 4/10/25 at 1:10 PM, the Director of Nursing who is the Infection Preventionist, stated the Antibiotic Stewardship review is completed with the Medical Director during which they review the Line List of Antibiotics and Infections, and discuss the duration of antibiotic use, and stated changes may be made. The Director of Nursing did not know why Residents #78 and #190 were not documented on the Line List of Antibiotics and Infections. The Director of Nursing stated Residents #78 and #190 should have been documented on the Line List of Antibiotics and Infections to ensure all antibiotics were reviewed and monitored. During an interview on 4/10/25 at 05:23 PM, the Medical Director stated they review the resident's antibiotic use with the Director of Nursing monthly, they review bacteria and germ lab test results, and review the duration and appropriateness of antibiotic use. They stated that if the residents are not documented on the Line List of Antibiotics and Infections, they would not be reviewed for antibiotic use. 10 NYCRR 415.19

Based on observation, record review and interview during the recertification survey from 4/6/2025 to 4/11/2025, the facility did not ensure that needed services, care and equipment were provided to assure that residents with limited range of motion and mobility maintained or improved function based on the residents' clinical condition for one (1) of two (2) residents (Resident #18) reviewed for Position and Mobility. Specifically, Resident #18 with contracture of the right hand was observed on 3 occasions without the use of a right hand gauze roll as per physician order. Findings include: The policy and procedure titled Contractures Management with Splints, Braces, Orthotic Devices last reviewed 1/2024, documented every resident to be assessed for the presence of contractures or risk thereof. Therapy will issue an order for the supportive device to the nursing team with an outline of the devices wearing schedule. A plan of care will be implemented by the therapy department to manage a contracture or to support a limb at risk for contracture due to the lack of physical function with the appropriate device. Resident #18 was admitted to the facility with diagnoses including cerebrovascular accident, functional quadriplegia and contracture of right hand. The Minimum Data Set (MDS) dated [DATE] documented Resident #18 had severely impaired cognition, impairment on both sides of upper and lower extremities and was dependent on staff with all activities of daily living. The physician order dated 2/22/25 documented gauze roll to be worn at all times to right hand, to be removed for skin checks, hygiene, and range of motions. Active Status. The comprehensive care plan titled Actual Contracture on Right Upper Extremity last revised 2/22/25, documented gauze roll to be worn at all times to right hand, to be removed for skin checks, hygiene, and range of motions. The Kardex dated 04/08/25 at 10:31 AM documented gauze roll to be worn at all times to right hand, to be removed for skin checks, hygiene, and range of motions. During observations on 4/6/25 at 6:41 PM, 4/7/25 at 5:13 PM and 4/8/25 at 9:32 AM Resident #18 was laying down in bed with contracture of the right hand. There was no gauze roll in place to the right hand. During interview on 4/8/25 at 10:35 AM Certified Nurse Aide #8 stated Resident #18 was dependent on staff for positioning and assistance with range of motions during cares. Certified Nurse Aide #18 stated they were aware Resident #18 had contracture of the right hand, but they did not know that the resident was supposed to have a gauze roll applied to the right hand. During an interview on 4/8/25 at 11:22 AM Registered Nurse Manager #2 stated at times they observed the gauze roll in Resident #18's right hand They stated they could not explain why Certified Nurse Aide #8 was not aware the resident should use a gauze roll. Registered Nurse Manager #2 stated there was a gauze roll order on the certified nurse aide Kardex, documented physician order in the computer, and the care plan dated 2/22/25 included the use of a gauze roll for the resident's right hand. 10 NYCRR 415.12(e)(1)

