Every finding on record at Central Queens Rehab & Nursing Center

Based on observation, record review, and interviews conducted during the Recertification Survey from 07/28/2025 to 08/04/2025, the facility did not ensure each resident was treated with respect and dignity. This was evident for 1 (Resident #38) of 1 resident reviewed for Dignity out of 37 total sampled residents. Specifically, the Infection Control Preventionist was observed using profane language when speaking to Resident #38.The findings are: The facility's policy titled Quality of Life - Dignity last reviewed 01/2025 stated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Staff shall speak respectfully to residents and staff shall treat cognitively impaired residents with dignity and sensitively, including addressing the underlying motives or root causes for behaviors. Resident #38 had diagnoses including Non-Alzheimer's Dementia, Anxiety Disorder, and Major Depressive Disorder.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #38 had moderate cognitive impairment, exhibited physical and verbal behavioral symptoms, rejected care daily, and exhibited wandering behaviors daily. On 07/28/2025 at 10:47 AM, Resident #38 was observed removing personal protective equipment from a bin in the hallway. The Infection Control Preventionist was observed using profane language while telling Resident #38 to stop touching things. The Infection Control Preventionist was then observed using profane language while telling Housekeeper #1 to clean urine on the other side of the unit.The Comprehensive Care Plan titled At Risk to Be a Victim of Abuse, Neglect, and/or Mistreatment last updated 06/08/2025 documented a goal of Resident #38 would not be abused or victimized by others. Interventions included calmly redirecting Resident #38 away from areas of potential harm.The Comprehensive Care Plan titled Behavioral Symptoms last reviewed 11/26/2024 documented a goal of Resident #38 would be free of conditions that may contribute to behaviors. Interventions included approaching Resident #38 calmly and using a calm and friendly tone, and careful gestures. On 07/28/2025 at 11:39 AM, Housekeeper #1 was interviewed and stated after a resident urinated in the hallway, Resident #38 had attempted to wipe it up with personal protective equipment and this made the Infection Control Preventionist upset. Housekeeper #1 also stated they felt like the way the Infection Control Preventionist spoke to Resident #38 was not right, and staff should not speak to residents like that. On 07/28/2025 at 12:40 PM, the Infection Control Preventionist was interviewed and stated they had become upset after a resident with a history of disruptive behaviors urinated in the hallway. The Infection Control Preventionist further stated Resident #38 had removed personal protective equipment from a bin near the urine, which the facility disposed of, but then continued to remove personal protective equipment from another bin on the other side of the unit. The Infection Control Preventionist stated they told Resident #38 to stop removing the items, but they were unusually stressed and should not have cursed at the resident. On 07/31/2025 at 12:20 PM, Registered Nurse #4 was interviewed and stated Resident #38 had severe dementia, was confused, and had behaviors including taking other residents' belongings. Registered Nurse #4 stated Resident #38 could be easily redirected when given time to calm down. On 08/04/2025 at 11:17 AM, Certified Nursing Assistant #3 was interviewed and stated Resident #38 had behaviors including being verbally aggressive and becoming agitated, but Resident #38 could be easily redirected by speaking to them nicely. On 08/04/2025 at 12:16 PM, the Director of Nursing was interviewed and stated they supervised the Infection Control Preventionist, and all staff, including the Infection Control Preventionist, were in-serviced annually and as needed on abuse, dignity, and providing respectful care. The Director of Nursing stated as soon as they became aware of the Infection Control Preventionist using profane language directed at Resident #38, they re-educated the Infection Control Preventionist and suspended them while they investigated the incident. On 08/04/2025 at 12:23 PM, the Administrator was interviewed and stated they had been made aware of the incident involving the Infection Control Preventionist speaking inappropriately to Resident #38. The Administrator stated they believed the Infection Control Preventionist had been stressed at the time, but that was not an excuse for their behavior. The Administrator further stated the Infection Control Preventionist should never speak to a resident like that and should have calmly redirected Resident #38. 10 NYCRR 415.5(a)

Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure a safe, clean, comfortable, and homelike environment was provided to the residents, and maintenance services necessary to maintain a sanitary, orderly and comfortable interior were provided to the residents. This was evident on 1 (Unit 5) of 5 units. Specifically, on Rooms 501, 505, 507, 509, and 517, and the general residents' bathroom were observed with air conditioners with dirty and rusty grill covers, mismatched chipped paint in the residents' room, hole in the wall and unclean discolored bathroom heater. The findings are: The facility's policy titled Homelike Environment effective 1/2017 last reviewed date 1/2025 states it is the policy of Central Queens Rehabilitation and Nursing Center to provide a safe, clean, comfortable and homelike environment to all residents. During multiple observations from 07/28/2025 at 10:00 AM to 08/04/2025 at 11:00 AM the following was observed: 1. On 07/28/2025 at 10:00 AM, in room [ROOM NUMBER] observed the air conditioner cover grill was dirty and rusted in multiple areas. 2. On 07/28/2025 at 10:30 AM, in room [ROOM NUMBER] observed a hole in the wall, approximately 3 inches by 3 inches, and cement debris was falling out from the hole.3. On 07/29/2025 at 11:00 AM, in room [ROOM NUMBER] observed the windowsills had peeling paint, and the air conditioner grill cover was rusty.4. On 08/04/2025 at 10:45 AM. in room [ROOM NUMBER] observed the floor had dry soap remnants, the floor stained with whitish dry sediments, and the air conditioner grill cover was rusty. 5. On 08/04/2025 at 11:00 AM room [ROOM NUMBER] observed the bathroom heater cover rusty and soiled with a brownish discoloration on the whole cover.6. In the resident's General Bathroom, the ceiling and a cubicle had mis matched, unfinished paint. On 08/04/2025 at 11:00 AM, the resident who resided in room [ROOM NUMBER] was interviewed and stated the bathroom heater cover has been dirty since they came to this room and it does not look good, and they wish someone would clean and paint it. On 08/04/2025 at 11:25AM, the Maintenance log book for the 5th floor was reviewed and revealed no entries regarding the observations in rooms 501, 505, 507, 509, 517 and the general residents' bathroom. On 08/04/2025 at 11:24 AM, the Director of Maintenance was interviewed and stated the issues identified on the fifth floor including the dirty, rusty air conditioner grill covers, hole in the wall, mismatched paint, dirty floors were missed during their rounds and should have been corrected, repaired and or cleaned. The Director of Maintenance also stated they do not know why the staff had not done the repair yet. The Director of Maintenance further stated the maintenance workers were supposed to do the repair and as the Director of Maintenance they were responsible for inspecting their work and making rounds on the unit. On 08/04/2025 at 1:57 PM, the Administrator was interviewed and stated areas of concern observed in the fifth floor were brought to their attention today and acknowledged the findings. The Administrator also stated the Maintenance and Housekeeping staff missed those areas and resident's immediate environment must be cleaned at all times since this is their home. Administrator further stated they make daily rounds in the morning to ensure areas needed repairs are done to make their environment homelike. 10 NYCRR 415.5(h)(2)

Based on observation, record review and staff interview conducted during the Recertification and Complaint survey from 07/28/2025 to 08/04/2025, the facility did not ensure that a Comprehensive Care Plan for each resident was developed and implemented consistent with the resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing and mental psychosocial needs that are identified in the comprehensive assessment. This was evident for 1 (Resident #82) of 1 resident reviewed for Hospice and End of Life out of 37 sampled residents. Specifically, there was no care plan created that addressed comfort care for Resident #82. The findings are: The facility policy and procedure titled Comprehensive Care Planning with a review date of 01/2025 stated it is the facility policy to implement a Comprehensive, person-centered care plan for each resident that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The Interdisciplinary team will initiate upon admission and update the care plan quarterly and as needed. Resident #82 was admitted to the facility with diagnoses that included Squamous Cell Skin cancer, Heart Failure, and Respiratory Failure. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #82 was severely cognitively impaired and required dependent assistance of staff with most activities of daily living, including dressing, transfer and bed mobility. On 07/31/2025 from 12:15 PM to 12:32 PM, Resident #82 was observed in bed, awake with spouse at bedside. Resident #82 appeared weak, with poor appetite, taking only sips of a supplement with encouragement from their spouse. The Physician's order dated 06/12/2025 and renewed on 07/13/2025 documented an order for Comfort care, with advance directive of Do Not Resuscitate, Do Not Intubate, no tube feeding, no hemodialysis, and no weight taking. There was no documented evidence a care plan regarding comfort care had been created for Resident #82. On 08/04/2025 at 11:09 AM, Registered Nurse Supervisor #5 was interviewed and stated they are covering for the Unit Manager. Registered Nurse Supervisor #5 also stated the care plans for Hospice, Palliative and Comfort care is done by the Social Worker. On 08/04/2025 at 12:18 PM, the Director of Social Work was interviewed and stated they are responsible for creating care plans for Hospice, Palliative and Comfort Care, and Advance Directives. After reviewing the chart, the Director of Social Work stated there is a care plan for Advance Directives, but no care plan for comfort care was formulated. 10 NYCRR 415.11(c)(1)

