Every finding on record at Excel At Woodbury for Rehabilitation and Nursing,

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 7/15/2025 and completed on 7/22/2025, the facility did not ensure that drugs and biologicals were stored in a locked compartment. This was identified for one (Resident #7) of three residents reviewed for Accidents. Specifically, Resident #7 was observed with a tube of Lidocaine (a topical anesthetic that provides temporary pain relief by numbing the applied area) 5 percent ointment on Resident #7's overbed table. Additionally, there was an open storage box on top of Resident #7's overbed table containing two bottles of unlabeled glucose 4-gram tablets (treat low blood sugar). There was no Nursing staff in the vicinity of Resident #7's room. Resident #7 was not assessed to administer their medications. The finding is:The facility's undated policy titled Storage of Medications documented that compartments containing drugs shall be locked when not in use. These include drawers, cabinets, refrigerators, carts, and boxes. Drugs for external use shall be stored separately from regular medications and shall be labeled for external use only on the medication container. No discontinued, outdated, or deteriorated drugs or medications shall be stored in the facility. All drugs not used shall be destroyed in accordance with established policies and returned to the issuing Pharmacy for credit. Resident #7 was admitted with diagnoses including Type 2 Diabetes, Chronic Obstructive Pulmonary Disease (COPD), and Chronic Kidney Disease. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated that Resident #7 had intact cognition. The Quarterly Minimum Data Set assessment documented that Resident # 7 received a scheduled pain medication regimen. The Quarterly Minimum Data Set assessment documented Resident #7 had an indwelling catheter (a flexible tube inserted into the bladder to drain urine). A Physician's order dated 12/7/2024 documented Acetaminophen 325 milligrams, 2 tablets every 6 hours as needed for Pain. A Physician's order dated 12/13/2024 documented Lidocaine 5 percent ointment applied to the tip of the penis twice a day PRN (as needed). The order was discontinued on 5/16/2025. A review of Resident #7's Electronic Medical Record revealed no order for Glucose 4-gram tablets. A review of Resident #7's Electronic Medical Record revealed that Resident #7 did not have an assessment to self-administer any of their medications. A Pain assessment dated [DATE] documented that Resident #7 was at risk for pain and had a history of pain. The Pain Assessment documented that Resident #7 had no current complaint of pain. A Comprehensive Care Plan (CCP) titled Diabetes, dated 12/8/2024, documented interventions including the administration of medication and observing signs and symptoms of hypoglycemia (low blood sugar), including sweating, pallor (abnormal paleness), chills, weakness, anxiety, and lethargy (state of fatigue, drowsiness, and lack of energy). A Comprehensive Care Plan (CCP) titled Pain, dated 12/18/2024, documented interventions including the administration of medication and monitoring the effectiveness of medications. During an observation on 7/15/2025 at 10:11 AM, Resident #7 was in bed with an overbed table in front of them. A labeled Lidocaine 5 percent tube of ointment was observed on top of the overbed table next to a transparent, half-opened plastic container. The plastic container was observed with two unlabeled bottles containing glucose tablets. There was no Nurse within the vicinity of Resident #7's room. Resident #7 stated that the Lidocain ointment was being applied by the Nurses to their back with each incontinence change. Resident #7 stated that the glucose tablets were brought from home, and they had never used them at the facility. During an interview on 7/15/2025 at 10:30 AM, the Assistant Director of Nursing Services, who was also the Medication Nurse, stated that Resident #7 should not have any medications stored in their room. The Assistant Director of Nursing Services stated that Lidocaine ointment was discontinued back in May 2025 and was ordered for Foley Catheter changes. The Assistant Director of Nursing Services stated they did not know the resident had glucose tablets stored in their room. During an interview on 7/16/2025 at 2:21 PM, Registered Nurse #1, Unit Manager, stated that Resident #7 should not have had any discontinued medications stored in their room. Registered Nurse #1 stated they did not initiate a self-administer medication assessment before because they (Nurses) did not know that Resident #7 had medications stored in their room that were brought from home. During an interview on 7/18/2025 at 12:53 PM, the Director of Nursing Services stated the facility staff should be observant of their environment, and any medications found in the resident's room should be reported and taken out. The Director of Nursing Services stated that the facility accommodated any request for self-administration of medication from residents after the residents were assessed for their cognitive ability, physical capability, and medication knowledge. The Director of Nursing Services stated that Resident #7 should not have any medications in their room, and if Resident #7 requested to self-administer any of their medication, the facility staff would have initiated a self-administration assessment. 10NYCRR 415.18(e) (1-4)

Based on observation, record review, and interviews during the Recertification Survey initiated on 7/15/2025 and completed on 7/22/2025, the facility did not ensure that it developed and implemented a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs for one (Resident #82) of two residents reviewed for Skin Conditions and one (Resident #64) of one resident reviewed for Edema. Specifically, 1) Resident #82 was admitted to the facility with a condition identified by the Physician as possible Melanoma (the most serious form of skin cancer). The location of the skin lesion was not identified in the medical record, and a comprehensive care plan was not created with nursing interventions for monitoring and care; and 2) Resident #64 had a Physician Order for an Ace wrap (a compression or elastic bandage that provides support and compression to an area of the body) to lower legs bilaterally (both) once daily for Lymphedema (tissue swelling caused by accumulation of protein-rich fluid). There was no care plan developed to address Resident #64's use of the Ace wrap and Lymphedema of both the lower extremities. The findings are: The facility's policy titled Comprehensive Care Plans and Resident/Patient Meeting, dated 4/2025, documented within 14 days of the resident's admission, a comprehensive assessment of the resident's needs will be prepared and developed by the interdisciplinary team; the purpose of the assessment is to accurately communicate the resident's capability to perform daily life functions and to identify significant impairment(s) in functional capacity and the plan suggested by the team for improvement/maintenance for each of the resident's primary care issues. Information obtained from the comprehensive assessment and staff interviews enables the facility staff to plan care that focuses on the resident's ability to achieve their highest practicable mode of functioning, which includes but is not limited to the following: Medically defined condition(s) and past medical history. 1) Resident #82 was admitted with diagnoses including Cerebrovascular Accident, Colon Cancer, and Muscle Wasting. The 5/28/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 11, indicating the resident had moderate cognitive impairment. There was no documentation of ulcers, wounds, or skin problems. The Nursing admission assessment dated [DATE] documented the resident had a scabbed area at the top of their head. The Physician #1 admission Note dated 5/28/2025 documented possible Melanoma under current diagnoses and in past medical history. During an interview on 7/16/2025 at 9:42 AM, Resident #82 was in their room in a wheelchair. The resident had a dry dressing on top of their head. The resident stated they have many scabs on their head, and they pick at them. The resident stated they had seen a Dermatologist prior to coming to the facility and were diagnosed with skin Cancer. A review of the medical record revealed no Comprehensive Care Plan for the skin lesions, scabs, or possible Melanoma on the resident's head, no order for the dry dressing, and no order for monitoring the skin lesions. During an interview on 7/16/2025 at 10:20 AM, Registered Nurse #2 and Registered Nurse #3 (both unit Managers) stated they did not know who put the dressing on Resident #82's head. They stated there was no current order for the dressing and there was no care plan for the lesions on the resident's head. A physician's order dated 7/16/2025 at 10:44 AM documented to put a dry protective dressing on the right parietal scalp to protect the dry scab for prophylactic measures. A comprehensive care plan was added effective 7/16/2025, titled Skin Integrity-Actual Impairment, Dry Scab on the Scalp. Interventions include monitoring for skin changes and a Dermatology consult. The care plan does not indicate that the scab was possibly a Melanoma; there were multiple scabs on the resident's head, and the resident had a behavior of picking the scabs on their head. During an interview on 7/16/2025 at 1:32 PM, Physician #1 stated they were not sure if the resident had Melanoma, and they were monitoring the resident. Physician #1 stated they could not recall the location of the resident's lesions without reviewing their notes. During a re-interview on 7/16/2025 at 1:37 PM, Registered Nurse #2 stated they were not sure of the location of the possible Melanoma and would have to clarify with the Physician. A nursing progress note dated 7/16/2025 at 1:55 PM, written by Registered Nurse #2, documented they spoke with Physician (#1) and clarified that the possible Melanoma was on the resident's right parietal scalp (located at the top and back of the skull). A dermatology consultation was ordered for further evaluation. During a re-interview on 7/21/2025 at 10:25 AM, Registered Nurse #2 stated the possible Melanoma was being monitored by the nurses daily and by the Certified Nursing Assistants on shower days during skin checks. Registered Nurse #2 further stated that they just added the care plan for Skin Integrity-Actual Impairment, which should indicate possible Melanoma. During a re-interview on 7/21/2025 at 10:52 AM, Physician #1 stated the location of the possible Melanoma was on top of the resident's head, and the nurses should be monitoring the resident's scalp for any changes in the lesions. A review of the medical record revealed no documented evidence before 7/16/2025 that the lesions on top of the resident's head were being monitored. During an interview on 7/21/2025 at 2:00 PM, Licensed Practical Nurse #1 stated on 7/16/2025, the resident requested the nurse to put a dressing on the resident's head because the scab was very itchy. Licensed Practical Nurse #1 stated they placed a dry dressing as per the resident's request and told Registered Nurse #2; however, they did not add a progress note or get an order for the dressing. A physician's order dated 7/21/2025 at 2:01 PM documented to obtain a dermatology consultation for 7/22/2025. During an interview on 7/22/2025 at 9:07 AM, Licensed Practical Nurse/Wound Care Nurse/Assistant Director of Nursing Services #1 stated that a care plan did not have to be put in because there was no definite diagnosis of Melanoma. The staff can not put a care plan for every resident who has a scab. The possible Melanoma did not require any special focus care planning. During an interview on 7/22/2025 at 9:45 AM, the Director of Nursing Services stated the lesion on the resident's head was just a scab when the resident was admitted , so there was no need for a care plan. The possible Melanoma was not an official diagnosis, and skin monitoring is completed during the skin checks; therefore, any special focus care planning was not required. 2) Resident #64 was admitted with diagnoses including Lymphedema, Asthma, and Anemia. The Quarterly Minimum Data Set (MDS) assessment completed on 5/2/2025 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated that Resident #64 had intact cognition. The Quarterly Minimum Data Set assessment documented an active diagnosis of Lymphedema. A Physician's Order dated 6/29/2025 documented Ace wrap to bilateral(both) lower legs daily for Lymphedema. A review of Resident #64's electronic medical record revealed no care plan indicating individualized goals and interventions for Lymphedema, and for the use of the Ace wrap or the compression stocking on both legs until 7/18/2025. During an observation on 7/15/2025 at 10:41 AM, Resident #64 was in bed and wearing the compression stockings on bilateral lower legs. Resident #64 stated they had Lymphedema and always needed the compression stockings. During an interview on 7/17/2025 at 3:26 PM, Registered Nurse #1, Unit Manager, stated there was no care plan developed to address Resident #64's Lymphedema, and the use of Ace wrap or compression stockings. Registered Nurse #1 further stated a care plan with individual goals and interventions should have been developed to address use of the Ace wrap or compression stocking for Lymphedema. During an interview on 7/17/2025 at 4:08 PM, the Assistant Director of Nursing Services stated a care plan should have been developed to address the resident's skin integrity, Lymphedema, and use of compression stockings. During an interview on 7/18/2025 at 1:20 PM, the Director of Nursing Services stated they expect all care plans to be updated to address the resident's individual needs. 10 NYCRR 415.11(c)(1)