Based on record review and interviews during an abbreviated survey (NY00343399, NY00332174, NY00337805), the facility did not ensure that all alleged violations of abuse, neglect, exploitation or mistreatment including injuries of unknown source was reported in accordance with the Federal Law immediately, but no later than 24 hours after forming the suspicion, if the events that cause the suspicion do not result in serious bodily injury. Incidents were not reported by facility staff to the administration in a timely manner and the facility did not submit the results of all investigations to the New York State Department of Health within 5 working days in accordance with State Law for 3 out of 3 residents (Resident #1, #2, #3) reviewed for abuse. Specifically, (1) on 5/27/2024, Licensed Practical Nurse #1 reported they heard a voice saying, shut up from Resident #1's room and what sounded like a slapping sound, and Housekeeper #1 stated they heard Resident #1 crying in their room and someone saying stop, stop; and what sounded like a slapping sound; (2) on 1/23/2024 there was an incident between Resident #2 and Certified Nurse Assistant #3 while providing care when Resident #2 became aggressive. The incident was not reported to the Administrator until 1/24/2024 when a visitor reported they witnessed Resident #2 being tapped on the back of the head by Certified Nurse Assistant #3 while in a wheelchair in their room; (3) Certified Nurse Assistant #7 witnessed Resident #3 been bopped on the head by Certified Nurse Assistant #5 on 4/1/2024. The incident was not reported to the Administrator by the staff until Resident #3 reported to the Medical Director of Managed Long Term Care during a visit on 4/2/2024 that they were left in the shower for a longtime wearing their adult brief and was bopped in the head by Certified Nurse Assistant #5 using their knuckle because the resident would not follow their commands. No investigative reports were submitted to the New York State Department of Health within 5 working days of the incidents. Findings include: The facility abuse policy documented that for reporting abuse the facility must follow time frames established in the regulations. Federal regulations and state regulations require the reporting of alleged violations of abuse, mistreatment and neglect including injuries of unknown origin, immediately to the facility administrator and in accordance with state law, to the Department of Health. An allegation, as previously stated, must be reported immediately to the Department of Health when meeting the reasonable cause standard. Resident #1 had diagnoses including but not limited to Dementia, Primary Lateral Sclerosis and Adjustment Disorder. A Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 12/15, associated with moderate cognition impairment (00-07 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). Resident #1 had other behavioral symptoms not directed towards others. Resident #1 had limited range of motion and impairment on both sides, upper and lower extremities; required supervision for eating and is dependent for toileting and transfers; required maximal assistance with bed mobility. A review of the investigative summary dated 5/27/2024 documented Licensed Practical Nurse #1 reported that they heard from Resident #1's room a voice saying, shut up and what sounded like a slapping sound. Housekeeper #1 stated they heard Resident #1 crying in their room and someone saying stop, stop; and what sounded like a slapping sound. A review of the investigation conclusion dated 5/29/2024 documented Resident #1 initially reported to the supervisor that Certified Nurse Assistant hit them on the forehead. The resident was emotional at the time and most likely did not understand the question; no signs of redness or bruising were identified at that time or later. The Resident denied being hurt by the Certified Nurse Assistant later that afternoon. Based on the investigation it is concluded that Resident #1 was never hit by the Certified Nurse Assistant. There was no documented evidence of a 5-day investigative summary with conclusion submitted to the New York State Department of Health. Resident #2 had diagnoses including but not limited to Dementia, muscle weakness, and Type II Diabetes Mellitus. A Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status score of 2/15 associated with severe cognition impairment. Resident #2 exhibited physical and verbal behavioral symptoms as well as rejecting cares. Resident #2 had impairment on both sides to the lower extremities; required supervision for eating, set-up assistance with bed mobility and moderate assistance for toileting and transferring. A review of the investigative summary dated 1/24/2024 documented that the Administrator was notified by a visitor in the facility of a potential abuse on 1/23/2024 in the form of a staff tapping on the head of a resident. The visitor stated that they were visiting their mother, and as they walked down the hall to exit the unit, and they may have witnessed the incident from the back. The resident was identified as Resident #2, and the staff was identified as Certified Nurse Assistant # 3. The report documented that Certified Nurse Aide #3 confirmed that they were assigned to Resident #2 on 1/23/2024 and during