Based on record review and staff interviews conducted during the Recertification survey from 07/28/2025 to 08/04/2025, the facility did not ensure that each resident's Comprehensive Care Plans were reviewed and revised. This was evident for 1 resident reviewed for Dignity out of 37 sampled residents. Specifically, there was no documented evidence that the Comprehensive Care Plans for Mood State, Cognitive Loss/Dementia, Wandering/Elopement, Behavioral Symptoms (Verbally Abusive Behavior), and Behavioral Symptoms were reviewed and revised for Resident #38 after their last quarterly Minimum Data Set assessment was completed.The findings include:The facility policy and procedure titled Comprehensive Care Planning last reviewed 01/2025 stated that it is the facility's policy to implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. The interdisciplinary team will review and update the care plan quarterly (in conjunction with the Minimum Data Set schedule) and as needed. Quarterly reviews of care plans are completed prior to the scheduled Comprehensive Care Plan meeting.Resident #38 had diagnoses including Non-Alzheimer's Dementia, Anxiety Disorder, and Major Depressive Disorder.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #38 had moderate cognitive impairment, exhibited physical and verbal behavioral symptoms, rejected care daily, and exhibited wandering behaviors daily.The Mood State Comprehensive Care Plan, effective 02/12/2023, documented Resident #38 was at risk for impaired mood state, psychosocial wellbeing, and behavioral disturbances, as evidenced by their diagnoses of Dementia, Major Depressive Disorder, and Altered Mental Status. The Mood State Comprehensive Care Plan was last reviewed on 02/20/2025 and there was no documented evidence the care plan was reviewed following Resident #38's Quarterly Minimum Data Set assessment on 05/23/2025. The Cognitive Loss/Dementia Comprehensive Care Plan, effective 02/19/2023, documented Resident #38 had impaired cognitive function/dementia or impaired thought processes related to their diagnosis of Dementia. The Cognitive Loss/Dementia Comprehensive Care Plan documented it was last reviewed on 02/22/2025, and there was no documented evidence the care plan was reviewed following Resident #38's Quarterly Minimum Data Set assessment on 05/23/2025. The Wandering/Elopement Comprehensive Care Plan, effective 03/04/2023, documented Resident #38 wandered with no rational purpose, seemingly oblivious to needs or safety. The Wandering/Elopement Comprehensive Care Plan documented it was last reviewed on 03/09/2025, and there was no documented evidence the care plan was reviewed following Resident #38's Quarterly Minimum Data Set assessment on 05/23/2025.The Behavioral Symptoms (Verbally Abusive Behavior) Comprehensive Care Plan, effective 06/19/2023, documented Resident #38 had the potential to demonstrate verbally abusive behaviors related to their diagnoses of Dementia, Major Depressive Disorder, and Altered Mental Status. The Behavioral Symptoms (Verbally Abusive Behavior) Comprehensive Care Plan documented it was last reviewed on 11/26/2024, and there was no documented evidence it was reviewed following Resident #38's Quarterly Minimum Data Set assessments 02/22/2025 and on 05/23/2025. The Behavioral Symptoms Comprehensive Care Plan, effective 04/23/2023, documented Resident #38 exhibited behavioral problems including episodes of wandering, threatening behavior, and resisting care. The Behavioral Symptoms Comprehensive Care Plan documented it was last reviewed on 11/26/2024, and there was no documented evidence it was reviewed following Resident #38's Quarterly Minimum Data Set assessments 02/22/2025 and on 05/23/2025. On 08/04/2025 at 10:59 AM, Registered Nurse #4 was interviewed and stated care plans are updated on a quarterly basis after the quarterly Minimum Data Set assessment is completed. Registered Nurse #4 further stated the Social Services department was responsible for updating the Mood and Cognitive Loss care plans, and the nurse manager was responsible for updating other care plans, including care plans related to Behaviors and Wandering/Elopement. Registered Nurse #4 was unable to provide an explanation for why Resident #38's care plans related to behavioral symptoms, wandering, and cognitive loss were not updated. On 08/04/2025 at 12:16 PM, the Director of Nursing was interviewed and stated Comprehensive Care Plans are updated on a quarterly basis by the relevant department. The Director of Nursing also stated there is an alert that is sent out through the electronic medical record when a review is due to alert staff to review it. The Director of Nursing was unable to provide an explanation for why the care plans were not updated for Resident #38. On 08/04/2025 at 12:50 PM, the Director of Social Services was interviewed and stated they were responsible for reviewing all Social Services Comprehensive Care Plans, which included care plans for Advanced Directives, Discharge, Cognitive Loss/Dementia, Psychosocial Wellbeing, Trauma Informed Care, Mood, and Victimization. The Director of Social Services also stated these reviews are done quarterly, and the electronic medical record alerts them when a review is due. The Director of Social Services further stated they did not realize that the Cognitive Loss/Dementia and Mood Care Plans had not been reviewed because they did not receive an alert related to it. NYCRR 415.11(c)(2)(i-iii)

Number of residents sampled: 5Number of residents cited: 1 Based on observation, record review and staff interviews conducted during the Recertification survey, the facility did not ensure that services provided or arranged by the facility as outlined by the Comprehensive Care Plan meet professional standards of quality including current evidence-based practice. This was evident for 1 (Resident #14) of 5 residents reviewed for Unnecessary Meds, Chemical Restraints/Psychotropic Meds, and Med Regimen Review out of 37 sampled residents. Specifically, Licensed Nurses did not inform the Physician or the Physician Assistant when a resident with diagnosis of Diabetes Mellitus had elevated blood glucose readings, of inconsistent blood glucose monitoring as per Physician's order of four times a day and of Resident's refusal of treatment as ordered by the Physician.The finding is: The Licensed Practical Nurse job description states charting and documentation includes transcribing physician's orders to resident charts, Kardex, medication cards, treatment or care plans, as required and chart nurses notes in an informative and descriptive manner that reflects the care provided to the resident as well as the resident's response to the care, prepare and administer medications as ordered by the Physician, and notify the Nurse Supervisor or Unit Manager for any discrepancies noted on your shift. Resident #14 had diagnoses which included Diabetes Mellitus, Hypertension, Morbidly Obesity, and Status Post Cardiac Arrest. The admission Minimum Data Set 3.0 assessment dated [DATE] documented Resident #14 was cognitively intact and was dependent on staff for most Activities of Daily Living and required set up assistance only for eating. The Physician's order dated 06/19/2025 with a renewal date of 07/05/2025 documented Admelog Insulin 8 units three times a day, Jardiance 10 milligram daily, Insulin Glargine 28 units at bedtime, and monitor blood glucose before each meals and at bedtime .Call Physician if lesser than 80 and greater than 400 milligram per dilution. The Comprehensive Care Plan on Diabetes Mellitus dated 05/09/2025 with revision date of 06/22/2025 documented a goal of resident will be free from signs and symptoms of hyper/hypoglycemia, will maintain glucose levels within the prescribed parameters. Interventions included administer medications as per physician's order, monitor effect and adverse effect and report to physician, educate resident and family with diabetes as a chronic disease and compliance is essential to prevent further complications, implement diet as prescribed, provide skin, foot care and refer to physician for consultations as needed. The blood glucose readings dated 07/01/2025 to 07/30/2025 documented elevated results with the lowest reading at 309 milligram per dilution (mg/dl) on 07/15/2025 at 11:49 am and the highest reading was 499 mg/dl at 1:53 PM on 07/02/2025. On the following dates the blood glucose readings were higher than 400 mg/dL:07/02/2025 AM-485 mg/dL07/02/2025 PM -499 mg/dL07/04/2025 AM-495 mg/dL07/04/2025 PM-495 mg/dL07/17/2025 PM-401 mg/dL07/19/2025 PM-402mg/dL There was no documented evidence that the Nursing Supervisor, Physician or Physician's Assistant were notified of blood glucose levels over 400mg/dL as per Physician's order. Further review of the Blood Glucose readings from 07/12/2025 to 07/21/2025 revealed blood glucose was not monitored as per Physician's order on the following dates and times:07/12/2025-dinner and bedtime 07/13/2025-breakfast, lunch and bedtime07/14/2025-breakfast and bedtime07/15/2025-bedtime07/17/2025-dinner07/18/2025-breakfast and bedtime07/19/2025-breakfast and bedtime 07/20/2025 breakfast and bedtime 07/21/2025-bedtime The Nurses Progress notes dated 07/01/2025 to 07/28/2025 revealed no documented evidence the Nursing Supervisor, Attending Physician or Physician Assistant were notified of blood glucose not taken and there was no documentation of resident refusal. On 08/01/2025 at 2:20 PM, Nursing Supervisor #4 was interviewed and stated no staff reported Resident #14's did have elevated blood glucose readings. Nursing Supervisor #4 also stated that they would not know about the elevated levels if the nurse did not inform them. On 08/01/2025 at 4:37 PM, the Director of Nursing was interviewed and stated all staff are educated on the blood glucose elevated readings and when to call the Physician. The Director of Nursing also stated it is the responsibility and is expected the Unit Nursing Supervisor is following up on the care residents receive on the unit, including elevated blood glucoses levels. 10 NYCRR 415.11(c) (3)(i)

Based on observation, record review and interview conducted during the Recertification survey, the facility did not ensure that each resident received treatment and care in accordance with goals for care and professional standards of practice. This was evident for 1 (Resident #6) of 4 residents reviewed for Limited Range of Motion out of 38 sampled residents. Specifically, Resident #6, who had a history of limited neck flexion, and a Physician's order for cervical brace to be worn at all times except for skin check, hygiene, and exercise was observed on several occasions without them.The findings are:The facility's policy titled Assistive Device and Equipment Policy last reviewed on 1/20/25 stated it is the responsibility of the facility to ensure residents are provided with a safe environment. The policy also stated all recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan, and direct care staff are trained and demonstrated competency on the use of devices and equipment prior to assisting or supervising residents.Resident #6 was admitted to the facility with diagnoses that included Non-Alzheimer's Dementia, Peripheral Vascular Disease, and Coronary Artery Disease.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #6 had moderately impaired cognition. The Minimum Data Set assessment also documented Resident #6 required dependent assistance of staff for personal and oral hygiene, toileting and transfer, and had no falls since the prior assessment.Occupational Therapy note dated 05/27/2025 documented Resident was seen after readmission and provided with cervical collar due to lateral flexion of neck. Nursing made aware. Will continue to follow.The Physician order dated 05/27/2025 documented cervical brace to be worn at all times except for skin check, hygiene, and exercise.The Comprehensive Care Plan for Mobility Devices effective 05/28/2025 documented that Resident #6 had a history of limited neck flexion, and cervical brace to be worn at all times except for skin check, hygiene, and exercise.On 07/28/25, 07/29/25 and 7/30/25 between the hours of 10:00 AM and 1:20 PM, Resident #6 was observed in bed, and there was no cervical brace observed placed on their neck. A cervical brace was observed in Resident #6's closet.The Resident Certified Nursing Assistant Documentation History dated from 07/28/2025 to 08/04/2025 documented Resident #6 had splint and braces were being used. On 07/30/2025 at 10:13 AM, an interview was conducted with Certified Nursing Assistant #1 who stated they were not aware Resident #6 had cervical brace to be worn to their neck. Certified Nursing Assistant #1 also stated they were not informed about the cervical neck brace, and they were not sure if the cervical neck brace included on their daily work plan.On 07/30/2025 at 10:33 AM, an interview was conducted with Registered Nurse #1, a unit supervisor, who stated they used to see the neck brace a while back when Resident #6 was first admitted to the unit in May 2025, but Resident #6 had not had it since then. Registered Nurse #1 also stated they believe the Interdisciplinary team were discussing the revaluation of the neck and the need for the continuation of the neck brace. Registered Nurse #1 concluded they were not aware Resident #6 was currently using the cervical neck brace.On 07/30/2025 at 10:42 AM, an interview was conducted with the Licensed Practical Nurse #1 who stated they had not seen Resident #6 with a neck brace since Resident #6 was transferred from the 2nd floor to the 6th floor.On 07/30/2025 at 10:42 AM an interview was conducted with the Licensed Practical Nurse #1 who stated that they have not seen the resident with neck brace since the resident came back from 2nd floor to the 6th floor. On 08/01/2025 at 11:50 AM, an interview was conducted with the Assistant Director of Nursing who stated Resident #6 had a Physician's order for a cervical neck brace for comfort of the neck and to prevent any deterioration because Resident #6 had limited mobility and impairment to their neck. The Assistant Director of Nursing also stated that the order was still active, and the resident's plan of care had not been changed. The Assistant Director of Nursing further stated that the Nursing Supervisors are responsible to ensure that the Certified Nursing Assistants are doing their work according to the resident's plan of care. On 08/01/2025 at 12:11 PM, an interview was conducted with the Director of Nursing who stated the cervical neck brace order was still active, and the Certified Nursing Assistants are responsible for the application of it. The Director of Nursing also stated they spoke with the assigned Certified Nursing Assistants about it, and they are currently in servicing the staff on need to apply residents' devices, not only the neck brace but all other devices necessary to improve the quality of life of residents.On 08/01/2025 at 02:20 PM, an interview was conducted with the Director of Rehab who stated once a device is determined to be used on a resident, they would get a Physician's order, and they would also train the nursing staff on the proper application of device. The Director of Rehab also stated Resident #6 was seen after readmission and provided with a cervical collar due to lateral flexion of neck, and they ensured staff did a return demonstration of the proper application of the cervical collar. 10 NYCRR 415.12

