Every finding on record at Fairview Nursing Care Center Inc.

Number of residents sampled:Number of residents cited:Based on observation, record review, and interviews, the facility failed to maintain each resident's right to a safe, clean, comfortable, and homelike environment. This was evident in 3 of 5 units (Unit 1, Unit 4, and Unit 3.) observed. Specifically, resident's rooms were noted with torn window screen, ceiling tiles not firmly affixed to ceiling, paint plastered on wall, dining room furniture in disrepair, shower room with stains and shower curtains that were soiled and in disrepair. The findings included but were not limited to: The facility policy titled 'General Housekeeping Policy' dated revised 01/10/2025 documented it is the policy of the facility to provide a clean, safe, orderly comfortable and attractive home-like environment both indoors and outdoors, including walls and floors are to be maintained in accordance with state and federal codes and regulations. 1.During multiple observations from 12/01/2025 at 11:16 AM to 12/03/2025 at 10:01 AM, on Unit 1, two blue chairs were observed with ripped seat cushions in the resident's day room. 2. During multiple observations from 12/01/2025 to 12/08/2025, the following was observed in room [ROOM NUMBER]. Ceiling tiles above upon entering and between two beds in room [ROOM NUMBER] were not firmly affixed to the ceiling. Window screens were torn. Wall noted with white paint patches and chipped broken wallpaper. The review of maintenance log on unit 5 revealed no work related to the above concerns were requested. On 12/08/2025 at 12:30 PM, the Director of Environmental and Maintenance Services was interviewed and stated they are doing maintenance round of the rooms daily so the concerns in room [ROOM NUMBER] should have been addressed. The Director of Environmental and Maintenance Services stated they do not know why these were missed but they will repair them right away. 3. During multiple observations from 12/01/2025 to 12/08/2025, the following were observed on Unit 4: 1. Dining Room: a. nine (9) torn vinyl seat chair cushions. b. ceiling tile not firmly affixed to ceiling, and brownish colored stained ceiling tiles. c. a hung framed cork board torn and in disrepair. d. five (5) round dining room tables with sharp and broken chipped edges all around the base of the tables. 2. Resident Shower Room: a. two (2) of two (2) shower room curtains had a black substance and were stained and frayed. b. one (1) of two (2) shower room across from room [ROOM NUMBER], with a large square opening on wall. c. toilet bowl heavily scratched with yellowish stains. d. surrounding sink area heavily stained with an accumulation of dirt and debris around faucet. e. shower room stall across from room [ROOM NUMBER] with cracked ceiling broken ceiling. f. toilet grab bars not firmly affixed to the wall. On 12/08/2025 at 1:00 PM, the Director of Environmental and Maintenance Services was interviewed and stated a clean safe and homelike environment makes people feel good, specifically residents, staff and visitors and prevents the spread of infection. The Director of Environmental and Maintenance Services also stated their role is to ensure the facility is clean, orderly and functions safely and they make multiple rounds each day on all floors to observe for cleanliness of the high touch areas like resident rooms, sinks areas, floors, dining rooms, shower rooms and that trash is being emptied. The dining room is swept and mopped every day before breakfast and again after supper, and the tables are also wiped clean and disinfected. The Director of Environmental and Maintenance Services further stated the logbook is checked daily, and they have come across issues of debris on floors or other areas, and they address this on the spot with their staff, however at times there is a communication problem with staff due to a language barrier. The Director of Environmental and Maintenance Services stated they ordered and replaced two hundred (200) resident room chairs, and while there are no orders for dining room chairs, they are planning to continue to renovate the entire facility. The Director of Environmental and Maintenance Services also stated they recently removed the vent in the shower room because it was dusty, and they did not replace it right away, and the shower curtains are changed when necessary. 10 NYCRR 415.5(h)(2)

Number of residents sampled:37Number of residents cited:4 Based on observations, record review and interviews, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards and practices. This was evident for one (1) resident (Resident #86) of three (3) residents reviewed for Activities of Daily Living out of a sample of 38 residents. Specifically, 1). Resident #86 was not assisted out of bed, but documentation reflected that resident was taken out of bed, 2). Requested documents for Residents #79, Resident #221 and Resident #220 and access to the facility electronic medical record were not provided in a timely manner. The findings are: 1. Resident #86 was admitted to the facility with diagnoses include Coronary Artery Disease, Hypertension, and Opioid Dependence. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #86 has intact cognition, did not refuse care, was dependent on staff for sit to stand, chair to bed transfer, and uses a wheelchair for mobility. On 12/01/2025 at 10:05 AM, Resident #86 was interviewed and stated they have been at the facility since June 2025 and was being taken out of bed daily to attend therapy. Resident #86 also stated therapy ended few months ago and has only been out of bed a few times to go out for appointments. Resident #86 further stated they are very heavy and understands it is difficult for staff to get them out of bed. Resident #86 stated when they asked nursing assistants for assistance getting out of bed, they were told that there were no instructions for Resident #86 to get out of bed. The Physician Order revised 09/05/2025, last renewed 10/23/2025 documented transfer out of bed to standard wheel chair with gel-foam cushion and bilateral leg rests via mechanical lift. The Resident Nursing Instruction for Transfer revised on 09/05/2025 documented resident to transfer out of bed to standard wheelchair with gel-foam cushion and bilateral leg rests via mechanical lift every day at 7 AM to 3 PM, 3 PM to 11 PM and 11 PM to 7 AM. On 12/01/2025 from 10:05 AM to 1:15 PM, Resident #86 was observed in bed and was not taken out of bed during these times. Review of Certified Nursing Assistant Accountability Record dated 12/01/2025 documented for the 7 AM to 3 PM shift, Resident #86 transfer out of bed was performed on 12/01/2025. For 3 PM to 11 PM, Resident #86 transfer out of bed was performed on 12/01/2025, 12/02/2025, 12/03/2025. leg rests via mechanical lift every day at 7AM to 3PM, 3PM to 11PM and 11PM to 7AM. Following observations were also made on 12/01/2025 at 10:05 AM to 1:15 PM, on 12/02/2025 from 9:30 AM to 1:30PM, on 12/03/2025 from 9 AM to 1:05 PM and revealed that Resident #86 was observed in bed and was not out of bed. Review of Certified Nursing Assistant Accountability Record from 12/01/2025 to 12/03/2025 documented the following: For 7AM to 3PM shift, Resident #86 transfer out of bed was performed on 12/01/2025 and not performed on 12/02/2025 and 12/03/2025. For 3 PM to 11 PM, Resident #86 transfer out of bed was performed on 12/01/2025, 12/02/2025, 12/03/2025. On 12/04/2025 at 12:49 PM, Certified Nursing Assistant #2 stated they were assigned to Resident #86 only few times and they have not assisted Resident #86 to get out of bed but have assisted in other care needs. Certified Nursing Assistant #86 also stated they documented as performed for transfer out of bed on 12/01/2025 during 7 AM to 3 PM shift because the therapist transferred Resident #86 to the main floor for therapy. On 12/08/2025 at 10:02 AM, Certified Nursing Assistant #1 stated they cared for Resident #86 during 3 PM to 11 PM shift on 12/01/2025 and 12/02/2025. Certified Nursing Assistant #1 also stated Resident #86 was not taken out of bed on 12/01/2025 and 12/02/2025 during their shift so they do not recall why they documented as performed in their documentation. On 12/04/2025 at 12: 58 PM, Registered Nurse #3 stated Resident #86 reported pain and refused when staff attempted transfer using the mechanical lift. Resident #86 has been refusing to get out of bed when staff asks. Registered Nurse #3 stated they could not explain why staff documented performed when Resident #86 was not taken out of bed. On 12/04/2025 at 10:10 AM, Registered Nurse #4 stated they are newly hired and has worked been working on the unit for two weeks. Registered Nurse #4 stated Resident #86 is very pleasant and has never refused any care/treatment. Registered Nurse #4 stated they have only seen Resident #86 lying in bed and have not seen coming out of bed during their shift. The Director of Nursing was out of the country and unavailable for the interview. The Assistant Administrator was new to the role and could not give any information related to this deficiency. 