cares Resident #2 became combative and aggressive, kicking and slapping and trying to get out of the wheelchair. Certified Nurse Assistant #3 to prevent Resident #2 from falling went to the back of the wheelchair and tried to pull the resident back in the chair. Resident #2-bit Certified Nurse Assistant #3's finger and while trying to get out their finger, they saw a family member walking by. Certified Nurse Aide #3 stated they reported the incident to Licensed Practical Nurse #2(the nurse on duty) who advised them to report to the nursing supervisor. No broken skin was noted on Certified Nurse assistant #3. Certified Nurse Assistant #3 told Certified Nurse Assistant #4 on the day of the incident that they held Resident #2's head backwards to release their finger from the resident's mouth. Nursing Supervisor stated they were only informed by Certified Nurse Assistant #3 that Resident #2 was combative but was not informed that Resident #2 was hit in the head. A complete head to toe assessment was completed on the resident on 1/24/2024 when the administrator was made aware of the incident by the visitor who returned to the facility the day after the incident. Review of the investigation conclusion dated 1/24/2024 documented that based on the investigation it was determined that no abuse occurred. However, it was identified that Certified Nurse Assistant #3 did not call for assistance once Resident #2 became physically combative. It was also recognized that Certified Nurse Assistant #3, Licensed Practical Nurse #2, and Certified Nurse Assistant #4, did not communicate to the nursing supervisor about the visitor's concern of the potential abuse. There was no documented evidence of a 5-day investigative summary submitted to the New York State Department of Health. Resident #3 had diagnoses including but not limited to Asperger's syndrome, muscle weakness and dysphagia. An Admission Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15/15 denoting intact cognition. Resident #3 socially isolates sometimes and exhibits physical and verbal behaviors. Resident #3 also exhibits other behavioral symptoms not directed towards others. Resident #3 had impairment to the upper extremity on one side and to both lower extremities; required set up for meals, maximal assistance for toileting and transfers and moderate assistance for bed mobility. A review of the investigative summary documented that on 4/2/2024, at approximately 4:30 PM the Social Worker was informed by the medical director on the Managed Long-Term Care, that Resident #3 reported that on 4/1/2024 they were left in the shower by a Certified Nurse Assistant wearing only their adult depends. Resident #3 also reported Certified Nurse Assistant#5(a friend of the certified nurse assistant #6 who provided the shower) bopped them on the head with their knuckles because they would not follow their demands. The report documented that Certified Nurse Assistant #7 stated while in the hallway, they saw Resident #3 been wheeled back to their room and Certified Nurse Assistant #5 was walking next to Resident #3 Certified Nurse Assistant #7 stated they heard Resident #3 telling Certified Nurse Assistant #5 don't hit on my head. Certified Nurse Assistant #7 looked and saw Certified Nurse Assistant #5 hit Resident #3 on the head x2. Certified Nurse Assistant #7 did not report the incident to the Nurse Supervisor because they stated that Resident #3 was alert and they assumed Resident #3 will report the incident. Review of the investigation conclusion documented that based on the investigation Resident #3's complaint of being left in the shower for a long time by Certified Nurse Assistant #6 could not be corroborated. Resident #3's report of being bopped on the head by Certified Nurse Assistant #5 was witnessed by Certified Nurse Assistant #7. Therefore, it was concluded that Certified Nurse Assistant #5 bumped Resident #3 on their head at some point while passing by the resident. There was no documented evidence of a 5-day investigative summary submitted to the New York State Department of Health. During an interview on 6/4/2024 at 9:35 AM, the Director of Nursing stated they do not submit a 5-day investigative conclusion because they are usually contacted by the Department of Health and requested to submit, if needed. During a follow up interview on 6/6/2024 at 12:05 PM, the Director of Nursing stated allegations of abuse with no injury are investigated internally and reported to the Department of Health. The Director of Nursing stated if there is found to be an injury then the incident will be reported to the police as well. The Director of Nursing stated none of the incidents were reported to the police as there was no physical evidence of injury to the residents involved. The Director Nursing stated their policy for reporting abuse, they believe is up to date with the current regulations. 10NYCRR 415.4(b)(1)(ii)