Based on observation, record review and interviews conducted during the Recertification survey, the facility did not ensure that the Physician reviewed the resident's total program of care at each visit. This was evident for 1 (Resident #14) of 5 resident reviewed for Unnecessary Meds, Chemical Restraints/Psychotropic Meds, and Med Regimen Review out of 37 sampled residents. Specifically, there was no documented evidence the Physician addressed Resident #14's consistently high blood sugars and non-compliance with diabetic management. The findings include: The facility policy and procedure titled Diabetes Protocol with a review date of 1/2025 stated all residents will have their diabetes managed according to Physician recommendations and resident/resident representative preferences. The Physician will follow up on any acute episodes associated with significant sustained change in blood glucose levels or significant deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. Resident #14 had diagnoses which included Diabetes Mellitus, Hypertension, Morbidly Obesity, and Status Post Cardiac Arrest. The admission Minimum Data Set 3.0 assessment dated [DATE] documented Resident #14 was cognitively intact and was dependent on staff for most Activities of Daily Living and required set up assistance only for eating. The Physician's order dated 06/19/2025 with a renewal date of 07/05/2025 documented Admelog Insulin 8 units three times a day, Jardiance 10 milligram daily, Insulin Glargine 28 units at bedtime, and monitor blood glucose before each meals and at bedtime. Call Physician if lesser than 80 and greater than 400 milligram per dilution. The Comprehensive Care Plan on Diabetes Mellitus dated 05/09/2025 with revision date of 06/22/2025 documented a goal of resident will be free from signs and symptoms of hyper/hypoglycemia, will maintain glucose levels within the prescribed parameters. Interventions included administer medications as per physician's order, monitor effect and adverse effect and report to physician, educate resident and family with diabetes as a chronic disease and compliance is essential to prevent further complications, implement diet as prescribed, provide skin, foot care and refer to physician for consultations as needed. The facility Clinical Monitoring Detail Report dated 07/01/2025 to 07/30/2025 documented elevated blood glucose readings results with the lowest reading at 309 milligram per dilution (mg/dl) on 07/15/2025 at 11:49 am and the highest reading was 499 mg/dl at 1:53 PM on 07/02/2025. On the following dates the blood glucose readings were higher than 400 mg/dL: 07/02/2025 AM-485 mg/dL07/02/2025 PM -499 mg/dL07/04/2025 AM-495 mg/dL07/04/2025 PM-495 mg/dL07/17/2025 PM-401 mg/dL07/19/2025 PM-402mg/dL The facility Clinical Monitoring Detail Report also documented the following elevated blood sugar levels: 07/12/2025 breakfast-384mg/dL lunch-396 mg/dL07/13/2025 dinner -396 mg/dL07/14/2025 lunch-301 mg/dL dinner-346 mg/dL07/15/2025 breakfast-312 mg/dL lunch-309 mg/dL dinner-341 mg/dL07/17/2025 breakfast-383 mg/dL lunch-401 mg/dL bedtime-328 mg/dL07/18/2025 lunch-397 mg/dL dinner-345 mg/dL07/19/2025 lunch-390 mg/dL dinner-342 mg/dL 07/20/2025 lunch-390 mg/dL dinner-400 mg/dL 07/21/2025 breakfast-400 mg/dL lunch-389 mg/dL dinner-342 mg/dL The Physician's Assistant Progress note dated 06/27/2025 documented last labs seen and appreciated from May 2025 with elevated Hemoglobin A1C of 11.5 % with glucose result of 400 mg/dL. Plan of care: Continue Admelog 8 units three times a day, Jardiance 10 mg daily and Lantus 28 units at Bedtime. Hold if blood glucose is 200 mg/dL. Lab results dated 07/12/2025 documented Hemoglobin A1C (HgbA1C) result of 12.8 % which was increased from result of 11% in May 2025. Glycated Hemoglobin or Hgb A1C is a blood test that provides a long-term average of a person's blood sugar levels which reflects how much glucose has attached to hemoglobin in red blood cells over the past 2-3 months which is crucial in the diagnosis of Diabetes Mellitus. The Physician Assistant Progress note dated 07/21/2025 documented monthly assessment, last labs were seen and appreciated. The plan for Diabetes Mellitus 2 was continue Ozempic, Jardiance, Admelog 8 units, and Lantus 28 units daily. Monitor for Hyper/Hypoglycemia, trend HgbA1C and fingerstick. The Physician Assistant Progress note dated 07/26/2025 documented follow-up on poorly controlled Diabetes. Finger sticks are in the 300 range, this visit at 312 mg/dL sometimes higher, medication regime remains the same, hold parameters if below 200, which is seldom ever below 200. The resident is morbidly obese and is contributing to poorly controlled Diabetes with food choices that they get from the vending machine and from outside delivery. Plan of care: Hemoglobin A1C previously 11.5 now 12.8. Continue Admelog 8 units three times a day, Jardiance 10 milligram daily, Lantus 28 units bedtime. On 07/31/2025 at 12:14 PM, Physician Assistant #1 was interviewed and stated Resident #14 is noncompliant and will drink two bottles of soda. Physician Assistant #1 also stated that the medication was not adjusted because of the last holiday in July, and it should have been addressed at that time. On 07/31/2025 at 12:18 PM, Attending Physician #1 interviewed via telephone and stated Resident #14 is noncompliant and will order food from outside. Attending Physician #1 also stated they met with Resident #14 and Resident #14 refused to attend appointments with the Endocrinologist when they were at another facility prior to admission here. Attending Physician #1 further stated that they do not want Resident #14's blood sugars to go too low. Attending Physician #1 stated they would review Resident #14's and adjust medication if needed. On 08/01/2025 at 2:21 PM, the Medical Director was interviewed via telephone and stated they reviewed Resident #14's record and with elevated blood glucose such as this the medications should have been adjusted. The Medical Director also stated they would speak with Resident #14's Attending Physician about this matter. The Medical Director further stated this issue had not come to their attention. 10 NYCRR 415.15(b)(2)(iii)