2 a). On 12/03/2025 at 9:05 AM, the following documents for Resident #79 were requested: face sheet, current medical orders, current Medication Administration Record, policies and procedures for Gastric Tube Medication Administration, Standards of Professional Practice, Role of the Registered Nurse, List of Non Crushable Medications, Handwashing, staff in service records, Lesson Plan on Medication Administration via gastric tube and Comprehensive Care Plan for Tube Feed, and were not provided until 12/04/2025 at 3:00 PM. b). On 12/03/2025 at 3:30 PM, the following documents were requested for Resident #221: face sheet Minimum Data Set assessments, physician orders, nurse notes, investigation report for a fall, and a medication administration record which was not received until 12/04/2025 at 2:30 PM. c). On 12/01/2025 at 9:30 AM, the Entrance Conference was held with the Acting Administrator, and the facility was provided with information on the documents that would be needed within the hour, the next 4 hours, by the end of the first day of survey and within 24 hours. The Acting Administrator stated the Director of Nursing Services was out on vacation and they did not have a replacement. On 12/01/2025 at 1:30 PM, the Facility Matrix for all floors had not been received. On 12/01/2025 between 2 PM and 3 PM, the matrix for two floors were provided. The Acting Administrator further stated that the matrix for the remaining floors would be left in the conference room the same day. On 12/02/2025 at 11:37 AM, the Acting Administrator was notified that the team still had not received access to the Medication Administration Record or the Treatment Administration Records in the facility's electronic medical record. The Acting Administrator stated the Quality Assurance Staff had been in contact with the customer service department for the electronic medical record and they were not sure why this problem was still occurring. On 12/03/2025 at 11:30 AM, the Acting Administrator was notified that the team still did not have access to the Medication Administration Record, Treatment Administration Record and notes in the care plan. The Acting Administrator stated that they have been in contact with electronic medical record company and was disappointed about the delay. On 12/03/2025 at 12:52 PM, the Acting Administrator and Quality Assurance Staff was informed that the survey team was still having limited access to the Electronic Health Record. On 12/03/25 at 1:45 PM, the survey team held a meeting with the Acting Administrator and Quality Assurance Staff Member. The facility was notified that the survey team still had not received access to the Medication Administration Record, Treatment Administration Record and care plan notes in electronic medical record. The customer service department for the electronic medical record was contacted from the main conference room in the presence of the surveyors, and access to all areas of the medical record requested was provided within 25 minutes. The Quality Assurance Staff Member stated that they were unsure of the system and was informed the vendor on previous calls that surveyors had access to everything on the electronic medical record, but they failed to follow up by checking with the surveyors themselves. On 12/04/25 at 1:30 PM, the Acting Administrator was informed that multiple surveyors who had submitted lists for printed medical records the previous day, still had not received them. The Acting Administrator stated there was only one person working in Medical Records and that person was also responsible for printing the requested documents. The Acting Administrator further stated that more people would be put in place to assist Medical Records in printing documents. On 12/08/2025 at 12:25 PM, the Acting Administrator was interviewed and stated usually the Director of Nursing Services prepares the survey binder where everything is in place for the surveyor. The Acting Administrator also stated the Director of Nursing Services was out of the country and the facility could not get in touch with them to locate the binder. The Acting Administrator further stated they were aware that they did not provide the matrix within the 4 hours as required, and the electronic medical record vendor informed them that surveyors had access to the record, but the Quality Assurance Staff failed to follow up with the surveyors to ensure access. The Acting Administrator. Stated the delay in getting documents over to the respective surveyors was due to there being only one person responsible for printing and scanning the documents. 10 NYCRR 415.22(a)(1-4)

Number of residents sampled:Number of residents cited:Based on observations and staff interviews, the facility did not ensure that it provided a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This was evidenced by multiple observations of the staff bathrooms, elevators, lobby area and nursing stations.This was evident in the Lobby Area including on one (1) of five (5) units. Unit 4.The findings include but are not limited to: The facility policy titled General Housekeeping Policy dated 01/10/2025 documented that is the policy of this facility to provide a clean safe orderly comfortable and attractive homelike environment both indoors and outdoors.On multiple occasions from 12/01/2025 - 12/08/2025 the following was observed: 1. Lobby Area: a. three (3) of three (3) wall light fixtures located in the lobby wall area dusty shades, each missing one (1) of two (2) tear shaped crystal ornament.b. area located near kitchen area: corner panels missing and broken. c. ice machine located outside kitchen area with black and silver tape. d. broken ice tray rack2. Elevators A and B:a. two (2) of two (2) elevators with broken, wall panels in disrepair.b. floor embedded with accumulation of dirt dust and debris.3. 4th floor staff bathroom:a. loose sink faucet.b. floor corners embedded with ground in dirt.4. 4th floor Nurse Station:a. two (2) of two (2) torn vinyl seat cushion.b. floors with accumulation of layered dirt dust and debris.c. nurse station desk with Formica panels in disrepair.On 12/08/2025 at 1:00 pm the Director of Environmental and Maintenance Services was interviewed and stated that a clean safe and homelike environment makes people feel good, specifically residents, staff and visitors and prevents the spread of infection. I make multiple rounds a day of all floors including the basement. My role is to ensure that the facility is clean, orderly and functions safely. I observe for cleanliness of the high touch areas like resident rooms, sinks areas, light switches, floors, nurse stations, dining rooms, shower rooms and trash are being emptied and more. When making my daily rounds I have come across issues of debris on floors or other areas. I address this on the spot with my staff. I have a housekeeper on every resident floor. The nurse station is to be swept and mopped daily. The nurses are working at the nurse station, and we cannot always get to clean that space. There is a maintenance logbook on the units, for any staff to log in issues like loose bathroom sinks, broken ice machines, loose faucets. We are planning to purchase chairs for the nurse station. The lobby area ceiling light fixtures have been replaced, but not the wall light fixtures. There is a logbook on each unit for any Maintenance workorder that needs to be addressed. Staff can call or fill in a request. The logbook is checked daily. 10 NYCRR 415.29