Based on record reviews and interviews during an abbreviated survey (NY00343399, NY00332174, NY00337805), the facility did not ensure the residents right to be free from abuse for 1 (Resident #3) out of 3 residents reviewed for abuse. Specifically, on 4/1/2024 Certified Nurse Assistant #7 witnessed Resident #3 been bopped on the head by Certified Nurse Assistant #5 while in their wheelchair. The incident was not reported to the nursing supervisor or the administrator by the staff until Resident #3 reported the incident to the Medical Director of the Managed Long Term Care during a visit on 4/2/2024, that they were left in the shower for a longtime wearing their adult brief and that Certified Nurse Assistant #5 bopped them on their head using their knuckles because they would not follow their commands. Findings include: The facility abuse policy documented each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Resident #3 had diagnoses including but not limited to Asperger's syndrome, muscle weakness and dysphagia. An Admission Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15/15 denoting intact cognition. Resident #3 socially isolates sometimes and exhibits physical and verbal behaviors. Resident #3 also exhibits other behavioral symptoms not directed towards others. Resident #3 had impairment to the upper extremity on one side and to both lower extremities; required set up for meals, maximal assistance for toileting and transfers and moderate assistance for bed mobility. Review of a behavior care plan dated 3/1/2024 documented Resident #3 has a behavioral problem (refusal to participate in activities of daily living) related to uncooperative behavior and a developmental problem. Intervention listed include anticipate and meet the resident's needs, assist the resident with developing more appropriate methods of coping and interacting, caregivers to provide opportunity for positive interaction, attention, stop and talk with resident when passing by, explain all procedures to resident and allow a few minutes to adjust to changes. A nursing progress note dated 4/2/2024 at 6:38PM documented Resident #3 complained of staff deliberately hitting them on the head using knuckles yesterday (4/1/2024) in the evening shift. Documented body assessment done; no visible injuries noted, no discoloration noted. Range of Motion within normal limits. Director of Nursing made aware. A review of the investigative summary signed on 4/8/2024 documented that on 4/2/2024, at approximately 4:30 PM the Social Worker was informed by the medical director of Managed Long-Term Care, that Resident #3 reported they were left in the shower by a Certified Nurse Assistant #6 wearing only their adult depends on 4/1/2024. Resident #3 also reported another Certified Nurse Assistant #5 (a friend of the certified nurse assistant #6 who provided the shower) bopped them on the head with their knuckles because they would not follow their demands. The report documented that Certified Nurse Assistant #7 stated while in the hallway, they saw Resident #3 been wheeled back to their room and Certified Nurse Assistant #5 was walking next to Resident #3 Certified Nurse Assistant #7 stated they heard Resident #3 telling Certified Nurse Assistant #5 don't hit on my head. Certified Nurse Assistant #7 looked and saw Certified Nurse Assistant #5 hit Resident #3 on the head. Certified Nurse Assistant #7 did not report the incident to the Nurse supervisor because they stated that Resident #3 was alert and they assumed Resident #3 will report the incident. The investigation summary concluded that based on the investigation Resident #3's complaint of being left in the shower for a long time by Certified Nurse Assistant #6 could not be corroborated. Resident #3's report of being bopped on the head by Certified Nurse Assistant #5 was witnessed by Certified Nurse Assistant #7. Therefore, it was concluded that Certified Nurse Assistant #5 bumped Resident #3 on their head at some point while passing by the resident. A review of Certified Nurse Assistant #5's employee file revealed a disciplinary action form with a documented date of offense as 4/1/2024. Documented the nature of offense as resident abuse or neglect mistreatment. Documented the action taken as suspension from 4/11/2024 until 4/18/2024. Based on the investigation including Resident #3's report, and eyewitness account, it is concluded that Certified Nurse Assistant #5 at some point bumped Resident #3 on the head while passing them. As a result, Certified Nurse Assistant #5 was issued a 5-day suspension