Based on observation, record review and interviews during an abbreviated survey (NY00339419 and NY00342391), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, and mistreatment, are reported immediately, but not later than 2 hours after the allegation is made to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities). This was evident in three (3) out of five (5) residents sampled (Residents #1, Resident #2 and Resident #3). Specifically, on 04/11/2024 at 12:50 PM, Registered Nurse #1 documented while monitoring residents at the start of their shift 7:00 AM to 3:00 PM, Resident #1 complained of pain in their private area and stated they think someone might have touched their private area because it hurts. Resident #1 was transferred to the hospital for further evaluation. The facility reported the incident to the New York State Department of Health on 04/16/2024 at 4:17 PM. On 05/15/2024 at 5:45 PM, Resident #2 was sitting in the dining room when Resident #3 suddenly hit Resident #2 on their head with a soda can. Resident #2 was transferred to the hospital for further evaluation. The facility reported the incident to the New York State Department of Health on 05/16/2024 at 3:01 PM. The findings are: The facility's Policy and Procedure titled Abuse, Mistreatment, Neglect, Misappropriation of Resident 's Property, revised 01/2025. Number 6: Reporting and Response (pg.17) documented it is the facility's policy to report abuse allegations per Federal and State Law. The policy documented the facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Resident #1 was admitted to the facility with diagnoses including coronary artery disease and bipolar disorder (a chronic mental health condition characterized by extreme shifts in mood). The Minimum Data Set (an assessment tool), dated 03/22/2024, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 14 associated with intact cognition. An Incident/Accident Report dated 04/10/2024, documented Resident #1 reported their private area was hurting because they think the nurse on the 11:00 PM-7:00 AM shift touched their private area. The facility's investigation dated 04/16/2024, concluded there was no credible evidence to suggest that abuse occurred. Resident #1 has history of confabulation and manipulation. Resident #1 initially denied seeing someone enter their room and touching them. The 11:00 PM- 7:00 AM shift reported that Resident #1 was observed sleeping throughout the shift. Resident #1 was transferred to the hospital and was evaluated for alleged sexual abuse and treated prophylactic. Resident #1 is no longer residing at the facility, several attempts made to interview Resident #1 was unsuccessful. During a telephone interview on 02/11/2025 at 1:15 PM, Assistant Director of Nursing stated any allegation of abuse should be reported within two hours to the New York State Department of Health. They stated they did not report the incident because Resident #1 denied the allegation when they were re-interviewed. Assistant Director of Nursing stated they reported the incident to the New York State Department of Health five days later because they wanted to complete their investigation and have concrete details before reporting the allegation. During a telephone interview on 02/12/2025 at 9:05 AM, the Administrator stated on 04/11/2024 at 9:30 AM, during morning meeting, Resident #1's concern was discussed, and an investigation was started, and Resident #1 was transferred to the hospital for further evaluation. Administrator stated abuse allegation are supposed to be reported to the New York State Department of Health within 2 (two) hours, however, this incident was not reported because Resident #1 recanted their statement, and the facility staff wanted to have concrete details before reporting the incident to the New York State Department of Health. Resident #2 was admitted to the facility with diagnosis including coronary artery disease (heart damage), and Schizophrenia (inability to think, feel, and behave clearly). The Minimum Data Set, dated dated [DATE], documented Resident #2 had a Brief Interview of Mental Status score of 14 associated with intact cognition. Resident #3 was admitted to the facility with diagnosis including Diabetes Mellitus and Alzheimer's Disease. The Minimum Data Set, dated dated [DATE], documented Resident #3 had a Brief Interview of Mental Status score of 7 associated with severely impaired cognition. An Incident/Accident Report dated 05/15/2024 at 5:45 PM, documented Resident #3 approached Resident #2 in the dining room hit Resident #2's head with a soda can. Staff were present in the dining room and were unable to prevent the occurrence. The facility's investigation dated 05/20/2024, concluded the altercation was unavoidable and unpredictable. Staff responded appropriately and separated the residents. Resident #2 and Resident #3 were transferred to the hospital for further evaluation. Resident #2 no longer resides at the facility. Resident #3 no longer resides at the facility. During a telephone interview on 02/11/2025 at 2:25 PM, Director of Nursing stated after an incident was discussed with the team, the Assistant Director of Nursing is responsible for reporting the incident to the New York State Department of Health. The Director of Nursing stated any allegation of abuse is supposed to be reported within 2 (two) hours. The Director of Nursing stated the Resident-to-Resident incident was reported on 05/16/24 because Resident #3 was confused and did not have capacity, and they did not assume this incident fell under the category to report within two hours. During a telephone interview on 02/12/2025 at 9:14 AM, the Administrator stated they were informed by the Director of Nursing that Resident #3 hit Resident #2 on their head with a soda can (cannot recall the time or date they were informed). Resident #2 refused assessment, 911 was called and Resident #2 transferred to the hospital. The Administrator stated the incident was reported to the New York State Department of Health the following day because there were no serious bodily injury and Resident #2 refused assessment. 10 NYCRR 415.4(b)

Based on observation, record review, and interviews conducted during the recertification survey from 7/19/2023 to 7/24/2023, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during Kitchen observation. Specifically, cold sandwiches and milks were not maintained at the proper temperature of 41 degrees Fahrenheit (F) or below. The findings are: The facility policy titled Food Safety and Food Temperature dated 1/2023 documented food will be stored, prepared, handled, and served so risk of foodborne illness is minimized. During an observation of the kitchen on 7/21/23 at 11:19 AM, the Food Service Director (FSD) was calibrated a thermometer in the kitchen to test food items on the tray line. FSD removed two 8-ounce milks from residents' trays, two 8-ounce milks from dairy refrigerator, and two sandwiches from the tray line. Temperature checks of the cold items revealed: 1) an 8-ounce milk from first tray was 43.9 F, 2) an 8-ounce milk from another tray was 69 F, 3) 8-ounce milks from refrigerator were 44 F and 58.7 F, 3) an egg salad sandwich was 44.8 F, and 4) a tuna salad sandwich was 46.6 degrees F. On 7/21/23 at 11:48 AM, the FSD was interviewed and stated cold foods should be kept below 41 F; however, the temperatures of the milk were not within the acceptable range because the trays were set up too early. The milk should have been placed on the trays later in the tray line process to ensure proper temperature. The sandwiches were kept on ice to maintain the temperature, but the ice didn't hold the temperatures of the sandwiches below 41 F. 415.14(h)

Based on observation and staff interviews conducted during the Recertification and Abbreviated Survey from 7/19/23 to 7/26/23, the facility did not ensure that a resident was cared for in a manner that maintained or enhanced dignity. Specifically, a resident was observed on more than one occasion with no clothes on. This was evident for 1 of 1 resident reviewed for Dignity out of a sample of 35 residents. (Resident # 45) The findings are: The Facility's Policy titled 'Resident Right' last reviewed on January 2023, documented that it is the Policy of Central Queens Rehabilitation Center to treat all residents with kindness, respect and dignity. The policy also documented that Federal and state laws guarantee certain basic right to all residents of the facility. These rights include the resident's right to a dignified exitence. Resident # 45 was admitted to the facility on [DATE] with diagnoses which included Systemic Lupus Erythematosus, Respiratory Failure, Cerebral Ischemia and Chronic Obstructive Pulmonary Disease. The Quarterly Minimum Data Set (MDS) dated [DATE] documented that resident was cognitively intact. The resident required total assist of two people for bed mobility, transfer and toilet use and extensive assist of one person for personal hygiene. On 7/19/23 at 10:42 AM, Resident #45 was observed in bed with a gown on. When they were asked about clothing, Resident #45 stated they do not have any summer clothes to wear. Resident #45 stated their clothes are downstairs. They asked for their clothing, but the staff did not bring them up. On 7/24/23 at 10:29 AM, Resident #45 was observed in bed with just a diaper on. Resident #45 stated they returned to the facility after a hospitalization , and staff did not bring up their summer clothes. Resident #45 stated they only had winter clothes in their closet. The surveyor observed the closet and there were only winter clothes inside. On 7/26/23 at 10:58 AM, the Certified Nursing Assistant (CNA #7) was interviewed and stated when a resident is discharged to the hospital, the CNA and housekeeping brings their clothing to the basement in a bag. When the resident comes back from the hospital, nursing calls housekeeping to bring the clothes back up. Sometimes, family comes and and takes the clothes out. On 7/26/23 at 11:09 AM, Housekeeper #1 was interviewed and stated that when someone goes to the hospital, all the resident's clothing goes into a box labeled with the name and room number. When the resident is back from the hospital, the nurse or the CNA calls downstairs to request the clothing be brought up by the responsible person from housekeeping. On 7/26/23 at 11:47 AM, Housekeeper #2 was interviewed and stated when the resident is back from the hospital, nursing calls downstairs for the clothes. Last time, when the resident came back, the nurse went down to pick up some winter clothes; it was still winter. Resident has some winter clothes in the closet. Resident went back to the hospital and came back again. The resident's summer clothes were returned to them this week. On 7/26/23 at 12:00 PM, the Registered Nurse (RN #2) was interviewed and stated that when someone is readmitted from the hospital, nursing calls housekeeping to bring back the clothes. Nursing will then put it in the closet again. RN #2 looked at the medical record and stated Resident #45 was readmitted to the facility on [DATE]. The resident's clothes were given back on 7/24/23, almost 8 weeks after readmission. 415.5 (a)

Resident #168 Based on observations, interviews and record review conducted during the recertification and complaint survey from 7/19/23 to 7/24/23, the facility did not ensure that each resident has the right to make choices about aspects of life that are significant to the resident. This was evident for one (Resident #168) of six residents reviewed for Activities of Daily Living. Specifically, Resident #168 was was not asked about bathing preferences when their shower schedule was created, and they were informed about their shower schedule. The findings are: The facility's policy and procedure titled Activities of Daily Living Supporting dated 1/23 documented residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and person, and oral hygiene. Resident #168 was admitted to the facility on [DATE] with diagnoses of bilateral above knee amputation and muscle weakness. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident was cognitively intact. Resident #168 required total assist of two or more people for bathing and considered the bathing preference as very important. During an interview on 7/19/23 at 12:25 PM, Resident #168 stated they would like to receive a shower more consistently. Resident #168 stated that they get a shower only when it is requested. They were not aware that there was a shower schedule. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs), created 4/13/23, documented interventions to allow sufficient time to complete task, encourage to participate in ADL care as much as they are able, and to encourage resident decision making/choices during ADL care. It did not document resident's bathing preference or bathing schedule. Review of the interdisciplinary assessments dated from 4/13/23 to 7/19/23 revealed there was no documented evidence the resident was given opportunities to choose bathing preference and their schedule. Review of the interdisciplinary notes dated from 4/13/23 to 7/19/23 revealed there was no documented evidence that resident refused bathing/shower. On 7/24/23 at 2:14 PM, Certified Nurse Aide (CNA #1) stated that they have not consistently provided a shower as per the schedule found in Electronic Medical Record (EMR) for Resident #168. This is because a shower has been provided to the resident whenever it was requested by the resident. Resident #168 will usually ask when they want a shower. CNA #1 stated they are not sure if Resident #168 was made aware or knows about their shower schedule. On 7/21/23 at 10:26 AM, the Assistant Director of Nursing (ADON) was interviewed and stated that Resident #168 will be showered as per resident's request since this resident is alert and oriented x 3. Resident #168 is able to verbalize their needs; therefore, they will ask for a shower whenever needed. The ADON stated Resident #168 was informed of their weekly shower schedule, but the ADON was not able to explain where this is documented in the EMR. On 7/24/23 at 2:52 PM, the Director of Nursing (DON) stated that upon admission, nursing will complete an initial assessment which includes bathing preference/schedule. The DON stated they were not aware that Resident #168 did not get an opportunity to choose shower preference and schedule upon admission. 415.5(b)(3)