Based on record review and staff interviews during the Recertification Survey initiated on 7/15/2025 and completed on 7/22/2025, the facility did not ensure that all completed Minimum Data Set assessments were electronically transmitted to the Center for Medicare and Medicaid Services within 14 days of the resident assessment completion. This was identified for one (Resident #44) of six residents reviewed for the Resident Assessment Task. Specifically, Resident #44's Quarterly Minimum Data Set assessment dated [DATE] and Annual Minimum Data Set assessment dated [DATE] were transmitted more than 14 days after the assessment completion date. Additionally, there was no documented evidence that Resident #44's Significant Change in Status assessment dated [DATE] was transmitted to the Center for Medicare and Medicaid Services. The finding is:The facility's policy and procedure titled Minimum Data Set 3.0, last revised 4/25/2025, documented that all Minimum Data Set assessments will adhere to the guidelines set forth by the Center for Medicare and Medicaid Services (CMS) and the New York State Department of Health. Each department is expected to complete its assigned responsibilities no later than 14 days from the Assessment Reference Date (ARD) and/or a completion date set by the facility's Minimum Data Set Coordinator as per the regulatory guidelines. The policy did not document the procedure related to the transmission of any Minimum Data Set assessments.Resident #44 was admitted with diagnoses including Metabolic Encephalopathy, Dementia, and Dysphagia. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #44 had a Brief Interview for Mental Status score of 7, which indicated the resident had moderate cognitive impairment. The Quarterly Minimum Data Set assessment dated [DATE] was completed on 6/6/2024. A review of the Minimum Data Set 3.0 Nursing Home Validation Reports provided by the facility revealed the following:Resident #44's Quarterly Minimum Data Set assessment with the assessment reference date of 5/23/2024 was completed on 6/6/2024 and electronically transmitted to the Center for Medicare and Medicaid Services on 6/24/2024, 4 days past the due date of 6/20/2024.The message on the report indicated that the record was submitted late: the submission date was more than 14 days after the assessment completion date.Resident #44's Annual Minimum Data Set assessment with the reference date of 10/3/2024 was completed on 11/13/2024 and electronically transmitted to the Center for Medicare and Medicaid Services on 12/27/2024, 30 days past the due date of 11/27/2024. The message on the report indicated that the record was submitted late: the submission date was more than 14 days after the assessment completion date.Resident #44's Significant Change in Status Minimum Data Set (MDS) assessment, dated 3/10/2025, was completed on 3/14/2025; however, there was no documented evidence that the assessment was electronically submitted to the Centers for Medicare and Medicaid Services within 14 days of the assessment completion date.During an interview on 7/18/2025 at 11:19 AM, the Minimum Data Set Coordinator stated they were responsible for ensuring Minimum Data Set assessments were submitted on time. The Minimum Data Set Coordinator stated that all Minimum Data Set assessments should be transmitted to the Centers for Medicare and Medicaid Services within 14 days of completion. The Minimum Data Set Coordinator stated Resident #44's Quarterly Minimum Data Set assessment, dated 5/23/2024, was completed on 6/6/2024 and should have been transmitted by 6/20/2024. The Annual Minimum Data Set assessment, dated 10/3/2024, was completed on 11/13/2024 and should have been transmitted by 11/27/2024. The Significant Change in Status Minimum Data Set assessment, dated 3/10/2025, was completed on 3/14/2025 and should have been transmitted by 3/28/2025. The Minimum Data Set Coordinator stated there were significant changes to the Resident Assessment Instrument process back in October 2024, which impacted the timeliness of transmission. The Minimum Data Set Coordinator stated they had encountered technical difficulties on occasion when assessments were electronically submitted to the Center for Medicare and Medicaid Services. The Minimum Data Set Coordinator stated they did not verify whether the assessments were transmitted timely and successfully because the facility's electronic program, which was used to track assessment transmission, did not issue any alerts. During an interview on 7/18/2025 at 12:52 PM, the Director of Nursing Services stated they were not familiar with the timeframe requirements for the transmission of Minimum Data Set assessments. The Director of Nursing Services stated that the Minimum Data Set Coordinator should ensure that the Minimum Data Set assessments are transmitted within the regulatory timeframe.During an interview on 7/18/2025 at 2:17 PM, the Administrator stated they were not familiar with the timeframe requirements for the transmission of Minimum Data Set assessments. The Administrator stated they expected the Minimum Data Set assessments to be transmitted within the regulatory timeframe. The Administrator stated they were not aware that Resident #44's Minimum Data Set assessments were not transmitted on time. The Administrator stated that the Minimum Data Set Coordinator did not report to the Administrator. The Administrator stated that the Minimum Data Set Coordinator reported to the Corporate Minimum Data Set Coordinator, who was responsible for overseeing the Minimum Data Set transmission process and providing guidance and support. 10 NYCRR 415.11

Based on record review and interviews during the Recertification Survey initiated on 7/15/2025 and completed on 7/22/2025, the facility did not ensure all comprehensive resident assessments were completed according to the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, including the Minimum Date Set assessment completion date must be no later than 14 days after the Assesssment Reference date. This was identified for one (Resident #44) of six residents reviewed for the Resident Assessment Task. Specifically, Resident #44's Annual Minimum Data Set assessment, with Assessment Reference Date of 10/3/2024, was not completed until 11/13/2024, 27 days after the completion due date.The finding is:The facility's policy and procedure titled Minimum Data Set 3.0, last revised 4/25/2025, documented that all Minimum Data Set assessments will adhere to the guidelines set forth by the Center for Medicare and Medicaid Services (CMS) and the New York State Department of Health. Each department is expected to complete its assigned responsibilities no later than 14 days from the Assessment Reference Date (ARD) and/or a completion date set by the facility's Minimum Data Set Coordinator as per the regulatory guidelines.Resident #44 was admitted with diagnoses including Metabolic Encephalopathy (a series of neurological disorders that affect the brain), Dementia, and Dysphagia. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 11, indicating the resident had moderate cognitive impairment.The Annual Minimum Data Set, with an assessment reference date of 10/3/2024, was documented as completed on 11/13/2024, which was 27 days past the completion due date of 10/17/2024.During an interview on 7/18/2025 at 11:19 AM, the Minimum Data Set Coordinator stated they were responsible for the timely completion of Minimum Data Set assessments. The Minimum Data Set Coordinator stated Resident #44's Minimum Data Set assessment dated [DATE] should have been completed on or before 10/17/2024,14 days after the assessment reference date. The Minimum Data Set Coordinator stated they might have selected the wrong completion date (11/13/2024) and did not realize the mistake. During an interview on 7/18/2025 at 12:52 PM, the Director of Nursing Services stated they were not familiar with the timeframe requirements for the completion of Minimum Data Set assessments. The Director of Nursing Services stated that the Minimum Data Set Coordinator should ensure that the Minimum Data Set assessments are completed within the regulatory timeframe.During an interview on 7/18/2025 at 2:17 PM, the Administrator stated they were not familiar with the timeframe requirements for the completion of Minimum Data Set assessments. The Administrator stated they expected the Minimum Data Set assessments to be completed within the regulatory timeframe. The Administrator stated they were not aware that Resident #44's Minimum Data Set assessment was not completed on time. The Administrator stated that the Minimum Data Set Coordinator did not report to the facility Administrator. The Administrator stated that the Minimum Data Set Coordinator reports to the Corporate Minimum Data Set Coordinator, who was responsible for overseeing, providing guidance, and support related to Minimum Data Set assessments.10 NYCRR 415.11(a)(3)(i)