for mistreatment of a resident and final written warning. During an interview on 6/6/2024 at 12:05 PM, the Director of Nursing stated they did not report the Certified Nurse Assistant to the licensing board. The Director of Nursing stated Resident #3 was developmentally challenged, and their mood and attitude would fluctuate. The Director of Nursing stated Resident #3 would play around and joke around with the staff and on this day, they became upset instead. The Director of Nursing stated the resident has been in the facility prior and that is how they were. During an interview on 6/6/2024 at 4:40 PM Certified Nurse Assistant #7 stated they have been working in the facility since 2017. Stated when Certified Nurse Assistant #6 and certified nurse assistant #5 were passing in the hallway with Resident #3. Stated Certified Nurse Assistant #6 was pushing the wheelchair and Certified Nurse Assistant #5 was walking next to the wheelchair. Certified Nurse Assistant #7 stated they heard Resident #3 say do not hit me, and they turned and looked and saw Certified Nurse Assistant #5 tap Resident #3 in the back of the head. Resident #3 then said, I told you do not touch me, then Certified Nurse Assistant #5 tapped them in the head again. Certified Nurse Assistant #7 stated they then went to get their linen and went back to work. Certified Nurse Assistant #7 stated they did not tell anyone about the incident on the day of the occurrence. The next day the supervisor informed them that Certified Nurse Assistant #6 cannot care for Resident #3, because the resident reported they hit them. Certified Nurse #7 stated they then reported to Registered Nurse #3 that it was not Certified Nurse Assistant #6 that hit Resident #3, because they saw Certified Nurse Assistant #5 tap Resident #3 on the head and heard the resident state I told you not to touch me like that. Stated Registered Nurse #3 reported to the Director of Nursing, and they both came and asked them why they did not tell anyone what they witnessed. Certified Nurse Assistant #7 stated they were worried that their co-worker would retaliate against them. Certified Nurse #7 stated Resident #3 is alert and oriented and could report the incident. Certified Nurse Assistant #7 stated they did not receive in-service after the situation occurred but they do receive in-services on how to care for residents with behaviors. They are aware of Resident #3's behaviors, because the resident use to be on their assignment. Certified Nurse Assistant #7 stated Resident #3 has a history of panic attacks and would sometimes use bad words when they get nervous. During a telephone interview on 6/12/2024 at 1:42 PM Registered Nurse #3, they stated they stated they were notified by a physician from Managed Long-Term Care that Resident #3 reported to they were hit by staff. Resident #3 was alert and oriented and knows what is going on. Registered Nurse #3 stated they went into the Resident #3's room with the physician and spoke with Resident #3 and did an assessment to see if there were bruises or skin changes and there were none. Registered Nurse #3 stated Resident #3 told them they were hit on the head by a certified nurse assistant. Registered Nurse #3 stated the resident could not say the name of who it was that had hit them. Registered Nurse #3 stated they asked Resident #3 to describe the person that hit them, and Resident #3 was apprehensive, maybe even scared but stated a tall black female. Registered Nurse #3 stated they looked at the certified nurse assistants working at the time and were able to identify who the staff member was. Registered Nurse #3 stated they reported what Resident #3 told them to the Director of Nursing and an investigation was initiated and another skin assessment was done. Registered Nurse #3 stated Resident #3 went out to the hospital after that day, because they felt threatened, and they were scared that the staff member would retaliate and wanted to be sent out to the hospital. Registered Nurse #3 stated the investigation continued after the resident left to the hospital. Attempts to interview the Social Worker via phone on 6/11/2024 and 6/12/2024 was unsuccessful. 10 NYRCC 415.4(b)(1)(i)