Based on record review and staff interviews, the facility failed to ensure residents remained free from chemical restraints. This was evident for one (1) of five (5) residents (Resident #162) reviewed for Unnecessary Medication out of a sample of 38 residents. Specifically, the facility did not rule out underlying medical conditions prior to initiating and increasing a dose of an antianxiety medication. In addition, there was no evidence the continued need for the medication was evaluated after Resident #162 was treated for a urinary tract infection and no longer displayed behaviors that were present when the medication was initiated. The findings are: The facility's policy and procedure titled 'Use of Psychotropics' reviewed 4/2025 documented physicians use psychotropic medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. Evaluate the ongoing effectiveness, benefits as well as risks of non-pharmacological approaches and psychotropic medications. Monitoring and accurate documentation of resident's response to any treatment such as laboratory results, vital signs, progress notes, behavior flow sheets, medication administration records, and consultant pharmacist's drug regimen review. Resident #162 was admitted to the facility with diagnoses which included Non-Alzheimer's Dementia, Hyperlipidemia and Traumatic Brain Injury. The Quarterly Minimum Data Set, dated [DATE] documented Resident #162 had severely impaired cognition and received antianxiety medication seven (7) out of seven (7) days. The Comprehensive Care Plan for Psychotropic initiated 08/09/2025 reviewed 11/09/2025 documented resident on Buspirone 5mg tab for anxiety disorder. Interventions were to monitor behavior and intervene appropriately, monitor drug effectiveness.The Psychiatry Consultations completed 01/14/2025, 03/18/2025, 03/25/2025, 04/17/2025, 04/22/2025 and last completed 05/13/2025 documented Resident #162 with history of Dementia, Insomnia was seen. Chart reviewed. Discussed with nursing staff. Resident has no complaints and denies symptoms of depression or anxiety. Patient denies side effects from medications. Resident to continue current medications Donepezil 10mg at bedtime, Melatonin 5mg at bedtime and Namenda 10mg twice a day.The Physician Note dated 08/09/2025 documented Resident #162 was seen and examined at the bedside for evaluation of reported agitation. Buspirone was ordered. Labs reviewed. Will monitor clinically. The Physician Order initiated 08/09/2025 documented to administer Buspirone 5mg tab once daily at 4 PM for anxiety disorder. There was no documented evidence nonpharmacological interventions were attempted or that underlying medical conditions were ruled out prior to initiating Buspirone on 08/09/2025. The Physician Note dated 08/27/2025 documented Resident #162 was evaluated at bedside for reportedly feeling anxious. Resident is on Buspirone and offered alternative medication, but resident declined it. Psychiatry consultation was advised.There was no documented evidence that a psychiatry consultation was ever completed since 05/13/2025. The Behavior Note dated 09/21/2025 documented Resident #162 noted with agitation and noncompliance with care. Resident becomes physically aggressive during activity of daily living, needs a lot of encouragement and assistance during care. Will continue to monitor. The Physician Note dated 09/30/2025 documented Resident #162 evaluated after staff noted agitation, pacing, and having verbal outbursts. Also, restless. Resident #162 responded to calm counseling and redirection. Continue reinforce verbal redirection, low stimulation setting. There was no documented evidence that a psychiatry consultation was requested to evaluate increased behaviors or that underlying medical conditions were ruled out. The facility Discharge Summary Note dated 10/03/2025 and completed prior to Resident #162's transfer to the emergency room, documented Resident #162 noted with increased agitation and refusing evaluation after multiple redirections. Upon conversation with resident's spouse to increase Buspirone. Buspirone was later increased to manage resident's agitation so resident would be more compliant with hospital transfer for further evaluation and possible extension or modification to treatment (due to persistent refusal of facility evaluation). The Physician Order for Buspirone 5mg tab once daily at 4 PM for anxiety disorder was discontinued on 10/03/2025. The Physician Order dated 10/03/2025, renewed 10/23/2025 and last renewed 12/05/2025 documented Buspirone 5mg tab twice daily at 9 AM and 9 PM for anxiety disorder. The Nursing Note dated 10/03/2025 documented physician order Buspirone 5mg every 12 hours, order carried out. Buspirone 5mg once daily was increased to 5mg twice a day at 9 AM and 9 PM on 10/03/2025. The Physician Note dated 10/03/2025 documented Resident #162 was transferred to the hospital for further evaluation.The Hospital Discharge Summary Note dated 10/04/2025 documented Resident #162 was diagnosed with acute urinary tract infection, a dose of Ceftriaxone 1gram was administered. Resident #162 to complete antibiotic medication upon returning to the nursing facility. The Physician Orders for Ceftriaxone 1 GM in 100 ml by intravenous route once daily for 5 days was initiated and Buspirone 5 PM twice a day was continued upon readmitting to the nursing facility on 10/04/2025. There was no documented evidence in Physician Notes dated 10/05/2025 and 10/09/2025 that resident was evaluated upon readmission from hospital for necessity of the increased dose of Buspirone 5 MG twice a day. The Physician Monthly assessment dated [DATE] documented Resident #162 evaluated for monthly review. Consultations and labs were reviewed. Resident with anxiety, continue Buspirone, continue clinical monitoring, follow up with labs. The Physician Note dated 10/14/2025 documented Resident #162 expressed hesitancy regarding the need for certain medication, citing concerns about side effects and feeling fine without them. Resident counseled at length regarding purpose and importance of adherence. Will follow up to reassess compliance and evaluate any emerging concerns or side effects. There was no documented evidence of ongoing behaviors to support use of an antianxiety medication following completion of antibiotic therapy for a urinary tract infection for Resident #162. In addition, there was no documented evidence that the necessity of the medication was evaluated, or adjustments made after Resident #162 expressed concerns about continued use of the medication. The Physician Monthly assessment dated [DATE] documented Resident #162 evaluated for monthly review. Previous consultations and labs were reviewed. Resident with anxiety, continue Buspirone, and continue with behavioral pattern monitoring. The Behavior Notes dated 10/18/2025 and 11/27/2025 documented Resident #162 is verbally responsive, calm and quiet. Resident is being monitored for Dementia without behavioral disturbances and Insomnia. Resident was last seen by the psychiatrist on 05/13/25, there is no new recommendation. No noted behavior at this time. Resident is currently on Donepezil 10 mg for dementia, Melatonin 5 mg at bedtime for insomnia and Namenda 10 mg twice a day for dementia. No side effects noted. Will continue to monitor. The behavior notes did not document Resident #162 was also receiving on Buspar also at this time. On 12/05/2025 at 10:48 AM, Registered Nurse #5 stated Resident #162 has dementia, and was evaluated by the Psychiatrist upon admission with last follow up done in May 2025. Registered Nurse #5 also stated they were informed of the increased order for Buspirone 5mg to twice daily by the covering physician on 10/03/2025. Registered Nurse #5 stated resident with any change in medication regimen are monitored especially for antipsychotic medication. Unit nurses will create behavior note documenting an episode or event when resident was noted with change in behavior. On 12/08/2025 at 12:35 PM, Medical Doctor #3 was interviewed by telephone and stated they were covering physician who saw Resident #162 on 10/03/2025. Resident #162 was agitated, refusing to transfer for hospital evaluation. Medical Doctor #3 stated after discussing with Resident #162's spouse they decided to increase Buspirone for Resident #162 to comply in hospital transfer for further evaluate resident's condition. Medical Doctor #3 could not explain why the increased dose of Buspar was continued after Resident #162 was treated for a urinary tract infection and was no longer displaying behaviors. On 12/08/2025 at 12:05 PM, Medical Doctor #2 was interviewed by telephone and stated they were covering doctor on 10/23/2025 and renewed Resident #162's medications because they were due to be renewed on 10/23/2025. Medical Doctor #2 also stated they were not aware that of any prior changes in medication dosage or frequency. On 12/08/2025 at 12:15 PM, Medical Doctor #1 was interviewed by telephone and stated there is no assigned doctor for Unit 5, so all doctors are responsible to oversee and supervise resident's care and treatment. Medical Doctor #1 also stated they review previous consultant/physician notes and speak to unit nurses for any changes in condition or treatment. Medical Doctor #1 further stated they saw the increase dosage for Buspirone when they renewed the monthly medications in December 2025. Medical Doctor #1 stated if there were any changes in medication treatment, there would be ongoing evaluation and monitoring of the effectiveness, and it is the responsibility of all physicians to monitor the effects of medication change regularly and determine if treatment/interventions remain as appropriate. 10 NYCRR 415.4(a)(1)