Based on observation, record review, and interviews during the Recertification Survey initiated on 4/16/2024 and completed on 4/23/2024, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified for one (Resident #312) of four residents reviewed for medication administration. Specifically, during the medication pass observation on 4/17/2024 for Resident #312, the labels on the medication blister packs, for physician-prescribed Allopurinol (a medication to reduce uric acid to treat gout and kidney stones) and Torsemide (a diuretic to help reduce fluid in the body), did not match the physician orders. The finding is: The facility's policy titled, Pharmacy, dated June 2018, documented the facility utilizes its pharmaceutical services system to ensure the safe and effective use of medications for all our residents; this facility does not have an in-house pharmacy; this facility uses a blister pack system; Medications no longer in use shall be returned for credit or destroyed in accordance with established policies and procedures. The facility's policy titled, Medication: Administration-General dated December 2021, documented the nurse will review the physician's orders and compare them against the medication administration record. Compare the medication name, strength, and dosage schedule on the medication administration record against the prescription label. Resident #312 was admitted with diagnoses including Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Peripheral Vascular Disease. The 4/9/2024 nursing admission assessment documented that the resident was alert to person, place, time, and situation. A physician's order dated 4/11/2024 documented Allopurinol, 100 milligrams tablet, give 2 tablets (200 milligrams) by oral route once daily at 8:00 AM for a diagnosis of Gout. A physician's order dated 4/11/2024 documented Torsemide 20 milligrams tablet, give 1 tablet (20 milligrams) by oral route once daily at 8:00 AM for diagnosis of Hypertension. During the medication pass observation for Resident #312, performed by Licensed Practical Nurse #1, on 4/17/2024 at 8:34 AM, the blister pack label for Allopurinol documented 100 milligrams tablet, give one tablet every 12 hours. The delivery date on the blister pack was 4/9/2024. The blister pack label for Torsemide documented 20 milligrams tablet, give two tablets by mouth daily. The delivery date on the blister pack was 4/10/2024. Licensed Practical Nurse #1 acknowledged the blister pack labels did not match the physician's orders and would report this to the supervisor. Licensed Practical Nurse #1 administered the medications as per the physician's order. Licensed Practical Nurse #1 was re-interviewed on 4/17/2024 at 10:48 AM and stated if there was a discrepancy between the physician's order and the medication label, they would report the discrepancy to the nursing supervisor and the supervisor would contact the pharmacy. Licensed Practical Nurse #1 stated they have not reported the discrepancy to the supervisor yet. Registered Nurse Supervisor #1 was interviewed on 4/17/2024 at 10:50 AM regarding the observed discrepancy between the physician order and the blister pack labels. Registered Nurse Supervisor #1 stated when there is an order change, the pharmacy is supposed to send a new blister pack; when there is a change in the physician's orders the facility does not use see the medication administration record labels to be put on a blister pack to indicate changes in the physician's orders. Registered Nurse Supervisor #1 stated if the pharmacy does not send the new blister pack, the facility staff should follow up with the pharmacy. Registered Nurse Supervisor #1 stated the medication nurses have to bring the discrepancy to their attention and they would then call the pharmacy. An email correspondence with pharmacy representative #1 dated 4/17/2024 at 1:10 PM documented, an every-12-hour Allopurinol order blister pack was last provided on 4/9/2024; the order was changed to once a day on 4/11/2024 and the facility was expected to use the supply on hand. A new supply blister pack of Torsemide was delivered on 4/12/2024 that matched the physician's order. Registered Nurse Supervisor #1 was re-interviewed on 4/17/2024 at 2:01 PM and stated the facility just received stickers to put on the medication label that document: see the medication administration record. Registered Nurse Supervisor #1 stated Putting stickers on a blister pack is new to me. Registered Nurse Supervisor #1 stated the sticker will be placed on the Allopurinol blister pack. Regarding the Torsemide, Registered Nurse Supervisor #1 stated they were not aware that a new supply for Torsemide was delivered on 4/12/2024. Registered Nurse Supervisor #1 and Licensed Practical Nurse #1 checked the medication cart and found the not-yet-started Torsemide blister pack that was delivered on 4/12/2024. The Director of Nursing Services was interviewed on 4/18/2024 at 8:04 AM and stated they were not sure of the facility's policy regarding when there is a discrepancy between the physician's order and the medication label; however, they thought the nurses should put a see the medication administration record label on the medication when a physician's order is changed and the medication supply on hand has to be utilized or reach out to the pharmacy to rectify the discrepancy. 10 NYCRR 415.18(e) (1-4)

Based on observations, record review, and interviews during the Recertification Survey initiated on 4/16/2024 and completed on 4/23/2024, the facility did not ensure that a comprehensive person-centered care plan was implemented for each resident that includes measurable objectives and timeframes to meet resident's medical and nursing needs. This was identified for one (Resident #16) of one resident reviewed for position and mobility. Specifically, Resident #16 had a physician's order for a hip abduction flexion contracture cushion (abduction pillow) to be worn at all times. During observations on 4/17/2024 at 9:00 AM and on 4/19/2024 at 9:00 AM Resident #16 was observed in bed without a hip abduction flexion contracture cushion. The finding is: The facility's policy titled, Assistive Devices last revised 11/2022 documented nursing staff is responsible for ensuring the wearing schedule for assistive devices is followed. Conduct skin inspection at a minimum every shift unless otherwise ordered. Nursing or any other clinical discipline shall report any adverse reaction from the assistive device such as redness, discomfort, discoloration, excoriation, etc to the Occupational or Physical Therapist. Resident #16 was admitted with diagnoses including a Fracture of the Left Femur, Dementia, and Cardiomyopathy. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 3, indicating the resident had severe cognitive impairment. The Minimum Data Set documented the resident had functional limitations in the range of motion to both lower extremities. The Comprehensive Care Plan (CCP) titled, Fracture of Left Hip dated 6/02/2023 documented interventions including a hip abduction pillow to be worn as tolerated for positioning and to prevent contractures. The hip abduction pillow is to be removed for skin checks and hygiene. The Physical Therapist's Evaluation and Plan of Treatment dated 8/11/2023 documented the resident maintains their hip in an adducted and flexed position requiring the need for a hip abduction wedge for positioning. The Physical Therapist's Discharge Summary dated 8/31/2023 documented a recommendation for a hip abduction flexion contracture cushion while in bed and to remove it for skin checks and hygiene. The Comprehensive Care Plan titled, Activities of Daily Living effective 9/01/2023 documented an intervention for the placement of a pillow between knees when in bed for comfort as tolerated. A Physician's order dated 2/20/2024 and last renewed on 4/05/2024 documented the hip abduction flexion contracture cushion to be worn at all times in bed and the Geri chair; remove for skin checks/hygiene. On 4/17/2024 at 9:00 AM, Resident #16 was observed curled up in bed. The resident was not wearing the hip abduction flexion contracture cushion. On 04/19/2024 at 9:00 AM, Resident #16 was observed in bed with no hip abduction flexion contracture cushion in place. Certified Nursing Assistant #2 was interviewed on 04/19/2024 at 9:04 AM and stated that Resident #16 often removes and puts the hip abduction flexion contracture cushion on the floor. The Certified Nursing Assistant located the hip abduction flexion contracture cushion in Resident #16's closet. The Certified Nursing Assistant stated the hip abduction flexion contracture cushion was on the floor when they came in to provide care and they put the hip abduction flexion contracture cushion in the closet. Certified Nursing Assistant #2 stated they did not notify anyone regarding the resident's behavior of removing the abduction pillow. Certified Nursing Assistant #2 then asked the resident if they (Certified Nursing Assistant #2) could place the hip abduction flexion contracture cushion on them and the resident refused. Certified Nursing Assistant #2 stated they would notify the nurse that Resident #16 refused their hip abduction flexion contracture cushion. Registered Nurse #4, the Unit Manager, was interviewed on 4/19/2024 at 9:06 AM and stated they were not aware that Resident #16 refused the hip abduction flexion contracture cushion. Registered Nurse #4 stated the Certified Nursing Assistants should have notified them of the resident's refusal to use the abduction pillow. They would have then notified the Rehabilitation department to re-evaluate the resident. The Occupational Therapy Evaluation and Plan of Treatment dated 4/19/2024 documented Splint /Orthotic Recommendations: It is recommended the [resident] continue to wear the current device with current orders as [resident] was able to tolerate today without [complaint of] pain or discomfort. Physical Therapist #1 was interviewed on 4/22/2024 at 9:30 AM and stated Resident #16 has both hips and leg contractures and was recommended by the Rehabilitation Therapy Department to use the hip abduction flexion contracture cushion upon discharge from therapy on 8/31/2023. The cushion is utilized to keep the hips from rotating and the legs from contracting. If Resident #16 was refusing the hip abduction flexion contracture cushion, the nursing staff should have notified the Physical Therapy department to re-evaluate the resident for alternate devices. The Director of Nursing Services was interviewed on 4/23/2024 at 9:22 AM and stated Resident #16 had been refusing the hip abduction flexion contracture cushion; the Physical Therapy Department was alerted on 4/19/2024. The Director of Nursing Services stated the nurses were expected to notify the resident's Physician and/or Physical Therapist to re-evaluate Resident #16 for alternative devices. 10 NYCRR 415.11(c)(1)