Based on record review and interviews conducted during the Recertification and Complaint Survey (NY00310807) from 7/19/23 to 7/26/23, the facility did not ensure that the resident and/or the designated representative was promptly notified when there was an accident involving the resident which resulted in an injury. This was evident for 1 of 4 resident reviewed for Notification of Change out of a sample of 38 residents (Resident # 155). Specifically, the facility did not notify the designated representative when Resident #155 was observed with a bruise of unknown source under their left eye. The findings are: The facility policy titled Notification of Change in Condition with effective date 10/20/2022 documented it was the policy of the facility to inform the residents; consult the physician; and if known, notify the resident's legal representative or an interested family member when there has been a change in the resident's condition. It included an accident involving the resident which results in injury. The family will be notified about all Accident and Incidents. It also documented the licensed nurse/designee will notify the resident's legal representative or interest family member of the change in resident's condition and document the notification in the resident's medical record. It further documented the unit manager/nursing supervisor shall record all attempts to contact the next of kin, inclusive of the time of the day and forward such for inclusion in the resident's medical record. Resident # 155 was admitted to the facility with diagnoses that included Vascular dementia, Other seizures, and Weakness. The Admission Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident # 155 had severely impaired cognition, had no rejection of care or wandering behavior, did not walk, and was totally dependent with 1 person assist for locomotion on/off unit. It also documented Resident # 155 was frequently incontinent of bladder and bowel. It further documented Resident # 155 had no fall history. It documented only the representative participated in the assessment. On 07/19/23 at 11:02 AM, the representative was interviewed and stated they observed Resident #155 had black left eye during their visit on 2/5/23. The representative also stated the facility did not notify them of the injury. The nursing note dated 2/4/23 documented Resident #155 was very confused. It also documented Resident # 155 was constantly walking in the hallway, going into other residents' rooms, and very resistive to redirection. The nursing note dated 2/5/23 documented Resident #155 woke up with a bruise under the left side eye. It also documented the bruise was from unknown source. Review of progress notes from 2/5/23 to 2/9/23 in the electronic medical record (EMR) system and the hard copy chart revealed no documented evidence that Resident # 155's designated representative was notified of the bruise around Resident # 155's left eye. On 07/24/23 at 10:12 AM, the Registered Nurse (RN) # 4 was interviewed and stated Resident #155 was always confused with severe dementia. The RN # 4 also stated Resident #155 had a lot of fall incidents on the unit, and they were not sure if these falls caused the bruise and scratches on the face. The RN # 4 stated they had to notify the designated representative and Director of Nursing (DON) if something happened to the resident. The RN # 4 also stated they did not remember if the representative or DON was notified of the bruise under Resident # 155's left eye observed on 2/5/23. The RN # 4 further stated they should notify the representative and the DON about the bruise as it was considered as injury of unknown origin. On 07/24/23 at 10:36 AM, the Director of Nursing (DON) was interviewed and stated they made rounds to the unit at least 1 time for the day shift and another time for the evening shift. The DON also stated they spoke to the staff, observed resident care, and checked the environment during the rounds. The DON stated they should notify the representative and document the notification if something happened to the resident. The DON also stated they were not aware that Resident # 155 was found with a bruise around the left eye on 2/5/23. The DON further stated they had to notify the representative of the bruise around Resident #155's left eye. The DON was not able to locate any documented evidence in Resident #155's medical record that the representative was notified of the bruise around Resident #155's left eye. The DON was also not able to explain the failure of notification of change. 415.3(f)(2)(ii)(a)

Based on observation, and staff interviews during the Recertification and abbreviated survey conducted from 7/19/23 to 7/26/25, the facility did not ensure that residents' privacy and confidentiality were maintained. This was evident for 1 of 1 resident reviewed for Privacy out of a total sample of 35 residents (Resident # 15). Specifically, Resident #15's privacy curtain was missing and left the resident exposed to everybody entering the room. The findings are: The facility policy and procedure on resident's right last reviewed on January 2023 document that employees shall treat all residents with kindness, respect and dignity. The policy and procedure further documented that Federal and State laws guarantee certain basic rights to all residents in the facility. These rights include the resident's right to privacy and confidentiality. On 7/19/2023 at 10:11 AM, Resident #15 was observed in bed talking to his roommate. No privacy curtain noted. On 7/19/2023 at 2:21 PM, Resident #15 was observed in bed talking to his roommate, and there was no privacy curtain curtain. Resident #15 was admitted to the facility on [DATE] with diagnoses which includes Type 2 Diabetes Mellitus, Essential Hypertension and Major Depressive Disorder. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The MDS further documented that the resident required the extensive assist of 2 for bed mobility, total assist of 2 for transfer, and total assist of 1 for toilet use. During an interview on 7/19/2023 at 10:42 AM, Resident #15 stated that the curtain has been broken for a while. They took it off but did not replace it. On 7/26/2023 at 10:40 AM, CNA #6 was interviewed and stated that they did not notice the missing privacy curtian when entering the room to help the resident. Missing curtain was not aware by staff. On 7/26/23 at 12:41 PM, RN #2 was interviewed and stated that resident never wants to get out of bed. As per RN #2, the missing curtain was never noticed when entering the resident's room. 415.3(d)(1)(ii)

Based on observation, record review, and interviews conducted during a Recertification survey from 07/19/2023 to 07/26/2023, the facility did not ensure a clean, comfortable, and homelike environment was maintained. This was evident for 1 (2nd Floor) of 5 Units. Specifically, resident rooms were observed with mismatched paint and dry wall patches, clutter including multiple cardboard boxes and food containers, rusty and cracked light fixtures, ripped fall mats, ripped leather on a resident's recliner, and ripped and dirty privacy curtains. The findings are: The policy titled Care of Equipment revised 01/31/2023 documented curtains observed to be soiled or in disrepair should be reported to the Maintenance department for immediate removal and resolution. All equipment in disrepair should be communicated to the Maintenance department in a timely manner. On 7/19/2023 between 9:47 AM and 3:33 PM, the following was observed on the 2nd Floor: -room [ROOM NUMBER] had fall mats on the floor by resident beds with ripped edges and white threading visible. The privacy curtain for bed 201 B had a 15-inch rip at the top of the curtain. -room [ROOM NUMBER] had gray paint at bottom of the walls near the baseboards that was scratched in multiple areas exposing the dry wall beneath. A rusty metal light fixture above the resident sink in the room had a glass outer light bulb cover that was cracked. -room [ROOM NUMBER] ad multiple boxes, clothing on the floor, used plastic food containers at bedside, and a dusty plastic bin. -room [ROOM NUMBER] had an open area to the right of the resident's sink uncovered by tile and exposing white paint beneath. There was a 16 X 9 inch area of peeling paint on the ceiling with dry wall. -The hallway had a recliner with multiple areas of ripped fabric on the left side. -room [ROOM NUMBER] had scraped wall edges and mismatched paint on the wall. -room [ROOM NUMBER] had multiple spots and white stains on the green wallpaper and chipped paint by the sink. -room [ROOM NUMBER] had multiple areas of drywall visible and mismatched paint above the baseboards. -room [ROOM NUMBER] had gray paint peeling and a ripped privacy curtain. -room [ROOM NUMBER] had gray paint spackle, brown paint, and white drywall on the wall in multiple areas to the right of the air conditioning unit and above baseboards. A brown wooden divider on the wall was dusty. -Resident #139 had a left wheelchair armrest with missing leather and foam exposed. Resident #81 had a back that was ripped, and the foam was exposed. On 7/25/2023 at 03:10 PM, the following was observed on the 2nd Floor: -room [ROOM NUMBER] had dry wall visible by the B bed. -room [ROOM NUMBER] had scratched paint on the walls and a missing baseboard by the B bed. -room [ROOM NUMBER] had mismatched paint and dry wall patches visible. -room [ROOM NUMBER] had a red stained privacy curtain with a missing hook. -room [ROOM NUMBER] had mismatched paint and exposed drywall throughout the room. On 07/26/2023 at 11:09 AM, the following was observed on the 2nd Floor: -room [ROOM NUMBER] had ripped wallpaper and a rusty light to the right of the sink. The bedside tabletop had cracks and missing veneer along the edges. -room [ROOM NUMBER] had a stained Stop sign on the room door. -room [ROOM NUMBER] had a ripped privacy curtain. The 2nd Floor Maintenance Logbook for July 2023 documented on 7/12/2023 the ceiling was plastered in Rooms 208, 210, 201, and 219. On 7/14/2023 signed 7/14 and damage on ceiling wall 209/210 entry documented. On 07/26/2023 at 12:58 PM, Registered Nurse (RN) #4 was interviewed and stated they do environmental rounds 2-3 times. Staff tell RN #4 when the curtain is dirty, has stains or is ripped and RN #4 calls housekeeping. RN #4 stated they saw walls being patched last week by Maintenance. The Maintenance Logbook is used to report repair needs on the floor. On 07/26/2023 at 11:20 AM, Housekeeper #3 was interviewed and stated there are stains on the wall, they wipe but they won't come off. They stated in room [ROOM NUMBER] they were informed there was leak from the 3rd floor and this morning they noticed room leaking dripping down wall. They noticed rooms patched and staff wanted to paint, and painting not done and is not sure when the patching was done. Housekeeper #3 took down and changed curtains last week, but they are waiting on a n order of big curtains to change out other ones. Curtains are changed out monthly and if they are soiled the housekeeper changes it. They look for rips, tears, and stains on the curtains. On 07/26/2023 at 11:40 AM, the Maintenance Worker was interviewed and state that they did dry wall work for rooms on the 2nd, 3rd and 6th floor. They will do painting when paint flake and they get a list and mark the maintenance book if they see a room needs to be painted. On 07/26/2023 at 11:37 AM and 12:29 PM, the Acting Director of Maintenance (ADM) was interviewed and stated they do rounds daily, check books for complaints and fix what they can. room [ROOM NUMBER] they noticed a leak this morning and stated that there was a leak on 3rd floor room above that they are trying to fix. Painting is done every 6 months and was last completed on 10/2022. Plaster work was done last week. Curtains are changed weekly and if stained. The facility has extra curtains in stock and are 36 curtains to switch out dirty or ripped curtains if necessary. The ADM checks rooms along with the nursing supervisor 1-2 times a week. room [ROOM NUMBER] has issues going on in the room and staff try to get the resident to throw items out, but they can't control the resident. When the resident leaves the room, the social worker lets the staff know they can go in and o work. On 07/26/2023 at 1:58 PM, the Director of Nursing (DON) stated that they do environmental rounds daily. They stated they also read the nursing supervisor notebook for the floor. The 1st floor is under renovation, and it is the only floor under renovation currently. The units were renovated before they got here. On 07/26/2023 at 04:11 PM, The Administrator stated we do rounds, and the units have a maintenance logbook on the floor. They look at it daily and maintenance is being provided. Maintenance sees items that need fixing in the logbook. 415.12(h)(1) (2)