Number of residents sampled: 35Number of residents cited:1Based on observation, staff interview and record review, the facility failed to ensure needed care and services that are resident centered, in accordance with the professional standards of practice that will meet resident's physical, mental, and psychosocial needs are provided to a resident. This was evident for one (1) of two (2) residents (Resident #79) reviewed for Tube Feeding out of 38 sampled residents. Specifically, 1). functioning of a gastrostomy tube was not checked prior to the administration of medications, and 2). Multiple medications were crushed and administered together. The findings included but were not limited to:The facility policy and procedure titled 'Medication Administration via Gastrostomy, Nasogastric or Jejunostomy Tube' dated 06/2025 documented pour medication into individual plastic bag and crush medications individually, pour powdered medications into a plastic calibrated medication cup and dilute with sufficient amount of water usually 10 cubic centimeters to facilitate administration. Stir the medications until totally dissolved. Keeps medications separate. To ensure tube is in proper place, place stethoscope with 10 -15 cubic centimeter of air and listen for swish sound OR draw back plunger and observe aspiration of stomach contents and returns to stomach. Flush the tube with approximately 10 cubic centimeters of water after each medication, final medication flush of 30 cubic centimeters of water (or otherwise indicated). Resident #79 was admitted to the facility with diagnoses that included Amyotrophic lateral sclerosis (a progressive disease that leads to muscle weakness and loss of voluntary muscle control), Gastrostomy status, and Dysphagia (difficulty swallowing). The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #79 was severely cognitively impaired. The Medical orders dated 12/05/2025 documented the following:crush medications to facilitate administration, gastrostomy tube, check placement prior to start of feeds, call medical doctor if return is greater than 100 cubic centimeters (cc). Ferrous sulfate (iron) 325 milligram by gastric tube daily, glycopyrrolate (reduces salivary secretions) 1 milligram by gastric tube twice daily, baclofen (control muscle spasm) 10 milligrams via gastric tube, folic acid (vitamin B) 1 milligram via gastric tube daily. On 12/03/2025 at 8:45 AM, Registered Nurse #1 was observed conducting medication administration for Resident #79. Registered Nurse #1 placed (1) Folic acid 100 mg tablet, one (1) ferrous sulfate 325 mg tablet, one (1) baclofen 10 mg tablet, and one (1) glycopyrrolate tablet 1 mg in a plastic medication cup. Registered Nurse #1 then placed all four (4) medications in a clear plastic pouch and crushed them together, using a medication crusher. Registered Nurse #1 entered Resident #79's room and placed the powdered medications into a five (5) ounce (approximately 150 cubic centimeters) clear plastic cup and added water. Registered Nurse #1 filled a second five (5) ounce clear plastic cup with water and placed it at the bedside table. Registered Nurse #1 then proceeded to administer a water flush of 60 cubic centimeters into the gastric tube. Registered Nurse #1 continued by withdrawing 60 cubic centimeters of the medications mixed with water solution and pushed this into the gastric tubing. An additional 40 cubic centimeters of the remaining medication mixed with water solution was then administered into the gastric tube. Registered Nurse #1 completed the medication administration process by flushing 35 cubic centimeters of water into the gastric tube.Registered Nurse #1 did not verify that the tube was functioning before they administered medication, and they did not give each medication individually and flush with 10 cubic centimeters between each medication. On 12/03/2025 at 11:29 AM, Registered Nurse #1 was interviewed and stated they were nervous, and they do not administer medications to residents with gastric tubing in this manner. Registered Nurse #1 also stated they have received training on how to administer medications to residents with a gastric tube in place, and medications need to be given separately because they each have a side effect and can cause a side effect reaction. On 12/05/2025 at 10:06 AM, the Attending Physician was interviewed and stated Resident #79 has a gastric tube due to their diagnosis of Amyotrophic Lateral Sclerosis, which is a serious disease that kills muscles, and leads to an inability to swallow. The Attending Physician also stated medications are to be administered separately, one at a time and slowly as the body needs time to absorb them as the Resident #79 has a slow absorption rate due to their diagnosis. The Attending Physician further stated checking for patency prior to administering medications is necessary to ensure the stomach is not full which can cause bloating, vomiting and discomfort, and if too much fluid is administered, it can cause the resident discomfort. On 12/08/2025 at 8:28 AM, Registered Nurse Supervisor #2 was interviewed and stated frequent rounds are conducted every day on every floor, after reports are obtained from prior shifts to ensure that continuity of care and services and needed follow ups are done. Registered Nurse Supervisor #2 also stated medications given to residents who have a gastric tube are to be crushed and administered separately, and checking for stomach contents is important to ensure placement stomach filling amount. Registered Nurse Supervisor #2 further stated the facility policy is to flush the gastric tube with 30 cubic centimeters of water after checking for patency. If there is 100 cubic centimeters of stomach content of more, then the feeds and medications are to be held, and the medical doctor is to be notified. Registered Nurse Supervisor #2 stated we dilute each medication with ten cubic centimeters of water for dilution of each medication, and flush with thirty cubic centimeters of water once all medication has been given. Registered Nurse Supervisor #2 also stated the nurse did not follow standards of practice and this could have had consequences for Resident #79. 10 NYCRR 415.11 (c) (3)(i)

Based on observations, record review and interviews, the facility failed to ensure that residents who are unable to carry out activities of daily living receive the necessary services and assistance to maintain grooming, and personal hygiene. This was evident for one (1) of three (3) residents (Resident #86) reviewed for Activities of Daily Living out of a sample of 38 residents. Specifically, Resident #86 was not assisted out of bed as per physician's order and their plan of care. The findings are:The facility's policy and procedure titled 'Activities of Daily Living Supporting' reviewed 01/10/2025 documented residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Resident #86 was admitted to the facility with diagnoses include Coronary Artery Disease, Hypertension, and Opioid Dependence. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #86 has intact cognition, did not refuse care, was dependent on staff for sit to stand, chair to bed transfer, and uses a wheelchair for mobility. On 12/01/2025 at 10:05 AM, Resident #86 was interviewed and stated they have been at the facility since June 2025 and was being taken out of bed daily to attend therapy. Resident #86 also stated therapy ended few months ago and has only been out of bed a few times to go out for appointments. Resident #86 further stated they are very heavy and understands it is difficult for staff to get them out of bed. Resident #86 stated when they asked nursing assistants for assistance getting out of bed, they were told that there were no instructions for Resident #86 to get out of bed. The Comprehensive Care Plan for Mobility dated 06/02/2025 revised 09/24/2025 documented Resident #86 is dependent for bed mobility from lying to sit to stand and transfer from bed to chair. Intervention included transfer out of bed to standard wheelchair with gel-foam cushion and B leg rests via mechanical lift.The Comprehensive Care Plan for Noncompliance dated 06/02/2025 documented Resident #86 failure to follow therapeutic plan of care, refusal of optometrist. Interventions included to allow the resident to make decisions about treatment regime, to provide sense of control, and if possible, negotiate a time for activities of daily living so that the resident participates in the decision-making process, return at the agreed upon time.There was no documented evidence Resident #86 was noncompliant with getting out of bed or had refused to get out of bed.The Physical Therapy note dated 09/05/2025 documented Resident #86 was discharged from physical therapy at maximum for transfers. However, for safety of both the resident and staff on unit, transfers recommended to be updated to include dependent on two staff with Hoyer lift. This plan will be implemented to ensure safe and consistent transfer practices. Patient and interdisciplinary team verbalized understanding and in agreement.The Physician Order revised 09/05/2025, last renewed 10/23/2025 documented transfer out of bed to standard wheelchair with gel-foam cushion and bilateral leg rests via mechanical lift.The Resident Nursing Instruction for Transfer revised on 09/05/2025 documented resident to transfer out of bed to standard wheelchair with gel-foam cushion and bilateral leg rests via mechanical lift every day at 7 AM to 3 PM, 3 PM to 11 PM and 11 PM to 7 AM. On 12/01/2025 from 10:05 AM to 1:15 PM, on 12/02/2025 from 9:30 AM to 1:30 PM, on 12/03/2025 from 9:00 AM to 1:05 PM Resident #86 was observed in bed and was not taken out of bed during these times. Review of Certified Nursing Assistant Accountability Record from 12/01/2025 to 12/03/2025 documented the following: For 7 AM to 3 PM shift, Resident #86 transfer out of bed was performed on 12/01/2025 and not performed on 12/02/2025 and 12/03/2025. For 3 PM to 11 PM, Resident #86 transfer out of bed was performed on 12/01/2025, 12/02/2025, 12/03/2025.For 11 PM to 7 AM, Resident #86 transfer out of bed was not performed on 12/01/2025, 12/02/2025 and 12/03/2025. On 12/03/2025 at 11:04 AM, the Director of Rehabilitation stated when Resident #86 was on therapy, the therapist assisted Resident #86 to get out of bed and into the wheelchair to go down to the gym five (5) to six (6) times per week. The Director of Rehabilitation also stated therapy ended sometime in September 2025, and on 09/05/2025, there is discharge recommendation to transfer resident out of bed with two staff using mechanical lift on the unit which has not changed and is currently still active for staff to follow for transfer.On 12/04/2025 at 12:49 PM, Certified Nursing Assistant #2 stated they were assigned to Resident #86 only few times and they have not assisted Resident #86 to get out of bed but have assisted in other care needs. Certified Nursing Assistant #86 also stated they documented as performed for transfer out of bed on 12/01/2025 during 7 AM to 3 PM shift because the therapist transferred Resident #86 to the main floor for therapy.On 12/03/2025 at 12:35 PM, Certified Nursing Assistant #3 stated they regularly taking care of Resident #86, so they are familiar with resident's care needs. Certified Nursing Assistant #3 also stated that in the past they attempted transferring Resident #86 out of bed using the Hoyer lift, but this could not be done because Resident #86 reported having pain on their left right leg. Certified Nursing Assistant #3 further stated they permanently stopped transferring Resident #86 out of bed after that, and documented not performed for the transfer out of bed task On 12/08/2025 at 10:02 AM, Certified Nursing Assistant #1 stated they cared for Resident #86 during 3 PM to 11 PM shift on 12/01/2025 and 12/02/2025. Certified Nursing Assistant #1 also stated Resident #86 was not taken out of bed on 12/01/2025 and 12/02/2025 during their shift so they do not recall why they documented as performed in their documentation.On 12/04/2025 at 12: 58 PM, Registered Nurse #3 stated Resident #86 reported pain and refused when staff attempted transfer using the mechanical lift. Registered Nurse #3 also stated Resident #86 has been refusing to get out of bed when asked by staff. Registered Nurse #3 further stated Resident #86 is cognitively intact and was spoken to when they refused to get out of bed and all refusals and related documentation is done by the nursing supervisors. Registered Nurse #3 stated they could not explain why staff documented 'performed' when Resident #86 was not taken out of bed.On 12/04/2025 at 10:10 AM, Registered Nurse #4 stated they are newly hired and has worked been working on the unit for two weeks. Registered Nurse #4 stated Resident #86 is very pleasant and has never refused any care/treatment. Registered Nurse #4 stated do medication pass on the unit and they have only seen Resident #86 lying in bed and have not seen them being taken out of bed during their shift.On 12/08/2025 at 11:02 AM, Registered Nurse #5, who is the supervisor on the unit, stated Resident #86 has a history of refusing care and treatments which have been documented in the medical record. Registered Nurse #5 also stated Resident #86 complained of pain during transfer in the past and did not want to come out of bed, however, they were not aware that Resident #86 had not been out of bed for some time. Registered Nurse #5 further stated the certified nursing assistants are responsible to provide care as per resident needs and inform nurses of any care refusal/concerns so the team can evaluate and find a solution in timely manner. 10 NYCRR 415.12(a)(3)

Based on observation, staff interview and record review conducted during the Recertification survey, the facility failed to ensure that a resident fed by enteral means receives the appropriate treatment to prevent complications of enteral feeding. This was evident for one (1) of two (2) residents (Resident #79) reviewed for Tube Feeding out of a 38 sampled residents. Specifically, 1). The functioning of a gastrostomy tube was not checked prior to the administration of medications, and 2). Multiple medications were crushed and administered together.The findings included but were not limited to:The facility policy and procedure titled 'Quality of Care' dated 02/15/2025 documented the facility will deliver high quality, person-centered care based on accurate assessment, individualized care plans, resident rights, professional standards and evidenced based clinical practices.The facility policy and procedure titled 'Medication Administration via Gastrostomy, Nasogastric or Jejunostomy Tube' dated 06/2025 documented pour medication into individual plastic bag and crush medications individually, pour powdered medications into a plastic calibrated medication cup and dilute with sufficient amount of water usually 10 cubic centimeters to facilitate administration. Stir the medications until totally dissolved. Keeps medications separate. To ensure tube is in proper place, place stethoscope with 10-15 cubic centimeters of air and listen for swish sound OR draw back plunger and observe aspiration of stomach contents and returns to stomach. Flush the tube with approximately 10 cubic centimeters of water after each medication, final medication flush of 30 cubic centimeters of water (or otherwise indicated). Resident #79 was admitted to the facility with diagnoses that included Amyotrophic lateral sclerosis (a progressive disease that leads to muscle weakness and loss of voluntary muscle control), Gastrostomy status, and Dysphagia (difficulty swallowing). The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #79 was severely cognitively impaired. The Medical orders dated 12/05/2025 documented the following:crush medications to facilitate administration, gastrostomy tube, check placement prior to start of feeds, call medical doctor if return is greater than 100 cubic centimeters (cc). Ferrous sulfate (iron) 325 milligram by gastric tube daily, glycopyrrolate (reduces salivary secretions) 1 milligram by gastric tube twice daily, baclofen (control muscle spasm) 10 milligrams via gastric tube, folic