Based on observation, interview, and record review during the Recertification Survey and Abbreviated Survey (Complaint # NY00319453) completed on 4/23/2024, the facility did not ensure resident rights to be free from abuse. This was identified for one (Resident #311) of two Residents reviewed for Abuse. Specifically, Resident #311 who had a history of verbally disruptive and intrusive behavior such as attempts to enter other resident rooms, antagonize residents, excessive talking, inappropriate outbursts, and mocking other residents, was transferred to Resident #310's unit on 5/3/2023 after returning from emergency room status post verbal altercation with a resident on the previous unit. Resident #311 continued to have disruptive behaviors including paranoia, agitation, incessant speaking, and being accusatory toward others on the newly assigned unit. On 7/3/2023 Resident #310 punched Resident #311 on the face. Resident #310 stated they hit Resident #311 because they (Resident #311) used foul language toward them. Resident #311 sustained a three-centimeter linear scratch to the right face and an open area to the right upper ear. The finding is: The facility policy entitled Abuse Identification and Investigation, Prevention, and Reporting dated 10/31/2022 documented that the Federal definition of abuse is the willful infliction of injury with resulting physical harm, pain, or mental anguish. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The New York State definition of abuse is inappropriate physical contact with a resident of a residential health care facility while the resident is under the supervision of the facility, which harms or is likely to harm the resident. The facility will be cognizant to identify trends in the behaviors of residents that are likely to provoke situations that could lead to abuse and to care plan those behaviors with individualized and appropriate interventions. -Resident #310 was admitted to the facility with the diagnoses of Anxiety Disorder, Depression, and Psychotic Disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #310 had a Brief Interview for Mental Status score of 5, indicating severely impaired cognition. Resident #310 was independent in bed mobility, transfers, and walking. Resident #310 had no behaviors noted on the minimum data set assessment. The Medical Note dated 6/1/2023 documented Resident #310 was noted to be hallucinating therefore urine culture was done along with a psychiatric evaluation. Resident #310 was noted with a history of Anxiety, Depression, and previous psychiatric hospitalization in 2020. Resident #310 with a negative work-up for infection, remains calm, and cooperative with no further Psychosis. Resident #310 is to continue with Risperdal (an antipsychotic medication) 3 milligrams, monitor, and supportive care for now. The Behavior care plan for Resident #310 dated 7/4/2023 documented that Resident #310 was at risk for resident-to-resident altercation related to confusion, impaired judgment, and mood disorder. Interventions included to keep Resident #310 away from other residents exhibiting physical/verbal behavioral symptoms directed towards others, Redirect/Refocus attention by offering alternatives, keep engaged in varied activities to reduce the possible chance of wandering into the space or room of residents exhibiting physical/verbal behavioral symptoms directed towards others, 1:1 observation for 48 hours. Resident #310's medical record lacked documented evidence of an altercation on 7/2/2023 between Resident #310 and Resident #311. The Resident Accident and Incident Report dated 7/3/2023 for Resident #310 documented that at 6:10 PM a Resident-to-Resident incident occurred. Registered Nurse Supervisor # 5 was called to Unit B by Certified Nurse Aide #7 for an altercation between Resident #310 and Resident #311. Certified Nurse Aide #7 reported that Resident #310 punched Resident #311 in the face after Resident #311 cursed at Resident #310. Resident #310 was alert, confused, calm, and cooperative. Resident #310's statement documented I hit [Resident #311] because [they] said F you. -Resident #311 was admitted to the facility with the diagnoses of Coronary Artery Disease, Depression, and bipolar disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #311 had a Brief Interview for Mental Status score of 15, indicating intact cognition. The Minimum Data Set assessment documented that Resident #311 had verbal behaviors directed towards others. Resident #311 also rejected care and wandered. Resident #311 had impairment on one side at the lower extremity. Resident #311 used a walker and wheelchair for mobility. The Behavior care plan for Resident #311 dated 7/16/2022 and last revised on 5/17/2023 documented that Resident #311 exhibited disruptive behavior including verbal symptoms directed toward others (threatening others, screaming at others, and cursing), cursing and screaming at nursing staff, as well as rolling their (Resident #311) wheelchair around the nursing station to disturb nurses during their med passes. The interventions included to keep Resident #311 within viewing distance for observation as much as possible, redirect and refocus the resident's attention by offering alternatives (comfort foods or engaging in individual therapy). A review of progress notes from 4/5/2023 to 5/2/2023 revealed that Resident #311 presented with paranoid and disruptive behaviors. Resident #311 was noted with intrusive behavior such as attempts to enter other resident rooms, antagonizing other residents, excessive talking, inappropriate outbursts, and mocking other residents. On 5/2/2023, Resident #311 was noted screaming at another resident while sitting outside of the resident's room. Resident #311 made accusations against the resident and was not responsive to redirection. Resident #311 was sent to the emergency room for evaluation. The Social Work progress note dated 5/3/2023 documented that Resident #311 continued to present with increased behavioral symptoms as evidenced by verbal disruption, intrusiveness, and threatening and accusatory behaviors. It was difficult to redirect the resident. The resident is provided with ongoing reminders/cueing/re-direction/reality orientation; however, behaviors persisted. As per the interdisciplinary team's recommendation Resident #311 will be temporarily moved to another unit today. Staff will continue to observe the resident for changes in mood and/or behavior and validate concerns. A review of progress notes from 5/4/2023 to 6/27/2023 (after the resident was moved to Resident #310's unit) revealed that Resident #311 continued to present with disruptive behaviors including paranoia, agitation, incessant speaking, and accusatory towards others. Resident #311 was also noted to be interruptive to other people's conversations while wheeling themselves around the facility. The Resident Accident and Incident Report dated 7/3/2023 for Resident #311 documented that at 6:10 PM a Resident-to-Resident incident occurred. Registered Nurse Supervisor #5 was called to Unit B by Certified Nurse Aide #7 for an altercation between Resident #310 and Resident #311. Certified Nurse Aide #7 reported that Resident #311 was punched by Resident #310 while passing each other in the hallway. Resident #311 was found in the wheelchair in the hallway agitated and uncooperative. Resident #311 had an approximately 3-centimeter linear scratch to the right side of the face and a pinpoint open area to the right upper ear. Resident #310's statement documented [Resident #310] punched me for no reason. The updated Investigative Summary concluded Resident #310 did have intentional contact with Resident #311. The investigation revealed that there is no cause to believe abuse has occurred. Certified Nurse Aide #7 was interviewed on 4/19/2024 at 3:29 PM. Certified Nurse Aide #7 stated they were the regularly assigned Certified Nurse Aide for Resident #311 on the 3:00 PM to 11:00 PM shift since the resident moved to Unit B on 5/3/2023. Certified Nurse Aide #7 stated that Resident #311 had episodes of screaming at others and would sometimes be in a bad mood. Certified Nurse Aide #7 stated that on 7/3/2023 at about 6:00 PM, they (Certified Nurse Aide #7) were serving dinner and heard Resident #310 and Resident #311 yelling back and forth. Certified Nurse Aide #7 overheard Resident #311 say F-you very loudly. Certified Nurse Aide #7 then observed Resident #310 and Resident #311 throwing fists at each other. Certified Nurse Aide #7 stated they (Certified Nurse Aide) immediately separated the residents and called for help. Certified Nurse Aide #7 confirmed that Resident #311 was punched in the face by Resident #310. Registered Nurse Supervisor #5 was interviewed on 4/22/2024 at 10:51 AM and stated that they responded to the incident on 7/3/2023. Registered Nurse Supervisor #5 stated that Resident #311 was struck by Resident #310. Resident #310 told Registered Nurse Supervisor #5 that Resident #311 was always bothering Resident #310 and that is why Resident #310 reacted by punching Resident #311. Registered Nurse Supervisor #5 stated that Resident #311 had a history of behavioral issues and was very persistent and difficult to redirect. The Director of Nursing Services was interviewed on 4/22/2024 at 1:50 PM and stated that on 7/3/2023, they got a call from the Administrator that Resident #310 and Resident #311 had an altercation. When the Director of Nursing Services arrived at the facility, the Administrator had already called the local police for assistance. The Director of Nursing Services stated Resident #311 had a scratch on the right side of their head. Resident #311 was encouraged to go to the hospital but refused. Resident #311 was upset about the situation, saying [Resident #310] punched me for no reason. The Director of Nursing Services stated that Resident #310 admitted to punching Resident #311 because Resident #311 cursed at Resident #310. The Director of Social Work was interviewed on 4/22/2024 at 3:35 PM. The Director of Social Work stated that Resident #311 had consistent behavior of interjecting in other people's conversations and boisterousness with other residents. Resident #311 was difficult to redirect and required to be kept within viewing distance to help avoid potential conflicts with other residents. The Director of Nursing Services was re-interviewed on 4/22/2024 at 3:55 PM. The Director of Nursing Services stated Resident #310 did abuse Resident #311 when Resident #310 hit Resident #311 on 7/3/2023. The Director of Nursing Services stated that in the Incident Report summary dated 7/3/2023, they erroneously documented that the altercation between Resident #310 and Resident #311 was not abuse. The Director of Nursing Services stated that when they reported the incident to the New York State Department of Health they indicated the altercation between Resident #310 and Resident #311 resulted in abuse for Resident #311. The Director of Nursing Services further stated that the incident between Resident #310 and Resident #311 resulted in abuse for Resident #311. 415.4(b)(1)(ii)

Based on observation, record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 190, NY 964) initiated on 9/18/2022 and completed on 9/22/2022, the facility failed to maintain an effective pest control program so that the facility was free of pests. Specifically, there was evidence of bugs in the kitchen, kitchen storage room, and on the B wing. The finding is: On 9/21/2022 at 8:40 AM, a brown bug with antenna measuring 1 inch in length, was observed on the B unit between room 134 and 136. On 9/21/2022 at 10:20 AM, 3 bugs lying on their backs, were observed on the floor in the kitchen storage room. On 9/21/2022 at 10:45 AM, 2 brown bugs measuring 1/8 inch in length were observed walking on the floor below the dishwasher in the kitchen. Resident #59 was observed in the hallway on 9/18/22 at 1:20 PM. Resident #59 stated that the facility has had a lot of bugs like cockroaches and that there were mice in the facility. Resident #59 further stated that they had seen roach bait in the facility, but it was not enough to get rid of the bugs. Pest control records documented the following: - On 9/14/2022, the facility was treated for roaches in room 239, A, B, C Wings, bakery, kitchen, and gym. - On 9/7/2022, the facility was treated for roaches on the A, B, C Wings, and kitchen. - On 8/24/2022, the facility was treated for roaches on the A, B, C Wings, and kitchen. - On 8/17/2022, the facility was treated for rats and roaches on A, B, C wings, gym, bakery, and housekeeping closets. - On 8/10/2022, the facility was treated for roaches in the kitchen and dishwasher area. - On 8/3/2022, the facility was treated for roaches in the kitchen and dishwasher area. - On 7/27/2022, the facility was treated for roaches in the kitchen and the dishwasher area. An undated facility Pest Control Policy documented, it is the policy of Excel at [NAME] that an ongoing pest management program that included prevention, control of pest activity, infestation and ensures proper handling of all pesticides be in place. Additionally, the policy documented, a pest control company will be contracted to spray all areas of the facility. Services will be performed once a week for the 1st weeks of each month and as needed. Services will not be performed on the 5th week of the month if applicable. In an interview on 9/21/2022 at 2:45 PM, the Director of Maintenance (DOM) stated they oversaw both Housekeeping and Maintenance departments and stated that an exterminating company came in once a week to treat areas. The DOM further stated if there were pest sightings, staff were to enter it into a digital work order log system (TELS building management platform) or directly inform the DOM, who would log the sighting in the pest control book in the DOM office. 415.29(j)(5)