Based on record review and interview conducted during the Recertification/Complaint survey (NY00318475 and NY00310807), the facility did not ensure all alleged violations involving injuries of unknown source were reported immediately, but not later than 2 hours after the allegations were made to the State Survey Agency. This was evident for 2 (Resident # 42 and # 155) of 2 residents reviewed for Abuse out of 38 sampled residents. Specifically, the facility did not report an injury of unknown source for 1) Resident # 42 with abrasion on left arm and 2) Resident # 155 with bruise around left eye and scratches around the nose to the New_York State Department of Health (NYSDOH). The findings are: The facility policy titled Abuse Prevention with effective date 2/14/2022 and last reviewed/revised date 2/1/2023 documented the alleged violation is an occurrence that has not yet been investigated but if verified could be noncompliance with federal requirements related to abuse including injury of unknown source. It also documented under section of Reporting that all alleged violations must be immediately reported to the administrator, state agency, and any other required law enforcement agencies within the specified time frames. It further documented the facility had to report no later than 2 hours of the alleged violations including abuse. 1) Resident #42 was admitted to the facility with diagnoses including Peripheral Vascular Disease (PVD), Parkinson's Disease, Depression, Glaucoma. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #42 had severely impaired cognition with short-term memory and long-term memory problem. The resident never/rarely made decisions. The MDS further documented the resident required extensive assistance of two plus persons for bed mobility, total assistance of one person for eating, toilet use and personal hygiene, and total assistance of two plus persons for transfers. On 06/16/23, the complainant reported to the New_York State Department of Health (NYSDOH) Aspen Complaint Tracking System (ACTS) that Resident #42 was observed on 6/15/23 with a bruise that resembled a bite mark on the hand. A nursing progress note dated 06/15/2023 at 08:50 pm documented Resident #42 was awake and tolerated care as per MD's order. The resident's sister informed staff of left arm skin purpura. Nursing supervisor made aware and assessed the resident. The Physician's Assistant (PA) was informed and assessed resident with new orders. X-Ray of left arm and bacitracin regime. All care rendered and tolerated well. All needs were met, and the resident was made comfortable. Safety precaution maintained. Physician Assistant (PA) Medical progress note dated 06/15/2023 documented the resident was seen for follow-up on left forearm abrasion. The resident was seen with family members at bedside. The PA noted a left forearm abrasion with dried blood. The resident also has some mild scratch marks on the dorsum of the resident's forearm. The resident is nonverbal at baseline. The resident is status post history of Parkinson's disease, functional quadriplegia with dysphagia. The resident was unable to talk and communicate. The resident's daughter, also healthcare proxy, was at the visit and communicated on behalf of the patient. The PA ordered an x-ray of the forearm and planned to follow-up on the results. There were no reports of any injuries, falls or traumas. PA ordered bacitracin to be applied ot the affected areas and monitor for improvement. The remainder of the physical exam was unremarkable. Nursing progress notes dated 06/16/2023 at 04:15 pm documented Resident #42's daughter was called regarding result of X rays of left hand and forearm which showed no acute fractures nor dislocation with soft tissues unremarkable, has moderate Osteoarthritis. Resident on Aspirin. MD progress notes dated 6/16/2023 documented Medical History and Physical/Plan of care Monthly on 06/16/23 Interval History Abrasion / ecchymosis ( open purpura ) L- arm Records reviewed. Patient noted with generalized weakness, needing increased assistance with Activities of Daily Living (ADL). There was no documented evidence Resident #42's injury of unknown origin was reported to NYSDOH within 2 hours. The facility provided no documented evidence that the facility gathered statements from all staff on duty, witnesses, created an Incident report and or conducted a thorough investigation into Resident #42 unwitnessed abrasion to left hand on 6/15/2023. On 07/24/23 at 02:34 PM, an interview was conducted with Registered Nurse (RN#2) who was the Nursing Supervisor covering the day of the incident. RN #2 stated on 6/15/2023 the family reported a skin purpura to the left arm. RN #2 stated the Physician Assistant assessed the resident and ordered an x-ray and bacitracin to the area. RN #2 stated they called the daughter to explain the x-ray results. On 07/26/23 at 11:43 AM, a follow up interview conducted with RN #2. RN #2 stated the resident was on aspirin which can cause the purpura (red/purplish discoloration) scattered on the left outer aspect of the resident's left wrist. RN #2 stated did not speak to the PA because the PA saw the resident right away. RN #2 stated based on RN #2 nursing knowledge if the resident has a skin tear, an abrasion, a laceration, an incident report will be made. RN #2 stated they were aware the doctor documented an abrasion in the medical record, but RN #2 did not see an abrasion at the time and did not feel the need to do an incident report. RN #2 stated they believed the discoloration was caused by the resident taking aspirin daily and they did not need to do an incident report. RN #2 stated believed this was a Senile Purpura that opened, but they were unable to provide documented evidence of Senile Purpura diagnosis in the resident medical record. During an interview on 07/25/23 at 10:50 AM, RN #1, the nurse supervisor, stated there was no investigation for the discoloration. RN #1 stated the DON informed them there was no incident, and it was purpura because the resident was on aspirin. On 07/25/23 at10:59 AM, an interview was conducted with Director of Nursing (DON). The DON stated Resident #42's skin discoloration was reported in the morning report and the resident had Senile Purpura. The DON stated an x-ray and blood work was done, but everything was negative. The DON stated Senile purpura is a medical condition, and the doctor documented open purpura left arm. The DON stated they never did an incident report on senile purpura. Senile Purpura can open without reason and can appear for unknown reasons because the skin is fragile. The DON stated the doctor documented an abrasion, but they believed the wording was incorrect because the resident has a diagnosis of senile purpura. The DON could not show where the diagnosis of senile purpura was documented in the medical record. The DON stated they did not take statements from staff, initiate and investigation, or report the injury to DOH because they were informed the resident had senile purpura in the morning meeting which does not warrant an investigation. 44843 2) Resident # 155 was admitted to the facility with diagnoses that included Vascular dementia, Other seizures, and Weakness. The Admission Minimum Data Set (MDS) dated [DATE] documented Resident # 155 had severely impaired cognition, had no rejection of care or wandering behavior, did not walk, and required total dependence with 1 person for locomotion on/off unit. It also documented Resident # 155 was frequently incontinent of bladder and bowel. It further documented Resident # 155 had no fall history. It documented only the representative participated in the assessment. On 07/19/23 at 11:02 AM, the representative was interviewed and stated they observed Resident # 155 had a black left eye on 2/5/22 and scratches on the forehead on 2/8/23 during their visits. The nursing note dated 2/5/23 documented Resident # 155 woke up with a bruise under left side eye. It also documented the bruise was from unknown source. The Incident/Accident Report dated 2/8/23 documented Resident # 155 was observed having scratches close to the nose. It also documented it was injury of unknown origin. Review of progress notes from 2/5/23 to 2/9/23 in the electronic medical record (EMR) system and the hard copy chart revealed no documented evidence that the facility reported these 2 injuries of unknown source to NYSDOH. On 07/24/23 at 10:12 AM, the Registered Nurse (RN) # 4 was interviewed and stated they reported if anything happened to a resident on the unit to Director of Nursing (DON) immediately. The RN # 4 also stated the bruise around the left eye on 2/5/23 and the scratches around the nose on 2/8/23 observed for Resident # 155 were considered injuries of unknown source as Resident # 155 was very confused and not able to tell what happened and no one witnessed what happened. The RN # 4 further stated they knew they had to report injuries of unkown origin to the DON immediately as the facility had to report to Department of Health (DOH). The RN # 4 stated they did not remember if they notified the DON or any other responsible person about the bruise on the left eye for Resident # 155. On 07/24/23 at 10:36 AM, the Director of Nursing (DON) was interviewed and stated they made rounds to the unit at least 1 time for the day shift and another time for the evening shift. The DON also stated they spoke to the staff, observed resident care, and checked the environment during the rounds. The DON also stated the nurse supervisors on the units reported to them if something happened to the residents. The DON stated the Assistant Director of Nursing (ADON), the Administrator, and themselves had access to Health Commerce System (HCS) for reporting alleged violations to the DOH. The DON also stated the ADON was new to facility and did not report incident through HCS yet. The DON stated they were not aware of the bruise around Resident # 155's left eye on 2/5/23. The DON also stated the scratches around Resident # 155's nose were superficial. They did not consider these scratches as serious injury, and therefore they did not report the incident to DOH. The DON stated Resident # 155 had dementia, was very confused, and was not able to verbalize what happened. The DON also stated no staff, no other resident, and no visitor witnessed what happened causing the bruise around left eye on 2/5/23 and scratches around the nose on 2/8/23 for Resident # 155. The DON stated the two incidents should be considered injuries of unknown origin for Resident # 155. The DON also stated they should have reported both incidents to DOH within 2 hours when they were made aware of the allegation. On 07/24/23 at 12:08 PM, the Administrator was interviewed and stated they had to report the injury of unknown source to the State Department of Health within 2 hours. The Administrator also stated the injury of unknown source referred to an injury the resident was not able to tell what happened and no one witnessed it. The Administrator further stated they were not aware of the incidents on 2/5/23 and 2/8/23 for Resident # 15 and the incident related to left arm abrasion for Resident # 42. 415.4(b)(1)(i)