acid (vitamin B) 1 milligram via gastric tube daily. The Comprehensive Care Plan for Tube Feeding effective date 10/03/2025, documented check for placement, patency and residual prior feeding. There is no documented interventions about medication water flushes that are to be administered during the medication administration process. On 12/03/2025 at 8:45 AM, Registered Nurse #1 was observed conducting medication administration for Resident #79. Registered Nurse #1 placed (1) Folic acid 100 mg tablet, one (1) ferrous sulfate 325 mg tablet, one (1) baclofen 10 mg tablet, and one (1) glycopyrrolate tablet 1 mg in a plastic medication cup. Registered Nurse #1 then placed all four (4) medications in a clear plastic pouch and crushed them together, using a medication crusher. Registered Nurse #1 entered Resident #79's room and placed the powdered medications into a five (5) ounce (approximately 150 cubic centimeters) clear plastic cup and added water. Registered Nurse #1 filled a second five (5) ounce clear plastic cup with water and placed it at the bedside table. Registered Nurse #1 then proceeded to administer a water flush of 60 cubic centimeters into the gastric tube. Registered Nurse #1 continued by withdrawing 60 cubic centimeters of the medications mixed in the water solution and pushed this into the gastric tubing. An additional 40 cubic centimeters of the remaining medication mixed in the water solution was then administered into the gastric tube. Registered Nurse #1 completed the medication administration process by flushing 35 cubic centimeters of water into the gastric tube.Registered Nurse #1 did not verify that the tube was functioning before they administered medication, and they did not give each medication individually and flush with 10 cubic centimeters between each medication. On 12/03/2025 at 11:29 AM, Registered Nurse #1 was interviewed and stated they were nervous, and they do not administer medications to residents with gastric tubing in this manner. Registered Nurse #1 also stated they have received training on how to administer medications to residents with a gastric tube in place, and medications need to be given separately because they each have a side effect and can cause a side effect reaction. On 12/05/2025 at 10:06 AM, the Attending Physician was interviewed and stated Resident #79 has a gastric tube due to their diagnosis of Amyotrophic Lateral Sclerosis, which is a serious disease that kills muscles, and leads to an inability to swallow. The Attending Physician also stated medications are to be administered separately, one at a time and slowly as the body needs time to absorb them as the Resident #79 has a slow absorption rate due to their diagnosis. The Attending Physician further stated checking for patency prior to administering medications is necessary to ensure the stomach is not full which can cause bloating, vomiting and discomfort, and if too much fluid is administered, it can cause the resident discomfort. On 12/08/2025 at 8:28 AM, Registered Nurse Supervisor #2 was interviewed and stated frequent rounds are conducted every day on every floor, after reports are obtained from prior shifts to ensure that continuity of care and services and needed follow ups are done. Registered Nurse Supervisor #2 also stated medications given to residents who have a gastric tube are to be crushed and administered separately, and checking for stomach contents is important to ensure placement stomach filling amount. Registered Nurse Supervisor #2 further stated the facility policy is to flush the gastric tube with 30 cubic centimeters of water after checking for patency. If there is 100 cubic centimeters of stomach content of more, then the feeds and medications are to be held, and the medical doctor is to be notified. Registered Nurse Supervisor #2 stated we dilute each medication with ten cubic centimeters of water for dilution of each medication, and flush with thirty cubic centimeters of water once all medication has been given. Registered Nurse Supervisor #2 also stated the nurse did not follow standards of practice and this could have had consequences for Resident #79. 10 NYCRR 415.12(g)(1-7)

Number of residents sampled:Number of residents cited:Based on observation and staff interviews, the facility failed to ensure infection control prevention practices and procedures were maintained to provide a safe and sanitary environment, and to help prevent the development and transmission of communicable diseases and infections. This was evident during the Infection Control Task. Specifically, Resident #3 was observed with an open right shoulder wound and was not maintained on Enhanced Barrier Precautions. The findings are:The facility policy titled 'Enhanced Barrier Precautions' dated 05/18/2019 and last revised 06/10/2025 documented Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of community acquired multidrug resistant organisms colonization's/infections in patient care areas. The policy also documented Enhanced Barrier Precautions may be indicated for resident with wounds or indwelling medical devices regardless of multidrug resistant organism status. Wounds generally include chronic wounds, not shorter lasting wounds such as skin breaks or skin tears covered with an adhesive bandage or similar dressing. Examples of chronic wounds include but are not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds and venous stasis ulcers. Resident #3 was admitted with diagnoses that included Cirrhosis, unspecified fracture of left patella and unspecified fracture of upper end of right humerus and was status post repair fracture of the shoulder. The admission Minimum Data Set, dated [DATE] documented Resident #3 had a major surgical procedure during the prior inpatient hospital stay and had a surgical wound with surgical wound care in place.Order details dated 10/23/2025 documented surgical site: cleanse right shoulder wound and peri-wound with wound cleanser, pat dry, apply skin-prep to peri-wound, apply Medi-honey to wound bed, cover with silver alginate twice daily and as needed. The Wound Care note dated 10/21/2025 documented right shoulder, 100% primary closed surgical wound with previous 19 sutures removed at clinic measured at 13.0 centimeters x 1.5 centimeters x 0.6 centimeters, 30% slough (dead tissue in a wound that can slow healing and may be yellow, tan or white in color) and 70% epithelial (healed cells that cover a wound) tissue. Dehiscence (a complication of surgery where a closed wound reopens) noted in the middle of surgical wound, 1.5 x 1.5 x 0.6 centimeters, 100% yellow slough and serous moderate exudate (fluid that leaks from a wound during the healing process). Start surgical site: cleanse right shoulder wound and peri-wound with wound cleanser, pat dry, apply skin prep to peri-wound, apply Medi-honey to wound bed then cover with silver alginate and dry protective dressing twice daily and as needed. Wound care note dated 12/04/2025 documented right shoulder 100% primary closed surgical wound with previous 19 sutures removed at clinic measured at 13.0 centimeters x 1.0 centimeters x 0.6 centimeters, 10% granulation tissue (new healed tissue on a wound), 90% epithelial tissue. Dehiscence noted in the middle of surgical wound measuring 1.0 centimeters x 1.0 centimeters x 0.0 centimeters, 100% pink granulation tissue and serous-sanguineus moderate exudate.Resident #3's name was not included on the Enhanced Barrier Precautions list last updated on 12/08/2025.On multiple observations between 12/01/2025 and 12/08/2025, there was no Enhanced Barrier Precautions signage noted in front Resident #3's room. On 12/04/2025 at 10:48 AM, the Wound Care Specialist was interviewed and stated Resident #3 has a history of methicillin-resistant staphylococcus aureus which is currently not active. Resident #3 initially presented with a closed right wound and a left open knee which eventually healed. On 10/14/2025, right shoulder sutures were removed and as of 10/21/2025, Resident #3 started having dehiscence from the right shoulder. The right shoulder wound is currently open but improving currently. From the right shoulder, there is moderate serosanguinous drainage. Wound care was performed this morning and Resident #3 was noted with small to moderate serosanguinous with orders to continue with alginate. The Wound Care Specialist also stated Resident #3 is not on the list for Enhanced Barrier Precautions at this time, and Enhanced Barrier Precautions are indicated for people who