Based on observation and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 190, NY 964) initiated on 9/18/2022 and completed on 9/22/2022, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 3 of 3 residents units, the kitchen and the basement. Specifically, floors were soiled with litter and sticky substances, and exhausts vents contained a build-up of dust. The finding is: During a tour of the facility on 9/21/2022 to 9/22/2022, the following was observed: (1) the Kitchen Storage room located in the basement contained a sticky substance on the floor. Within the substance were 3 bugs lying on their backs. (2) In the Central Supply closet on the A Wing, plastic bottles, a box of q- tips, and litter was observed on the floor and underneath the metal storage racks (3) In the Staff Lounge, litter was observed behind and along the sides of the refrigerator (4) In the Kitchen, the corners on the floor near the range contained a build-up food, litter, and unknown particles. (5) In the Kitchen, the floor below the coffee maker contained a build-up of litter, dust, and coffee beans (6) In the Soiled utility rooms on A wing, B wing and C wing, the exhaust ducts contained a build-up of dust. In an interview on 9/21/2022 at 10:20 AM, the Director of Maintenance stated they would clean the floor. In an interview on 9/21/2022 at 10:45 AM, the Food Service Director stated there was no assigned cleaning schedule, and that they cleaned the floors and behind the stove every few days. In an interview on 9/21/2022 at 11:10 AM, the Director of Maintenance stated they would instruct the staff to clean up the storage room floor. In an interview on 9/21/2022 at 11:20 AM, the Director of Maintenance stated they would let housekeeping know to clean behind the refrigerator. In an interview on 9/21/2022 at 11:40 AM, the Corporate Environmental Coordinator stated they would check and clean all the vents. In an interview on 9/21/2022 at 2:45 PM, the Director of Maintenance stated that they oversaw both Maintenance and Housekeeping departments, but that there was a housekeeping supervisor. The Director of Maintenance further stated that each department was responsible for their own storage areas and that kitchen staff were responsible to clean the kitchen, but that Maintenance staff cleaned the laundry area and removed junk out of the basement. They further stated there was no scheduled cleaning for the areas. 10NYCRR 415.29

Based on record review and staff interviews during the Recertification survey and Abbreviated survey (NY 018) initiated on 9/18/2022 and completed on 9/22/2022, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #189) of one resident reviewed for change of condition. Specifically, Resident #189 had a [MEDICATION(S)] catheter (a drainage system that allows for the drainage of pleural effusion, which is a build-up of fluid in the chest) with orders for the catheter to be drained two times per week. On 11/8/2021 the drainage of the catheter was scheduled; however, the treatment was not administered, although there was qualified staff in the facility that day to provide the treatment. There was no documentation in the medical record regarding the treatment was not administered or that the physician was notified. Furthermore, on two occasions when the [MEDICATION(S)] catheter was drained, there was no documentation of the amount of fluid that was drained. The finding is: The facility's undated policy, titled [MEDICATION(S)] Catheter, documented that the objective is to facilitate drainage of fluid from the chest and prevent infection and to document fluid drainage amount and resident's tolerance to the procedure in the nurses' notes. Resident #189 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/11/2021 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Document output. Notify Registered Nurse (RN)/Physician of any abnormalities. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Notify RN/Physician of any abnormalities. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's competency, titled [MEDICATION(S)] Catheter Change and Drainage, documented that two staff members, RN #1 and the current Director of Nursing Services (DNS), who was an RN supervisor on 11/8/2021, were the only two staff members who received training and completed the competency to perform the [MEDICATION(S)] catheter drainage and dressing change. The date of the competencies was 10/28/2021. Review of the Treatment Administration Record (TAR) for November 2021 revealed that on 11/8/2021 (Monday) Licensed Practical Nurse (LPN) #1 documented that both treatment orders for the [MEDICATION(S)] catheter (the drainage and dressing change) were not administered. There were no reasons provided in the comments section of the TAR. In addition, review of progress notes for 11/8/2021 revealed no progress note was written indicating why the treatments were not administered. As per the staffing data provided by the facility for 11/8/2021, the RN supervisor for the 7 AM-3 PM shift was the current DNS, who was one of the nurses who received the competency to perform the [MEDICATION(S)] drainage. Further review of the TAR for November 2021 revealed that the [MEDICATION(S)] drainage was performed by RN #1 on 11/5/2021 (Friday) and 11/12/2021 (Friday) and 11/16/2021 (Tuesday). Review of the TAR revealed that RN #1 documented the drainage on 11/12/2021 as 25 cubic centimeters (cc) of pleural fluid. There was no documentation of drainage amount on 11/5/2021 or 11/16/2021 in either the TAR or the progress notes. LPN #1 is no longer employed at the facility and was not reachable by phone. RN #2, who is the current inservice coordinator and Infection Preventionist, was interviewed on 9/20/2022 at 10:07 AM. RN #2 stated that if the drainage of the [MEDICATION(S)] catheter was not done as ordered, then there should have been documentation as to why it was not done. RN #2 further stated that the amount of drainage should be documented in the medical record. RN #4 (Corporate Educator) was interviewed on 9/20/2022 at 12:44 PM. RN #4 stated that in order for a nurse to perform the [MEDICATION(S)] catheter drainage the nurse would have to be inserviced and pass a competency. RN #4 stated they (RN #4) only provided inservice to RN #1 and the current DNS, who was a supervisor at the time of the competency. LPN #2 was interviewed On 9/20/2022 at 2:46 PM. LPN #2 stated they (LPN #2) were the Unit C manager on 11/8/2021 for the 7 AM-3 PM shift. LPN #2 stated they have no recollection of LPN #1 reporting that the [MEDICATION(S)] treatment was not done for Resident #189. LPN #2 stated that if they (LPN #2) were made aware that the treatment was not done, they (LPN #2) would have reported it to the RN supervisor. The DNS was interviewed on 9/21/2022 at 8:32 AM. The DNS stated they (DNS) were the RN supervisor on 11/8/2022 when Resident #189 required the [MEDICATION(S)] catheter treatments. The DNS stated that LPN #1 should have notified them (DNS) or the unit manager that they (LPN #1) could not do the [MEDICATION(S)] procedure. The DNS stated if they (DNS) had known that the procedure was not done, they (DNS) would have done it. The DNS stated the former DNS should have ensured that the two nurses trained to complete the [MEDICATION(S)] procedure were available and aware that they were responsible to complete the treatment as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] RN #1 was interviewed on 9/21/2022 at 10:40 AM and stated they (RN #1) completed the [MEDICATION(S)] treatment on 11/5/2021 and 11/16/2021 for Resident #189. RN #1 stated that they (RN #1) sent a secure text message to the Physician on 11/5/2021 noting that 150 cubic centimeters (cc) of fluid was drained and another text message on 11/16/2021 that barely 25 ccs was drained. RN #1 stated the text messages are not part of the medical record and that the drainage should have been documented in the medical record. The physician was interviewed on 9/21/2022 at 12:22 PM and stated they (Physician) do not remember being advised the day (11/8/2021) the drainage was not done and would expect to be notified. 415.12

Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 436) initiated on 9/18/2022 and completed on 9/22/2022, the facility did not ensure that each resident had a Comprehensive Care Plan (CCP) developed to meet each resident's individualized care needs. This was identified for one (Resident #190) of one resident reviewed for Unnecessary Medications. Specifically, Resident #190 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no CCP developed to address the DM diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The finding is: The facility's policy titled, Comprehensive Care Plans (CCP) and Resident/Patient Meeting dated 11/27/2017 documented that a comprehensive assessment for resident's needs shall be prepared within 14 days from admission and a CCP developed within 21 days from admission. The policy also documented that information obtained from the comprehensive assessment and staff interviews enables the facility staff to plan care that focuses on the resident's ability to achieve his/her practicable mode of functioning that includes, but is not limited to the following: Medically defined condition(s) and Past Medical History. Resident #190 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a BIMS score of 13 which indicated Resident #190 had intact cognition. Diabetes Mellitus was listed as one of the resident's Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no blood glucose parameters for nursing staff to notify the physician when abnormal results are identified. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Insulin Sliding Scale if BS (blood sugar) is between 60 - 150 give 0 units of insulin; 151 - 200 give 2 units of insulin; 201 - 250 give 4 units of insulin; 251 - 300 give 6 units of insulin; 301 - 350 give 8 units of insulin; 351-400 give 10 units of insulin. If greater than 400 or below 60 Call MD. The resident's entire CCP was reviewed on 9/21/2022 at 3:00 PM. There was CCP found to address the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Director of Nursing Services (DNS) was interviewed on 9/21/2022 at 3:30 PM and stated that they (DNS) would have expected the resident to have a Diabetes Care Plan. The DNS stated that the resident should have had a CCP developed for DM because the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS stated that it was the responsibility of the RN Unit Manager to put the care plan into place. 415.11(c)(1)