Based on record review and interviews conducted during the Recertification and Complaint (NY00318475 and NY00310807) survey, the facility did not ensure that all allegations of abuse, including injuries of unknown origin, were thoroughly investigated. This was evident for 2 (Resident # 42, Resident # 155) of 2 residents reviewed for Abuse out of 38 sampled residents. Specifically, 1) there was no documented evidence an investigation was conducted when Resident #42 sustained an abrasion to the left hand, and 2) there was no documented evidence an investigation was conducted for Resident # 155 who had ecchymosis area under left eye. The findings are: The facility policy titled Abuse Prevention with effective date 2/14/2022 and last reviewed/revised date 2/1/2023 documented the alleged violation is an occurrence that has not yet been investigated but if verified could be noncompliance with federal requirements related to abuse including injury of unknown source. It also documented under section of Investigation that investigation includes but is not limited to Investigate all allegations immediately; Determine if abuse, neglect, mistreatment has occurred; and Provide a thorough and complete documentation of the investigation. 1) Resident #42 was admitted to the facility with diagnoses including Peripheral Vascular Disease (PVD), Parkinson's Disease, Depression, Glaucoma. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #42 had severely impaired cognition with short-term memory and long-term memory problem. The resident never/rarely made decisions. The MDS further documented the resident required extensive assistance of two plus persons for bed mobility, total assistance of one person for eating, toilet use and personal hygiene, and total assistance of two plus persons for transfers. On 06/16/23, the complainant reported to the New_York State Department of Health (NYSDOH) Aspen Complaint Tracking System (ACTS) that Resident #42 was observed on 6/15/23 with a bruise that resembled a bite mark on the hand. A nursing progress note dated 06/15/2023 at 08:50 pm documented Resident #42 was awake and tolerated care as per MD's order. The resident's sister informed staff of left arm skin purpura. Nursing supervisor made aware and assessed the resident. The Physician's Assistant (PA) was informed and assessed resident with new orders. X-Ray of left arm and bacitracin regime. All care rendered and tolerated well. All needs were met, and the resident was made comfortable. Safety precaution maintained. Physician Assistant (PA) Medical progress note dated 06/15/2023 documented the resident was seen for follow-up on left forearm abrasion. The resident was seen with family members at bedside. The PA noted a left forearm abrasion with dried blood. The resident also has some mild scratch marks on the dorsum of the resident's forearm. The resident is nonverbal at baseline. The resident is status post history of Parkinson's disease, functional quadriplegia with dysphagia. The resident was unable to talk and communicate. The resident's daughter, also healthcare proxy, was at the visit and communicated on behalf of the patient. The PA ordered an x-ray of the forearm and planned to follow-up on the results. There were no reports of any injuries, falls or traumas. PA ordered bacitracin to be applied ot the affected areas and monitor for improvement. The remainder of the physical exam was unremarkable. Physician orders dated 6/15/2023 documented order for Bacitracin zinc 500 unit/gram topical ointment for Abrasion of left forearm Nursing progress notes dated 06/16/2023 at 04:15 pm documented Resident #42's daughter was called regarding result of X rays of left hand and forearm which showed no acute fractures nor dislocation with soft tissues unremarkable, has moderate Osteoarthritis. Resident on Aspirin. MD progress notes dated 6/16/2023 documented Medical History and Physical/Plan of care Monthly on 06/16/23 Interval History Abrasion / ecchymosis ( open purpura ) L- arm Records reviewed. Patient noted with generalized weakness, needing increased assistance with Activities of Daily Living (ADL). Medial progress note dated 6/17/2023 documented Resident #42 was seen for follow-up on left arm abrasion. The x-rays ordered were negative for any acute process, and there was no fracture or dislocation. The resident continued to receive bacitracin applied to affected area. The family was informed of the results, and all questions were addressed and answered. The abrasion looks more like a purpura bruising. The plan was to continue to monitor. There were no reports of any injuries, falls, or traumas associated with this abrasion. The facility provided no documented evidence that the facility gathered statements from all staff on duty, witnesses, created an Incident report and or conducted a thorough investigation into Resident #42 unwitnessed abrasion to left hand on 6/15/2023. On 07/24/23 at 03:46 PM, and interview was conducted with Certified Nursing Assistant (CNA #2). CNA #2 stated they were assigned to the resident at the time of the incident. CNA #2 stated the resident required total care with all Activities of Daily Living (ADL), with Hoyer lift of two persons for transfer. CNA #2 stated the resident needs to be fed by staff for all meals. On 6/15/2023, CNA #2 saw an ecchymosis area on Resident #42's left hand when they were putting the resident back to bed. CNA #2 stated the area was small but red and blackened at the same time. CNA #2 stated they immediately called the nurse, and the nurse called the supervisor. CNA #2 stated it looked like the discoloration older people get. CNA #2 sated they never saw this before on the resident. CNA #2 stated the resident cannot move thier hands and is not able to scratch themselves because the hands are contracted. CNA #2 stated they did not recall writing a statement about the incident. On 07/24/23 at 02:34 PM, an interview was conducted with Registered Nurse (RN#2) who was the Nursing Supervisor covering the day of the incident. RN #2 stated on 6/15/2023 the family reported a skin purpura to the left arm. RN #2 stated the Physician Assistant assessed the resident and ordered an x-ray and bacitracin to the area. RN #2 stated they called the daughter to explain the x-ray results. On 07/26/23 at 11:43 AM, a follow up interview conducted with RN #2. RN #2 stated the resident was on aspirin which can cause the purpura (red/purplish discoloration) scattered on the left outer aspect of the resident's left wrist. RN #2 stated did not speak to the PA because the PA saw the resident right away. RN #2 stated based on RN #2 nursing knowledge if the resident has a skin tear, an abrasion, a laceration, an incident report will be made. RN #2 stated they were aware the doctor documented an abrasion in the medical record, but RN #2 did not see an abrasion at the time and did not feel the need to do an incident report. RN #2 stated they believed the discoloration was caused by the resident taking aspirin daily and they did not need to do an incident report. RN #2 stated believed this was a Senile Purpura that opened, but they were unable to provide documented evidence of Senile Purpura diagnosis in the resident medical record. During an interview on 07/25/23 at 10:50 AM, RN #1, the nurse supervisor, stated there was no investigation for the discoloration. RN #1 stated the DON informed them there was no incident, and it was purpura because the resident was on aspirin. On 07/24/23 at 02:59 PM, an interview was conducted with Physician Assistant (PA). The PA stated the nurses reported Resident #42 had a discoloration. The PA stated they immediately went and examined the resident and observed an abrasion to the resident's left hand. There was no swelling, teeth marks, indentations, or any indications of a bite mark. The PA stated they ordered an x-ray and blood work with no negative findings. The PA stated it looked like and abrasion with ecchymosis. A fall was ruled out because if the resident fell , it would likely cause significant injuries as the resident would be dead weight. On 07/25/23 at 02:15 PM, an interview was conducted with the Medical Doctor (MD) for the resident. MD stated was aware of the discoloration on the resident hand and did examine the resident. MD stated when examined the resident observed an abrasion on the resident hand. MD stated at the time the resident was on aspirin and agreed to discontinue the aspirin because of the family request. MD stated a Purpura is bleeding under the skin, and an abrasion the cause is different etiology. MD stated an abrasion occurs if for example the resident scratch a purpura and it open then can become an abrasion. MD stated when look at the resident hand at the time when look at the resident the resident had an abrasion, and MD stated was not sure if it was a purpura, or if it was an ecchymosis area that was itched. MD stated a purpura, abrasion scratch all looks similar but is different. MD stated bottom-line the residents who have senile purpura it can be spontaneous, and this happens to people on blood thinner medications, and have fragile skin and this happens mainly in white residents. MD stated bottom line is that the resident had an abrasion or and is not sure what happen. MD stated did speak to the family and let the family know that did not know what happened, but the resident has an abrasion and do not know the cause. MD stated only discontinue the aspirin secondary to the family request and would of convince the family to keep the resident on the aspirin if the resident had heart attacks. MD stated understands the family wants piece of minds and is not sure what happened in this case, and this resident have no diagnosis of senile Purpura. On 07/25/23 at10:59 AM, an interview was conducted with Director of Nursing (DON). The DON stated Resident #42's skin discoloration was reported in the morning report and the resident had Senile Purpura. The DON stated an x-ray and blood work was done, but everything was negative. The DON stated Senile purpura is a medical condition, and the doctor documented open purpura left arm. The DON stated they never did an incident report on senile purpura. Senile Purpura can open without reason and can appear for unknown reasons because the skin is fragile. The DON stated the doctor documented an abrasion, but they believed the wording was incorrect because the resident has a diagnosis of senile purpura. The DON could not show where the diagnosis of senile purpura was documented in the medical record. The DON stated they did not take statements from staff, initiate and investigation, or report the injury to DOH because they were informed the resident had senile purpura in the morning meeting which does not warrant an investigation. 2) Resident # 155 was admitted to the facility with diagnoses that included Vascular dementia, Other seizures, and Weakness. The Admission Minimum Data Set (MDS) dated [DATE] documented Resident # 155 was severely impaired in cognition, had no rejection of care or wandering behavior, did not walk, and was total dependence with 1 person for locomotion on/off unit. It also documented Resident # 155 was frequently incontinent in bladder and bowel. It further documented Resident # 155 had no fall history. It documented only the representative participated in the assessment. On 07/19/23 at 11:02 AM, the representative was interviewed and stated they observed Resident # 155 had black left eye during their visit on 2/5/23. The nursing note dated 2/5/23 documented Resident # 155 woke up with bruise under left side eye. It also documented the bruise was from unknown source. Review of progress notes from 2/5/23 to 2/9/23 in the electronic medical record (EMR) system and the hard copy chart revealed no documented evidence that the facility investigated for this alleged violation. On 07/24/23 at 10:12 AM, the Registered Nurse (RN) # 4 was interviewed and stated they reported to Director of Nursing (DON) immediately if there was something happened to resident on the unit. The RN # 4 also stated the bruise around the left eye observed for Resident # 155 on 2/5/23 was considered injuries of unknown source as Resident # 155 was very confused and not able to tell what happened and no one witnessed what happened. The RN # 4 further stated they knew they had to report to DON immediately for the investigation to rule out abuse. The RN # 4 stated they did not remember if they notify DON or any other responsible person about the bruise on left eye for Resident # 155 on 2/5/23. On 07/24/23 at 10:36 AM, the Director of Nursing (DON) was interviewed and stated they made rounds to the unit at least 1 time for the day shift and another time for the evening shift. The DON also stated they spoke to the staff, observed resident care, and checked for environment during the rounds. The DON also stated the nurse supervisors on the units reported to them if there was something happened to the residents. The DON stated they were not aware that Resident # 155 was observed having bruise around left eye on 2/5/23. The DON also stated they had to conduct the investigation for this alleged violation as Resident # 155 was not able to verbalize and no one witnessed what happened causing the bruise around Resident # 155's left eye. The DON was not able to explain what happened causing the investigation was not conducted for the alleged violation. 415.4 (b) (3) 44843