have a foley, peripherally inserted central catheter, perma-catheter, pressure wounds at a stage 3 or 4 and those with a huge surgical site or incision. In Residents #3's case, since the right shoulder wound is improving and the open part is less than 1 centimeter in length, Resident #3 does not need to be on Enhanced Barrier Precautions. On 12/04/2025 at 11:30 AM, the Infection Control Preventionist was interviewed and stated they have been working at the facility for 2 years. The Infection Control Preventionist also stated Enhanced Barrier Precautions are indicated for residents who have catheters with peripherally inserted central catheters, midline, foley catheter, major wounds and for those with current infections. The Infection Control Preventionist further stated Resident #3 is on vancomycin for prophylactic measures as they had a history of methicillin-resistant staphylococcus aureus which was resolved on 10/21/2025, and if a resident has major wound and if it warrants risk for infection, then the resident will be on Enhanced Barrier Precautions. The Infection Control Preventionist stated Resident #3 is currently not on Enhanced Barrier Precautions and they are not sure if they should be on it.On 12/04/2025 at 12:10 PM, the Medical Director was interviewed and stated that if a resident has a wound that is open, it may warrant that the resident is placed on Enhanced Barrier Precautions. On 12/05/2025 at 3:02 PM, wound care observation was performed with the Wound Care Specialist. Resident #3 was noted with a small open wound to the right shoulder with pink granulation tissue noted and a small amount of serous drainage noted on soiled dressing. Enhanced Barrier Precautions were not utilized during the wound care observation and there was no signage for Enhanced Barrier Precautions in front of Resident #3's room. On 12/05/2025 at 1:23 PM, the Wound Care Doctor was interviewed and stated they last evaluated Resident #3 this past Tuesday and Resident #3 was noted with an open right shoulder wound. The Wound Care Doctor also stated usually if a resident has a pressure ulcer at a Stage 2 or higher they are put on Enhanced Barrier Precautions, and if a resident has an open wound, they may need to be on Enhanced Barrier Precautions. The Wound Care Doctor further stated that from their judgment if a resident has an open surgical wound, Enhanced Barrier Precautions may be needed to prevent any infection to the surgical site.On 12/08/2025 at 11:22 AM, Certified Nursing Assistant #5 was interviewed and stated Resident #3 was initially on precautions when they first came to the facility but not at this time. Certified Nursing Assistant #5 also stated Resident #3 currently has a wound to the shoulder which is open as the nursing staff frequently change the dressing. Certified Nursing Assistant #5 further stated that they do not wear a gown or anything when giving care as Resident #3 is not on any precautions at this time. On 12/08/2025 at 12:21 PM, the Acting Administrator was interviewed and stated they have been working as the Acting Administrator since 08/20/2025 and prior to that was an Assistant Director of Nursing from 2021. The Acting Administrator also stated Enhanced Barrier Precautions are indicated if a resident has an active infection, is on isolation or if the doctor decides the resident should be on Enhanced Barrier Precautions. The Acting Administrator further stated is determined by the Infection Control Preventionist and the doctor. The Acting Administrator stated they are not sure if a resident with an open surgical wound needs to be on Enhanced Barrier Precautions. 10 NYCRR 415.19 (b)(4)

Based on observations and staff interviews conducted during the recertification survey on 11/08/23 - 11/15/23 the facility did not ensure that pertinent State Agency information was posted as is required. Specifically, the New York Department of Health Complaint Hotline number and related information were observed not posted on any resident units. This was evident for 5 of 5 resident units. The finding is: The undated facility policy & procedure titled Residents' Rights documented that any written information required to be posted shall be posted conspicuously in a public place in the facility that is frequented by residents and visitors, posted at wheelchair level. During the initial tour on 11/08/23, and subsequent observations on all resident units (1-5) on 11/09/23 and 11/10/23, there were no postings informing residents of how to contact the New York State Department of Health Complaint Hotline. During the Resident Council Meeting conducted on 11/9/23 at 3:00 PM, all residents stated that they did not know how to formally complain to the State about care they are receiving. On 11/13/23 at 10:12 AM the Director of Recreation (DOR) was interviewed and stated that they receive posters to display from the Director of Social Services (DSS). The DOR also stated that the postings included but was not limited to the following the NYSDOH, Ombudsman, Resident Rights. The DOR further stated that they also post the facility process information from our Compliance Officers with contact information for our Grievance & Abuse Officer and includes contact telephone numbers for the Director of Nursing which the residents would use to file any complaints. On 11/13/23 at 10:18 AM the Director of Social Services was interviewed and stated that the NYSDOH Abuse Hotline information is posted in the lobby area. The DSS also stated that the postings should be in large readable print and posted at eye level and large enough for residents with visual impairment, or who are in wheelchairs, can easily read and access the required State information and postings. The DSS further stated that it is very important for residents, families, and staff to have independent and outside resources information to enhance the confidence and freedom in reporting complaints without facility constraints. 415.3(d)(3)

Based on observations, record review, and interviews conducted during the Recertification survey (17LT11) from [DATE] to [DATE] the facility did not ensure safe food storage and infection control was practiced. Specifically, two five- pound cottage cheese tubs with a use by date of [DATE] was noted with broken plastic seal and green colored discoloration on top of one container top. This was evident during the Kitchen Observation Task. The findings are: The facility policy on food storage was requested and it was not provided. On [DATE] between 09:29 AM and 09:45 AM during the tour of the main kitchen with the Food Service Director (FSD), two five-pound plastic containers of [NAME] Cottage cheese 4% milk fat minimum containers of cottage cheese were observed on the shelf in the kitchen. The containers were stamped with sell by [DATE] X AG 12:08 below the cover and stamped with a receive date stamp of [DATE] on top of the container lid. The containers were noted with broken plastic seals and both containers were approximately three-quarters full. One of the containers had a green colored substance covering the top layer (approximately 1 inch x ,d+[DATE] inch in length). The inventory order form with invoice number 1906680 dated [DATE] documented that there were 2 tubs of 5-pound cottage cheese 4% made by [NAME] delivered for the facility. An email from [NAME] Cheese Customer Service dated [DATE] at 4:04 PM, documented that the date printed on the package is the sell-by date. When properly refrigerated and unopened, we guarantee the product until that date. Once the seal is broken, it is difficult to predict how our product will react to the environment it is exposed to; hence, we do not provide any assurances once opened. During an interview on [DATE] at 09:45 AM, the FSD stated they did not know why staff did not see this and cottage cheese containers will be thrown out. The FSD also stated that the storeroom person is in charge of stocking. The FSD further stated that they wanted to return the containers to the company since this was not the cottage cheese that they normally use. During an interview on [DATE] at 09:59 AM, Dietary Aide (DA) #1 was interviewed and stated they check the cottage cheese before use and cottage cheese is used daily. DA #1 also stated that they look at the expiration, and check to see date is still good and food does not smell. DA #1 further stated that a new company is being used and items are being labeled differently with a sell by date instead of an expiration date. DA #1 stated that the cook uses the cottage cheese for cold plates for residents. During an interview on [DATE] at 01:01 PM, the Cook (# 1) was interviewed and stated that they make the cottage cheese trays on occasion, and check the expiration date and the temperature to make sure it is good. Cook #1 also stated that once cottage cheese is opened, they put an open date on it to track that item. Cook #1 further stated that they regularly have in-service on food handling and temperature, and safe zones for food. During an additional interview on [DATE] at 09:56 AM, the FSD stated no one touched the cottage cheese, and they were told by the manufacturer that if air got inside the container, it could form mold. The FSD also stated that the cottage cheese was never given to a resident and the manufacturer stated that the product is good for 30 days beyond the sell by date. The FSD also stated that staff is trained to do first in, first out. The FSD stated that all staff looks for expired food as it can be harmful to residents and cause an outbreak. The FSD also stated that the container was 100% full not one scoop was taken out. 415.14 (h)