Based on interviews and record review during the Recertification survey and Abbreviated survey (NY 386) initiated on 9/18/2022 and completed on 9/22/2022 the facility did not ensure that all allegations of abuse were thoroughly investigated. This was identified for one (Resident #187) of one Resident reviewed for Abuse. Specifically, Resident #187 complained that three facility staff handled the resident roughly during a transfer from one surface to another. The facility investigation did not include all statements necessary to rule out abuse, neglect, and mistreatment including a statement from Resident #187's assigned Certified Nursing Assistant (CNA) #4. The finding is: The facility Accident and Incident Reporting Policy dated 12/1/2019 documented that when an incident occurs to a resident, it will be documented in an Accident Incident Report and an internal investigation will be conducted to determine the root cause of the accident/incident. The facility Resident Abuse, Mistreatment, Neglect and Exploitation policy, and procedure dated 3/2019 documented an abuse investigation trigger includes resident/family/visitor allegation of abuse. A review of the investigation procedure revealed that the policy and procedure did not include a protocol on how an investigation should be completed including obtaining statements from appropriate staff and residents. Resident #187 was admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set, dated dated dated [DATE] documented that Resident #187 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS further documented that Resident #187 required extensive assistance of two persons for bed mobility and transfers. The Abuse Care Plan dated 8/29/2021 documented that Resident #187 was at risk for potential abuse as evidenced by loss of independence. The interventions included reporting any unusual markings on the body and reporting to the nurse in charge; monitoring for any signs and symptoms of distress and or sadness, monitoring the resident's body language and/or facial expression; encourage the resident to verbalize any concerns, report any suspected abuse via the facilities chain of command as in policy and procedure of abuse, educate the resident and family and ask resident/family to explain the procedure to assure understanding. The Activities of Daily Living Care Plan dated 8/30/21 documented that Resident #187 required extensive assistance of two people for bed mobility and transfers. The facility C-Wing 3 PM-11 PM Shift Assignment Sheet dated 8/29/21 documented CNA #4 was assigned to Resident #187. The sheet also documented CNA #2 and CNA #3 were on duty on the C-Wing during the 3 PM-11 PM shift. The Nursing Note dated 8/29/2021 documented that at approximately 8 PM, Resident #187 complained about the time they (Resident #187) went to bed today. Resident #187 stated that they were put in bed too early, and they wanted to be in bed at around 9 PM every night. CNA staff were made aware to accommodate Resident #187 with the time they want to be put in bed moving forward. Resident #187 and the family member agreed with the plan of care. Resident Grievance log completed by the Director of Social Work dated 8/31/2021 documented that Resident #187 reported to a family member over the weekend that Resident #187 was handled roughly by 3 staff members. A document entitled, Resident #187 statements regarding allegation of recent incident dated 8/31/2021 documented that the social worker met with Resident #187 who was alert, oriented, and able to make needs known with mild forgetfulness. Resident #187 stated that on Saturday or Sunday (8/28/2021 or 8/29/2021) one staff member was standing in front [of the resident] watching while 2 other staff members grabbed Resident #187's arms and legs. Resident #187's family member filed a police report, and an officer came to the facility and met with Resident #187. The facility Summary of Investigation dated 8/31/2021 documented that the date of the incident was 8/29/2021 at 7:00 PM. On 8/30/2021 at 10 AM, Resident #187's family member approached this writer and said Resident #187 was put back in bed by three staff members in a rough way. Resident #187 was assessed immediately by the on-duty supervisor for injury or pain. Resident #187 did not complain of pain or rough handling by caregivers during her care. The resident is alert and able to communicate with clear speech. Staff who did direct hands-on care was interviewed by the Director of Nursing and were not aware of any issues. Resident #187 was interviewed by the nursing administration and made no complaint. Statements were obtained by staff who provided care for Resident #187. The investigation revealed there is no cause to believe that alleged Resident abuse, mistreatment, or neglect regarding Resident #187 has occurred. RN #3 signed the summary. The Summary of Investigation did not document the resident's allegation that was received by the social worker on 8/31/2021. A statement from CNA #2 dated 8/31/2021 was reviewed. CNA #2 documented that on Sunday, 8/29/21, at around 7 PM to 8 PM, CNA #2 was helping CNA #4 provide care for Resident #187's roommate while CNA #3 was helping Resident #187 to bed. CNA #2 went over to help CNA #3 move Resident #187 over to the middle of the bed. A statement from CNA #3 dated 8/31/2021 was reviewed. CNA #3 documented that on Sunday, 8/29/2021, between 7 PM and 8 PM, CNA #3 was giving care to Resident #187 because CNA #4 who was the assigned CNA for Resident 187 had worked the 7 AM-3 PM shift. CNA #3 documented that there were 3 CNAs in the room including CNA #4 who was providing care to the roommate. A review of all statements associated with the incident investigation for Resident #187 (8/31/2021) revealed there were no statements from Resident #187's assigned CNA (CNA # 4). The Director of Nursing Services (DNS) was interviewed on 9/21/2022 at 1:09 PM. The DNS stated upon review of the investigation for Resident #187, they (DNS) believe that CNA #4 provided care to Resident #187's roommate. The DNS stated that CNA #4 may have left the room while Resident #187 was being transferred by CNA #2 and CNA #3. The DNS stated that this information was not included in the investigation summary. CNA #2 was interviewed on 9/21/2022 at 2:47 PM. CNA #2 stated that on 8/29/2021 they were providing care for Resident #187's roommate in Resident #187's room with CNA #4. CNA #3 was interviewed on 9/21/2022 at 3:07 PM. CNA #3 stated that Resident #187 used the call bell and when CNA #3 entered the room, Resident #187 complained about pain. Resident #187 asked to be put to bed but then complained to RN #7 that they (Resident #187) did not want to be put to bed early. CNA #3 assisted Resident #187 to the bathroom and then back to the wheelchair. Resident #187 did not have any discomfort or complaint when being transferred. CNA #2 and CNA #3 only placed Resident #187 into the bed because Resident #187 requested to be placed in the bed. CNA #4 was the assigned CNA but did not assist in the transfers. CNA #2 and CNA #3 wanted to assist CNA #4 who was busy with Resident #187's roommate in the resident's room. Voicemails were left for Resident #187's assigned CNA, CNA #4, on 9/21/2022 and 9/22/2022. CNA #4 was unavailable for an interview. The DNS was interviewed on 09/22/2022 at 11:49 AM. The DNS stated that they (DNS) were not in the DNS role on 8/31/2021 and were not involved in the investigation. The DNS stated that after reviewing the investigation, it appeared that Resident #187 did not want to go to bed at 7 PM, and there was something about grabbing arms and legs. The DNS stated that it seems that the staff used a draw sheet to reposition Resident #187. The DNS stated that the investigation summary documented that Resident #187 did not complain to the nursing administration that the staff had rough-handled the resident. The investigation summary did not reflect the statement that the Director of Social Work obtained from the direct Resident interview. The DNS would expect Resident #187's statement to be included in the summary. The DNS stated that the assigned CNA was not interviewed for a statement, and it would be expected as part of the investigation. 415.4(b)

Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 436) initiated on 9/18/2022 and completed on 9/22/2022, the facility did not inform the resident's Designated Representative (DR) when a new form of treatment was started. This was identified for one (Resident #90) of six residents reviewed for Unnecessary Medications. Specifically, there was no documented evidence that Resident #190's DR was notified 1) when the resident's [MEDICATION(S)] (an antidepressant medication) dosage was increased on 1/7/2022 and 2) when the resident was started on [MEDICATION(S)] (an antidepressant medication often used to increase appetite) on 1/4/2022. The finding is: The facility's policy titled, Notification of Family of Resident Status Change dated 8/25/2021 documented that it was the policy of the facility to inform the DR of any changes in the resident's condition/status and implemented interventions (If applicable). Residents with a Brief Interview for Mental Status (BIMS) of 12 or above will be notified and if requested, DR will also be notified. Resident #190 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a BIMS score of 13 which indicated Resident #190 had intact cognition. 1) The Medicare Nursing Progress Note dated 12/28/2021 documented that the resident had intermittent bouts of crying/sobbing due to missing their wife and their life in Arizona. The resident was offered emotional support with little/no results. The Physician was notified and a new order to start [MEDICATION(S)] 50 mg (milligrams) once daily was received. The resident's DR was made aware and was in agreement. A psychiatric consult was ordered and is pending. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Psychiatric Initial Evaluation Progress Note dated 1/6/2022 documented to start [MEDICATION(S)] 25 mg once daily (QD). The Nursing Progress Note dated 1/6/2022, written by Registered Nurse (RN)#1, documented that the resident was seen and evaluated by the Psychiatrist with a new order for [MEDICATION(S)] 25 mg QD for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was entered into the computer by RN #1. The Nursing Progress Note dated 1/7/2022, written by RN #6, documented that the Psychiatrist was notified for a medication clarification. The Psychiatrist clarified that the resident was to receive [MEDICATION(S)] 75 mg QD. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give in addition to [MEDICATION(S)] 50 mg (for a total of 75 mg QD) for Major Depressive Disorder. This order was entered into the computer by RN #6. RN #6 was interviewed on 9/20/2022 at 3:05 PM and stated that they (RN #6) had only called the Psychiatrist to see if they (Psychiatrist) wanted the 25 mg of [MEDICATION(S)] added to the resident's already 50 mg dose or if they (Psychiatrist) wanted the [MEDICATION(S)] reduced to a 25 mg dose. RN #6 stated that they did not contact the resident's DR because they (RN #6) only clarified the dosage of [MEDICATION(S)] the Psychiatrist wanted the resident to receive. RN #1 was interviewed on 9/20/2022 at 4:20 PM and stated that if they (RN #1) had called the family, they (RN #1) would have documented that they notified the DR. RN #1 stated that they (RN #1) should have called the family because when any orders change for a resident the family should be called because it is protocol. The Director of Nursing Services (DNS) was interviewed on 9/21/2022 at 3:35 PM and stated that contacting the family when a medication is started or changed would depend on the resident and their cognition. The DNS stated that Resident #190 had a BIMS of 13 and was capable of making their (Resident #190) own decisions. The DNS acknowledged that there was no documentation in the resident's medical record of the resident's wishes and if they (Resident #190) did or did not want their DR contacted when their medication dosage changed. 2) The Physician Follow-Up Progress Note documented on 1/4/2022 that the resident was depressed and would be started on [MEDICATION(S)] 7.5 mg QD. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was entered into the computer by RN #3. RN #3 was interviewed on 9/21/2022 at 10:15 AM and stated that the resident was alert and oriented. For someone who is alert and oriented, their care is discussed with the resident and if the resident tells us not to call their family, we do not. RN #3 stated that they (RN #3) did not remember the specifics of this resident, whether they (Resident #190) wanted their family involved or not. RN #3 stated that Resident #190 was alert and oriented and they (RN #3) did not call the resident's family or write a progress note regarding the initiation of [MEDICATION(S)]. The resident's Physician was interviewed on 9/21/2022 at 1:00 PM and stated that they (Physician) had ordered the [MEDICATION(S)] on 1/4/2022 because the resident was not eating and was depressed. [MEDICATION(S)] is an appetite stimulant and an antidepressant. The Physician stated that they (Physician) always call the resident's family member when the resident is not eating and when they (Physician) start [MEDICATION(S)]. The Physician stated that they (Physician) had talked to the resident's DR, but was not sure if it was about the start of the [MEDICATION(S)]. The Physician stated that they (Physician) would usually write in their note which family member they spoke to and their phone number. The Physician stated that they (Physician) did not write that in their note of 1/4/2022 and understood that if the information was not written, it was not done. The Director of Nursing Services (DNS) was interviewed on 9/21/2022 at 3:35 PM and stated that contacting the family when a medication is started or changed would depend on the resident and their cognition. The DNS stated that Resident #190 had a BIMS of 13 and was capable of making their (Resident #190) own decisions. The DNS acknowledged that there was no documentation in the resident's medical record of the resident's wishes and if they (Resident #190) did or did not want their DR contacted when their medications started. 415.3(e)(2)(ii)(c)