Based on record review and interviews conducted during the Recertification survey from 7/19/2023 to 7/26/2023, the facility did not ensure Minimum Data Set (MDS) 3.0 assessment was completed within 14 days of admission. This was evident for Resident #157 reviewed for Resident Assessment out of 38 total sampled residents. Specifically, Resident #157's admission MDS was not completed within 14 days of their admission to the facility. The findings are: The facility policy titled Submission and Correction of the MDS Assessments dated 1/19/2023 documented the MDS completion date for admission assessments must be no later than 13 days after the entry date. Resident # 157 was admitted to the facility on [DATE] with diagnoses of sepsis and metabolic Encephalopathy. The Admission MDS assessment for Resident #157 had an assessment reference date of 1/31/2023 and a completion date of 3/5/2023, more than 14 days after admission. On 07/25/23 at 11:37 AM, the MDS Coordinator (MDSC) was interviewed and stated they were responsible to monitor the completion and submission of MDS and they had to complete the Admission MDS assessment within 14 days of resident's admission to the facility. The MDSC stated they checked the dashboard of the electronic medical record (EMR) every day to monitor if any MDS assessment was due for completion and submission. The MDSC stated they were not working at the facility in January 2023, but they do know there was a staffing shortage in the Social Work Department at the time that caused a delay in Resident #157's admission MDS being completed. On 07/25/23 at 11:52 AM, the Administrator was interviewed and stated there was a change in ownership of the facility in the beginning of the year and some staff left the facility. This caused a gap in having adequate social workers to complete their respective sections in MDS assessment. The MDSC reported to them, and they were aware that one Admission MDS assessment was completed late for Resident #157. 415.11(a)(3)(iii)

Based on record review and staff interview conducted during the Recertification survey from 07/19/2023 to 07/26/2023, the facility did not ensure the resident and their representatives were provided with a written summary of the baseline care plan (BCP). This was evident for 2 (Resident #43 and #387) of 38 total sampled residents. Specifically, 1) Resident #43's representative was to provide with a copy of the BCP and, 2) Resident #387 was not provided with a copy of their BCP. The findings are: The facility policy titled Care Plans - Baseline dated 01/2023 documented the resident and their representative will be provided a summary of the baseline care plan. 1) Resident #43 had diagnoses of cerebral infarction and schizoaffective disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #43 had severely impaired cognition , did not participate in the assessment, and the resident's family or significant other participated in the assessment and goal setting. On 07/25/2023 at 4:10 PM, Resident #43's representative was interviewed and stated they have yet to attend a CCP meeting on Resident #43's behalf. Resident #43's representative stated they did not receive a copy of the resident's BCP. The BCP dated 2/14/2023 did not document a signature from Resident #43's representative confirming receipt of the BCP. There was no documented evidence a copy of the BCP was provided to Resident #43's representative. On 07/26/2023 at 12:12 PM, the Director of Social Work (DSW) was interviewed and stated the Social Work (SW) Department is responsible for printing out the BCP and giving it to the resident and putting a copy of the BCP in the resident's chart. Either the SW or the nurses give the BCP to residents within 48 hours of admission to the facility so residents can understand their care they will be getting. 44843 2) Resident # 387 had diagnoses of endocarditis and heart valve disorders. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident # 387 was cognitively intact and participated in the assessment. On 07/19/23 at 11:32 AM, Resident # 387 was interviewed and stated they were admitted to the facility 6/23/2023 and have not received a copy of their BCP. The BCP for Resident #387 was initiated 6/23/2023 and completed 6/25/2023. The BCP was not signed by Resident #387 or their representative confirming receipt of the BCP. There was no documented evidence Resident #387, and their representative received a copy of the BCP. On 07/24/23 at 11:45 AM, Registered Nurse (RN) # 5 was interviewed and stated the admission nurse initiates the BCP and each department completes their respective section within 48 hours of admission. The Social Worker (SW) is responsible for overseeing the completion of the BCP and providing a copy of the BCP to the resident and their representative. The SW then documents in the medical record that a copy of the BCP was given. On 07/24/23 at 02:06 PM, the Director of Social Work (DSW) was interviewed and stated they were assigned to Resident #387 and should have provided the resident with a copy of their BCP because Resident #387 is cognitively intact. The DSW was unable to find documented evidence the BCP was provided to Resident #387 and stated it should be documented in the resident's medical record once the BCP is provided. The DSW stated they forget to document in the medical record when they distribute the BCP. On 07/26/2023 at 02:06 PM and 04:18 PM, the Director of Nursing (DON) was interviewed and stated the SW speaks with the resident's family upon admission so nursing can gather the information for the BCP. Nursing issues the BCP to the resident's family or resident based on the SW follow up with the resident, resident's condition, family preference, and whether the resident is alert. Sometimes the resident is not cognizant, and staff try to give the BCP to the resident or their representative within 48 hours of admission, but sometimes this does not happen. 415.11 (c)

Based on observations, interviews, and record review conducted during the recertification survey from 7/19/2023 to 7/24/2023, the facility did not ensure an effective discharge planning process was developed and implemented. This was evident for 1 (Resident #82) of 3 residents reviewed for Discharge out of 38 total sampled residents. Specifically, documents needed for discharge planning were not submitted to another facility per Resident #82's request. The findings are: The policy titled Discharging the Resident dated 1/2023 documented the facility will facilitate a safe discharge for the residents. Resident #82 had diagnoses of peripheral venous insufficiency and opioid dependence. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #82 was cognitively intact, participated in the assessment, expected to be discharged to the community, and discharge planning was in progress. During the interview on 7/19/23 at 11:57 AM, Resident #82 stated they requested a transfer to another facility and did not receive a follow up response from the Social Worker (SW). The Comprehensive Care Plan (CCP) related to Resident #82's return to the community and discharge potential was initiated 2/20/2023, last reviewed 7/2/2023, and documented to allow the resident to ventilate feelings regarding interest in returning to community, assess for support system/community resources, invite the resident to attend CCP meeting, and educate the resident regarding safe discharge/community resources available. The SW Note dated 10/25/2022 documented Resident #82 wishes to return to the community upon discharge and the discharge plan is for the resident to return to a shelter. The Physician's Note dated 5/31/2023 documented Resident #82 was medically cleared for upcoming discharge planning. The SW Note dated 6/30/2023 documented Resident #82 requested discharge documents be sent to an alternate facility. Paperwork pending. There was no documented evidence a Resident #82's requested discharge documents were sent to an alternate facility of the resident's choosing. During an interview on 7/24/23 at 9:21 AM and 3:17 PM, the Director of Social Work (DSW) stated Resident #82's paperwork was already sent to multiple facilities the previous month. There have been staffing shortages and the DSW has not been able to follow up with the other facilities for Resident #82. After following up with the alternate facilities, DSW stated Resident #82's paperwork was never received by any of the resident's chosen facilities. 415.11(d)(3)

Based on observation, record review, and interviews conducted during the Recertification survey from 07/19/2023 to 07/26/2023, the facility did not provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This was evident for Resident #95 reviewed for Activities out of 38 total sampled residents. Specifically, Resident #95 was not provided with television (TV) stations in their preferred language. The findings are: The facility policy titled Activity Evaluation dated 1/2023 documented the activity evaluation is conducted to help develop an activity plan that reflects the choices and interests of the residents. Preferences are included in the evaluation. The facility policy titled TV Channel dated 3/20/2018 documented the facility offered regular TV channels (2-21), two Spanish channels, and one movie channel (6). Resident # 95 had diagnoses of cerebral infarction and unspecified dementia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #95 had moderately impaired cognition, was usually able to make themselves understood, and was usually able to understand others. The MDS documented Resident #95 found it important to do their favorite activities and only the resident's representative participated in the assessment. On 07/19/2023 at 11:41 AM, Resident # 95 was interviewed and stated their primary language is Fuzhouese and they prefer TV stations in their language. Resident # 95 stated staff have not asked them about their activity preferences and Resident #95 is taken to the dining room for most of the day. Resident # 95 used to watch TV stations in their language when they were living in the community. On 07/19/2023 at 11:58 AM, Resident # 95 turned on the TV in their room to check all channels available. The TV channels available were observed to be in English and Spanish only. From 07/19/2023 at 11:41 AM to 7/26/2023 at 09:46 AM, there were multiple observations of Resident #95 in their wheelchair in the dining room or hallway with no ongoing activities and the TV in their room was turned to a station in English. The Comprehensive Care Plan (CCP) related to activities initiated 2/14/2023 and last updated 7/19/2023 documented Resident #95 will be assisted as needed to the recreation program of interest, educated re: available recreation programs, and provided one-to-one visits based on the resident's available time and energy. The Recreation assessment dated [DATE] documented Resident # 95's primary language was Mandarin, an interpreter was required for the assessment, Resident #95 enjoyed watching TV in the dayroom. The Recreation assessment dated [DATE] documented Resident #95 liked to watch TV and listen to music. There was no documented evidence Resident #95's preference to watch TV in a language they understand was established. On 07/24/2023 at 11:58 AM, Certified Nursing Assistant (CNA) # 8 was interviewed and stated Resident # 95 was not English or Spanish speaking, and they used sign language for communication. Resident # 95 mainly sits in their wheelchair in the dining room or wheels themselves in the hallway. Resident #95 also did some painting or participated in some group activities in the dining room if they liked. CNA # 8 stated the TV channels in the facility were either in English or Spanish. Resident # 95 does not watch TV in their room. On 07/24/2023 at 02:20 PM, Recreation Aide (RA) #1 was interviewed and stated they conducted the activity assessment for Resident # 95 by calling the family members, using the language line, and having staff interpret because Resident #95 was not English speaking. Resident #95's preference is to watch TV. RA #1 did not ask Resident # 95 or their representative what language TV channels Resident # 95 preferred to watch and did not offer the TV channels in Resident # 95's preferred language. The facility only offers Spanish and English channels and Resident #95 does not understand English or Spanish. RA #1 stated they should establish Resident #95's TV channel preferences. On 07/24/23 at 02:44 PM, the Recreation Director (RD) was interviewed and stated the facility currently offers TV channels in English and Spanish. The facility is working on providing TV channels in different languages. The RD stated they do not recall the Resident #95's primary language. Resident #95's family members visit often and have never requested for Resident #95 to have TV channels in their language. The RD stated they did not ask Resident #95 what their language preference was for their TV channels. 415.5(f)(1)