Based on observations, record review and interviews during a recertification survey 1/17/24-1/25/24, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not effectively implement accurate tracking and monitoring of infections and outbreaks among residents and staff on the East Unit, staff did not use Personal Protective Equipment (PPE) correctly in an isolation room. Findings include: Review of the facility's Pandemic Planning and Operational Protocol, dated 8/10/23, documented advanced preparation and planning was undertaken to mitigate the effects of a pandemic. The plan included activation of an outbreak monitoring log so that case identification information and the course of spread could be tracked. The facility operational protocol also documented 6 feet social distancing strategies to separate individuals may be implemented, and group activities may be cancelled, as the number of affected residents are impacted. During an interview on 1/17/24, the Director of Nursing (DON) stated there were 3 residents positive for COVID-19 in the facility and 2 resided on the East Unit. During interviews on 1/20/24 and 1/21/24, the Director of Nursing reported 2 more cases each day on the East Unit. During an observation on 01/22/24 at 12:57 PM on the East Unit, a sign for droplet/contact precautions was posted outside Resident #188's room. Staff #26 went into Resident #188's room wearing a mask and no gown as signage for droplet/contact precautions directed. Staff #26 performed set up of the meal tray and was touching all the items on the tray, leaning on bed and over the resident lying in bed. Resident #188 was coughing and touching the side rails. During an interview with Staff #26 on 1/22/24 at 12:57PM, they stated they did not know the resident was on precautions and did not notice the signs. During an interview on 01/22/24 at 01:16 PM, Staff#27 (Licensed Practical Nurse) stated Staff #26 had been trained on the proper Personal Protective Equipment (PPE) for residents on contact/droplet precautions and should have worn a gown. During interviews on 1/23/24 and 1/24/24, the Director of Nursing reported 2 more cases each day on the East Unit; and on 1/24/24 Staff #26 was out sick after testing positive for COVID-19. During an observation on 1/24/24 at 2:27 PM on the East Unit, outside of contact/droplet isolation rooms [ROOM NUMBERS], the Activities staff was playing a guitar and singing with a mask on to residents. Three residents and a family member were gathered close together, and other residents were in the hallway being ambulated by staff. During an interview at that time with the Administrator, they stated they were aware of the activities taking place on the unit and was looking into it. During an interview on 1/24/24 at 2:30PM, the Director of Nursing stated they were the Acting Infection Preventionist. A line list for tracking of infections was requested and a document titled COVID Positive was provided. The Covid Positive list included names of residents and dates that isolation started and when isolation would finish. The DON stated the Assistant Director of Nursing used to track infections on a line list, but they resigned a few months ago. The Director of Nursing stated there was no current system of tracking infections. On 1/25/24 the DON reported that the entire East Unit was tested for COVID-19 and 7 additional cases were identified, for a total of 18 cases. 10 NYCRR 415.19(a)(1-3) 48822

Based on observation, interviews and record review during a recertification survey 1/17/24-1/25/24, the facility did not ensure residents had the right to a dignified existence for 1 resident (#73) observed during dining observation. Specifically, staff were observed standing over Resident #73 while feeding the resident their meal. Additionally, Resident #73 was assisted with their lunch meal while other residents at the same table were not provided their lunch meal in a timely manner, Findings include: Resident # 73 was admitted to the facility with diagnoses and conditions including but not limited to unspecified dementia, schizophrenia and dysphagia. The 2/17/23 Comprehensive care plan for Activities of Daily Living documented the resident required assistance of (1) staff to eat. The 9/9/23 Minimum Data Set (MDS- an assessment tool) documented the resident had severe cognitive impairment and required extensive assistance of 1 staff with eating. During an observation on 01/17/24 at 11:52 Resident #73 received the lunch tray at the table. Resident #73 finished lunch and the tray was removed, 3 other residents at the table still had not received their lunch trays. During an observation on 01/22/24 at 12:02 PM Staff #15 (Registered Nurse) was standing over Resident #73's geri chair while feeding Resident #73. During an interview on 01/17/24 at 12:15 PM Staff #24 (Certified Nurse Aide) stated that the trays for the residents in the dining room do not all come up from the kitchen at the same time. Staff #24 stated some of the trays come up on the second truck, causing other residents to receive their trays at a later time. During an interview on 01/22/24 at 12:28 PM Staff #15, stated they did not see a chair to sit down, but staff are supposed to sit down when assisting residents with their meals. 10 NYCRR 415.3(d)(1)(i)