Based on observation, record review, and interviews during the Recertification survey the facility did not ensure that pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, were provided to meet the needs of each resident. This was identified for 1 (Resident # 60) of 5 residents observed during medication administration. Specifically, Resident #60 had a physician's orders [REDACTED]. The Vitamin B12 500 micrograms (mcg)- folic acid 400 mcg tablet order was re-ordered in the Electronic Medical Record (EMR) on 12/23/19 and was not available for administration on 12/24/19 during the medication administration observation. The finding is: The facility's policy for Medication Administration, dated 6/2017, states that the nursing station shall have all necessary items for proper administration of medication through the Electronic Medical Record (EMR) provider. Resident # 60 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 6, indicating severe cognitive impairment. The resident required extensive assistance of one staff member for toileting, transfers, personal hygiene and dressing. The admitting physician orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. During a medication administration observation on 12/24/19 at 10:00 AM, the Vitamin B12 - 500 mcg- folic acid 400 mcg tablet was not administered because the medication was not available in the medication cart. The Licensed Practical Nurse (LPN) stated the medication was not available. She further stated she gave the last dose to the resident on 12/23/19 in the AM and requested, by using the computer, the medication to be delivered from the pharmacy on 12/23/19 in the morning. A review of the medication refill request form dated 12/23/19 confirmed the medication was requested by the LPN on 12/23/19 at 9:33 AM. A Pharmacist at the Pharmaceutical provider was interviewed on 12/24/2019 at 10:46 AM. He stated there were no requests made by the facility for Vitamin B12 500 mcg- folic acid 400 mcg tablet and it was last dispensed on 11/14/19. The pharmacist further stated that medications are not automatically dispensed every 30 days and the facility has to request the medications. The Registered Nurse (RN) supervisor was interviewed on 12/24/19 at 11:30 AM and stated the medication was not given because the medication was not in the facility. The Pharmacy should have delivered the medication because it was requested on 12/23/19. The Director of Nursing Services (DNS) was interviewed on 12/24/19 at 12:30 PM and stated the Pharmacy should have delivered the medication by 12/24/19 and could not understand why the medication was not sent. The DNS stated that there was a glitch in the system. A 30 day re-order and dispensing of medications by the pharmacy is not always implemented because some of the residents are sub-acute short stay residents. 415.18(a)

Based on record review and interviews during the recertification survey the facility did not ensure a drug regimen review completed by a licensed pharmacist identified irregularities to the attending physician, the facility's medical director and director of nursing. This was identified for 1 (Resident # 43) of 6 residents reviewed for medication review. Specifically, [MEDICATION NAME] (medication for Orthostatic [MEDICAL CONDITION]) was prescribed for Resident # 43 and being administered at bedtime despite a protocol on the Medication Administration Record [REDACTED]. The finding is: The undated Policy and Procedure for Five Rights of Medication Administration documents recommendations to reduce medication errors and harm is to use the five rights; the right patient, the right drug, the right dose, the right route, and the right time. Resident # 43 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. A review of the physician orders [REDACTED]. A Review of the MAR from 05/1/2018 to 08/2/2018 documented [MEDICATION NAME] 10 mg tablet, give 2 tablets (20 mg) by oral route 3 times per day at 8 AM; 2 PM; AND 10 PM for Orthostatic [MEDICAL CONDITION], Protocol: DO NOT TAKE DRUG AFTER EVENING MEAL OR WITHIN 4 HRS OF SLEEP. Medication Regimen Reviews dated 04/23/2018 - 8/15/2018 had not identified the manufacturer's warning not to give the mediation after the evening meal or within 4 hours of sleep. The Director of Nursing Services (DNS) was interviewed 9/6/18 at 11:30 AM and stated that although it was the family's wishes to give the medication at bedtime, Nurses should have questioned the directions in the MAR before administering the [MEDICATION NAME] medication as part of the 5 rights for Medication Administration (right time). She further stated if it was permissible to give as per family/resident wishes, this should have been documented for Nurses to refer to. The Pharmacist who does the monthly regimen review monthly was not reachable. The Supervising Pharmacist was interviewed on 9/6/18 at 2 PM and stated that the Pharmacist should have identified the protocol and addressed it with the facility. The Licensed Practical Nurse (LPN) medication nurse that administers the medication from 3 PM to 11 PM was interviewed on 9/6/18 at 2:30 PM and stated that she should have questioned the directions before giving the 10 PM medication of [MEDICATION NAME]. The drug Manufacturer (Micromedex) documents The last dose of [MEDICATION NAME] should not be taken after the evening meal or less than 3 to 4 hours before bedtime because high blood pressure upon lying down (supine hypertension) can occur, which can cause blurred vision, headaches, and pounding in the ears while lying down after taking this medicine. Also, [MEDICATION NAME] should not be taken if you will be lying down for any length of time. 415.18(c)(1)

Based on observation, record review and interviews conducted during the recertification survey, the facility did not ensure that services provided or arranged by the facility meet the current professional standards of quality. This was identified for 1 (Resident #43) of 6 residents reviewed for medication review. Specifically, for Resident #43, nursing staff were administering a medication ([MEDICATION NAME]) at bedtime despite a protocol on the Medication Administration Record [REDACTED]. The finding is: The undated Policy and Procedure for Five Rights of Medication Administration documents recommendations to reduce medication errors and harm is to use the five rights; the right patient, the right drug, the right dose, the right route, and the right time. Resident # 43 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident with a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. A review of the physician orders [REDACTED]. A Review of the MAR from 05/1/2018 to 08/2/2018 documented [MEDICATION NAME] 10 mg tablet, give 2 tablets (20 mg) by oral route 3 times per day at 8 AM; 2 PM; AND 10 PM for Orthostatic [MEDICAL CONDITION], Protocol: DO NOT TAKE DRUG AFTER EVENING MEAL OR WITHIN 4 HRS OF SLEEP. Medication Regimen Reviews dated 04/23/2018 - 8/15/2018 had not identified the manufacturer's warning not to give the medication after the evening meal or within 4 hours of sleep. The Director of Nursing Services (DNS) was interviewed 9/6/18 at 11:30 AM and stated that although it was the family's wishes to give the medication at bedtime, Nurses should have questioned the directions on the MAR before administering the [MEDICATION NAME] medication as part of the 5 rights for Medication Administration (right time). She further stated if it was permissible to give as per family/resident wishes, this should have been documented for Nurses to refer to. The Pharmacist who does the monthly regimen review monthly was not reachable. The Supervising Pharmacist was interviewed on 9/6/18 at 2 PM and stated that the Pharmacist should have identified the protocol and addressed it with the facility. The Licensed Practical Nurse (LPN) medication nurse that administers the medication from 3 PM to 11 PM was interviewed on 9/6/18 at 2:30 PM and stated that she should have questioned the directions before giving the 10 PM medication of [MEDICATION NAME]. The drug Manufacturer (Micromedex) documents, The last dose of [MEDICATION NAME] should not be taken after the evening meal or less than 3 to 4 hours before bedtime because high blood pressure upon lying down (supine hypertension) can occur, which can cause blurred vision, headaches, and pounding in the ears while lying down after taking this medicine. Also, [MEDICATION NAME] should not be taken if you will be lying down for any length of time. 415.11(c)(3)(i)

Based on observations, record review and staff interviews during the recertification survey, the facility did not ensure that residents received services in the facility with reasonable accommodation of needs. This was evident for 1 of 27 Stage 2 residents reviewed. Specifically, for Resident #149, the call bell was observed to not be within reach on two occasions. The finding is: During a medication pass observation on 3/31/17 at 9:00 AM on the A Nursing Unit, Resident #149 was noted to be in bed with the call bell lying on the floor at the right side of the bed, out of reach of the resident. A second observation was made of Resident #149 on 3/31/17 at 11:45 AM and the call bell was lying on the floor at the right side of the bed, out of reach of the resident. The Licensed Practical Nurse (LPN) was interviewed on 3/31/17 at 11:48 AM and stated that the bell should be clipped to the bed. The LPN then placed the call bell within reach of Resident #149 and asked the resident to demonstrate that he could ring the bell, which the resident did. The Certified Nursing Assistant (CNA) responsible for Resident #149 was interviewed on 3/31/17 at 11:50 AM and stated that the call bell was clipped in the morning, but sometimes the resident throws it on the floor. The CNA stated that she was not sure of the time that she last checked on the resident. A Comprehensive Care Plan (CCP) titled Falls, dated 11/3/16, documented to keep the call bell within reach and to answer quickly. 415.5(e)(1)

Based on observations, record review, and staff interview during the recertification survey the facility did not ensure that services were provided in accordance with each resident's written Comprehensive Care Plan (CCP). This was identified for 1 of 1 resident reviewed for Activities of Daily Living (ADL) from a total of 27 Stage 2 sampled residents (Resident # 79). Specifically, Resident #79 did not receive set up/supervision assistance during the Breakfast meal on 4/3/17 as per the CCP. The finding is: Resident #79 has [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 7 indicating severely impaired daily decision making skills. The Functional Status Section in the MDS documented that the resident required set up help and supervision for eating. A CCP for Cognitive Loss/Dementia dated 5/6/16 documented that the resident has inattention and disorganized thinking and altered level of consciousness. A CCP dated 5/6/16 for Activities for Daily Living, Functional/Rehabilitation Potential documented that the resident required set up help and supervision for eating. A Nursing Assistant Assignment and Accountability Record initiated from 4/8/2009 documented that the resident feeds self. The ADL Function flow sheet dated 4/1/17 documented that the resident needs set up help only for eating. A review of the monthly weights and Dietary Note dated 4/3/17 revealed that the resident had lost 6 lbs from 122 lbs in December 2016 to 116 lbs in April 2017. During the Breakfast meal observation on 4/3/17 at 7:45 AM, Resident #79 was observed seated in her room with a Breakfast tray in front of her. The tray had unopened/sealed containers of Health Shake, Juice, Milk, Butter and Jelly. The tray also had an uncovered bowl of hot cereal, and uncovered cup of coffee. There was also a cheese Omelette and a muffin on a plate. All the liquid and solid foods and the flatware were untouched with the exception of muffin. Approximately 1/6th of the muffin was crumbled but not consumed. The resident was confused and talked about random things and asked if the surveyor could find her mother. The resident was asked if she was going to eat and she pointed to the milk and health shake containers and stated, I don't know how to open these. No staff was observed to enter the room for the next 15 minutes and at 8:00 AM a Certified Nursing Assistant (CNA) was observed collecting trays from all rooms. The CNA was observed going into Resident #79's room and stating,You done? The resident did not respond and the CNA removed the tray and placed it on the truck in the hallway. The Unit Registered Nurse (RN) Coordinator was interviewed on 4/03/2017 at 8:05 AM. The RN was informed that the resident had not consumed Breakfast. The RN reviewed the resident's tray and ordered a yogurt and a new Breakfast tray. At 8:06 AM the resident was offered a 6 oz container of yogurt by a CNA, 80% of which was completed by the resident. A fresh Breakfast tray was offered to the resident soon afterwards. The staff was observed to set up the tray and cue the resident who started eating. The RN was interviewed at 8:30 AM and stated that Breakfast was served at 7:20 AM this morning and that Resident #79 was confused and needed tray set up. She stated that the resident's tray should have been set up. She stated that the unit staff should have made rounds during Breakfast. She stated that the CNA who collected the trays should have noticed that the resident had not eaten and should have set up the tray and cued or assisted the resident or provided the resident with a substitute if necessary. The RN stated that a Clerk from other unit had served Resident #79's Breakfast tray. The RN also stated that since Breakfast is served in rooms, every staff member who is on the unit is supposed to make rounds to ensure that all residents get the required set up, assistance or supervision. The RN further stated that no specific person is assigned to oversee specific residents or specific rooms. 415.11(c)(3)(ii)

Based on interview and record review during an abbreviated survey, the facility did not ensure that all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated. Specifically for two (Resident #1 and #3) of three residents reviewed for Abuse, Resident #1 reported facility staff being verbally abusive to her and the allegation was not investigated by the facility. Additionally, Resident #3 complained of physical abuse by a staff member and the allegation was not thoroughly investigated or reported to the New York State Department of Health according to the State Law. Complaint ID #: NY 819 (Resident #3) and NY 802 (Resident #1) The findings are: 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS-an assessment tool) dated 8/19/15 documented a brief interview for mental status score of 15 out of 15 indicating Resident #1 had intact cognition. The Resident's Comprehensive Care Plan (CCP) dated 8/7/15 documented a potential for knowledge deficit related to abuse reporting procedure and that the resident was at risk for injury/abuse related to loss of independence. CCP interventions included to educate resident and family as to whom and how to report allegations, incident and or complaints of abuse, reassure resident that this facility has a zero tolerance for abuse and that the resident need not fear retaliation. The CCP dated 9/2015 documented resident is non-compliant as evidenced by refuses to call for assistance and will attempt self-transfer. Interventions included notify physician of noncompliance, give explanations before care is rendered. During an interview with the Director of Nursing (DON #1) on 9/28/15 at 4:30 PM, DON #1 stated that she was aware of an allegation of verbal abuse related to Resident #1 which was reported to her by Resident #1's family member. DON #1 stated that she had spoken to the aide (Certified Nurse Aide, CNA #1) involved in the allegation, however she did not document her findings. DON #1 stated that she did not think that the allegation against CNA #1 was true. Furthermore, DON #1 did not consider the allegation (calling Resident #1 useless) as verbal abuse. DON #1 stated that she did not ask CNA #1 for a written statement nor did she write a grievance for the verbal abuse that was brought forward by the family member of Resident #1. DON #1 stated that, If I find something terrible just by the reaction of the aide, I would initiate a written investigation. The Resident's medical record lacked documented evidence of any incident of verbal abuse. The Facility provided no documented evidence of an investigation related to verbal abuse. During an interview with the Social Worker (SW) on 9/28/15 at 2 PM, the SW stated that Resident #1 needed instant gratification. She did not like to wait at all after she rang the bell. The SW stated that Resident #1 never complained of staff being verbally abusive to her. During an interview with the 7:00 AM-3:00 PM shift Registered Nurse (RN #1) on 9/28/15 at 2:45 PM, RN #1 stated that she was the medication nurse for Resident #1. RN #1 stated that if the staff did not respond to her promptly, Resident #1 would get upset. RN #1 stated that Resident #1 had cognitive deficit and was forgetful at times. At times, Resident #1 stated that she was not being treated nicely, however there were no specific concerns. RN #1 stated that she spoke with the social worker who went to speak with Resident #1 related to her generalized concerns. During an interview with the Registered Nurse Supervisor (RNS) on 9/28/15 at 4:00 PM, the RNS stated that Resident #1 was alert and oriented and had no complaint of verbal abuse. The RNS stated that the family had requested that CNA #1 to not provide care to Resident #1. The RNS stated that she was not sure why that request was made. RNS #1 stated that there were no prior complaints against CNA #1. During an interview with CNA #1, the 3:00 PM-11:00 PM shift Certified Nursing Assistant, on 8/10/16 at 11:00 AM, CNA #1 stated that Resident #1 was not assigned to her. CNA #1 went in to respond to the call bell, while assisting Resident #1 for toileting, Resident #1 commented to her that I feel useless. CNA #1 stated that in order to make Resident #1 feel better she told her you are not useless. CNA #1, further stated, that the next day (don't recall the day or date) when she came in to work she was told by DON #1 to not go to Resident #1 as the family had reported that CNA #1 had called Resident #1 useless. 2) Resident #3 was admitted to the facility on [DATE] and was discharged on [DATE] with [DIAGNOSES REDACTED]. The Psychosocial History and Initial assessment dated [DATE] documented Resident #3's cognitive status as oriented to time, place and person with good comprehension and good judgement. The Resident's Comprehensive Care Plan (CCP) dated 7/29/15 documented a potential for knowledge deficit related to abuse reporting procedure and that the resident was at risk for injury/abuse related to loss of independence. CCP interventions included to educate resident and family as to whom and how to report allegations, incidents and or complaints of abuse. Ask resident and family to explain procedure to ensure understanding. The Nursing progress note dated 8/1/15 documented that the resident states that last night a woman came in to change him and he said no. After the patient said no, the woman proceeded to grab patient's face. No injury was noted on the face. The facility lacked documented evidence of a summary of the investigation including the conclusion of the investigation to determine if there was any abuse, neglect or mistreatment and whether the incident required reporting to the New York State Department of Health according to the State Law. During an interview with the Director of Nursing (DON #2) on 8/10/16 at 1:59 PM, the DON stated that there is no investigative summary or conclusion related to Resident #3's allegation of someone placing their hand on his face. DON #2 stated that each investigation should have a conclusion to determine if any abuse occurred and if it needs to be reported to appropriate authorities. 415.4(b)(2)

Based on observation and staff interview during the recertification survey the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident in 1 of 3 nursing units toured. Specifically, 1) the hallway floors throughout Unit A were observed to be dirty and grimy and there was an odor throughout the unit; 2) Wheelchairs/recliner chairs designated for Residents #30, #67, #135, #1, #17, #97, #161, #271, and #272 had either left, right or bilateral arm rests torn. The findings include but not limited to: 1) On 2/25/2016 at 9:00 AM during the initial tour, the hallway floors throughout Unit A were observed to be dirty and grimy and there was an odor throughout the unit. On 2/25/2016 at 2:20 PM the hallway floors throughout Unit A were observed to be dirty and grimy and there remained an odor throughout the unit. On 2/26/2016 at 9:00 AM the hallway floors throughout Unit A were observed to be dirty and grimy and there remained an odor throughout the unit On 2/26/2016 9:05 AM the Licensed Practical Nurse (LPN) on the unit was interviewed. She observed the dirty floors and stated that the floors are cleaned and that they get dirty quickly. She then called the Maintenance Department. On 2/26/2016 at 9:31 AM a member of the maintenance staff was observed mopping one small area of the hallway floor on Unit A. The maintenance worker exited the unit after cleaning this small area. On 2/29/2016 at 11:30 AM the Unit A hallway floors were observed to be visibly cleaner and the odor was reduced. On 2/29/2016 at 11:37 AM the Assistant Director of Maintenance, who is in charge of Housekeeping, was interviewed. He stated that Unit A has not been refurbished yet and the floors are in very poor condition. He stated that the hallway floors are mopped daily and on 2/25/16 the hallway floors on Unit A were mopped. He added that there is no log kept regarding hallway floor cleaning. On 3/1/2016 at 11:00 AM the Director of Maintenance was interviewed. He stated that on Wednesdays a scrubbing machine is used to clean all hallway floors, and all hallway floors are mopped daily. He stated that there is no log kept for floor mopping, which is considered general maintenance. He stated that the floors on Unit A were scrubbed on 2/24/2016 (Wednesday) and mopped on 2/25/2016 (Thursday). 2) During an observation tour of the Units A, B, and C conducted on 3/2/16 at 9:00 AM with the Maintenance Director, the following was observed: a) The wheelchair that was designated for Resident #30 had torn right and left arm rests. The 7- 3 PM shift Certified Nurse Aide (CNA) was interviewed on 3/2/16 at 9:15 AM and stated that she was not aware that the resident's wheelchair had a torn bilateral arm rests. b) The wheelchair that was designated for Resident #67 had a torn right arm rest. The 7- 3 PM shift CNA was interviewed on 3/2/16 at 9:05 AM. The CNA stated that she did not know that the resident's wheelchair had a torn right arm rest. c) The wheelchair that was designated for Resident #161 had a torn left arm rest. The 7- 3 PM shift assigned CNA was interviewed on 3/2/16 at 9:20 AM and stated that she was not aware that there was a torn left arm rest. The CNA also stated the she was not aware that she had to report it to the Charge Nurse aside from reporting it to the Maintenance Department. The Director of Maintenance was interviewed on 3/2/16 at 9:30 AM. The Director stated that as of 3/2/16, he had not received any work request for the above mentioned resident's wheelchairs. The Director also stated that he would instruct his staff to replace or repair the torn arm rests immediately. 415.5(h)(2)