Based on interviews and record review conducted during the Recertification survey from 11/8/23 to 11/15/23, the facility did not ensure a resident received appropriate notice before the resident's room in the facility was changed. This was evident for 1 of 4 residents reviewed for Choices out of a sample of 38 residents. Specifically, Resident #115 was not given the opportunity to view the new room, meet roommates and ask questions before the room was changed. The findings are: The facility policy and procedure titled Room Changes effective 11/2017 and last reviewed 09/2023, documented that changes in rooms or roommate assignment are made when the facility deems it is necessary or when the resident request the change. Prior to changing a room or roommate assignment all parties involved are notified. Advanced written notice of a room change includes the reason why the change is being made and any information that will assist the roommate in becoming acquainted with their roommate. The policy also documented that documentation of the room change is recorded into the resident's medical record. Inquiries concerning room changes should be referred to Social Work. Resident #115 was admitted to the facility with diagnoses that included Coronary Artery Disease, Benign Prostatic Hypertrophy, and Diabetes Mellitus. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact and resident made own decisions. The MDS also documented that the resident had no behavioral symptoms and did not reject care. On 11/08/23 at 11:16 AM, during an interview Resident #115 stated that they had been moved from another room and had not been informed of the room change ahead of time. Resident #115 also stated that they were told that the room had one other resident and when they arrived at the new room they found out there were three roommates. Resident #115 also stated they would not have agreed to a room change with three new roommates. Social Services progress note titled request for room change dated 11/01/2023 at 6:47 PM documented that resident will have a room change based on medical necessity. Family and resident have been advised of room transfer and agreed with the plan. Notification provided in writing and verbally prior to transfer. Introduction to new roommate, unit staff, social worker (SWK). SWK will monitor adjustment to room transfer and provide support assistance with transition. A letter not located in the electronic medical record with no title was provided by the Social Work Assistant. The letter documented as follows: Note: the reason for this letter of notification is to inform that you are being moved to another room. The name of the resident's friend was added, and resident's name was listed after. The letter also documented that on 11/1/23 you were informed of a necessary room change for the above referenced resident due to medical necessity. In accordance with regulatory requirements, we are notifying you the new room number will be effective on 11/1/23. The letter further stated that notification was made to Resident #115's friend and that the notification of room change was made on 11/1/23 at 4:30 PM. The ADT (Admission, Discharge, Transfer) history in the Electronic Medical Record documented that Resident #115 was transferred to the new room on 11/1/23 at 4:51 PM. On 11/15/23 at 11:44 AM, the Social Work Assistant (SWA) was interviewed and stated that they informed Resident #115 that there was going to be a rom change however they could not recall how much in advance the notification had been made. The SWA also stated that they did not know why the notification letter was not included in the medical record. The SWA further stated that they are informed in the morning about potential room changes and also at the daily meeting done at 4 PM with the admissions staff. The SWA stated that notification for Resident #115 was done a little later in the day and they wrote the letter around 4 PM and wrote in the time when the resident's friend was notified. The SWA also stated that they know that they did notify Resident #115, however they could not recall how much in advance it was done, but they believe more than 20 minutes prior notice was provided. On 11/15/23 at 12:18 PM, the Director of Social Work (DSW) was interviewed and stated that room changes can occur throughout the day and happens most of the time during the afternoon. The DSW also stated that they let the resident know of the room change, the new room number, we give them a copy so they have a tangible note of the new room. We let the loved one know of the room change so they know where to visit. The DSW further stated that there was nowhere for the resident to sign acknowledging that they had been informed of the room change and provided the opportunity to visit the new room. The DSW stated that the room change notification letter is not included in the medical record. The DSW also stated that they were not involved in this room change and since the change occurred on the same unit, it could have all been done within 20 minutes. The DSW did not respond to what would be an appropriate amount of time for a resident to be informed of a room change. On 11/15/23 at 01:47 PM, an interview was conducted with the Facility Administrator (FA) who stated that residents are informed prior to any room change, and are give the opportunity to view the new room and meet the new roommates. The FA also stated that with Resident #115 the nursing supervisor was also involved with showing the Resident #115 the new room however did not document this in the medical record. The FA further stated they were not aware of how much notice Resident 115 received before the move. 415.5 (e)(2)

Based on staff interviews and record review conducted during the Recertification survey from 11/08/23-11/15/23, the facility did not ensure that all alleged violations including injuries of unknown origin were reported immediately but not later than two hours to the New York State Department of Health (NYSDOH). This was evident for 1 of 5 residents reviewed for Accidents out of 38 total sampled residents. Specifically, Resident #54 had an unwitnessed event which resulted in the fracture of the left hip. The finding is: The facility's Abuse, Prevention, Prohibition & Reporting, policy, revised date 04/21/2023, documented, that staff development provides and orientation program which includes reporting abuse including injuries of unknown origin, and to whom and when staff and others must report their knowledge. On 11/08/23 at 11:42 AM, Resident #54 was observed in their room in bed, awake, non-verbal with support cushions in place for contractures of lower extremities. Resident #54 was admitted with diagnoses that included Dementia, Osteoarthritis and Osteoporosis. The Quarterly Minimum Data Set, dated dated dated [DATE] documented that resident had short and long-term memory impairment and required total assistance of staff with most Activities of Daily Living. The MDS also documented that resident had limitation on both sides of upper and lower extremity. The Nurse Practitioner (NP) note dated 09/08/23 documented, called by nursing staff to evaluate resident for warm, painful edematous left leg. Has been moaning, which is not their baseline, pain medications were ordered, including X-rays of left pelvis and femur due to possible pelvis / femur fracture. The X-ray results dated 09/08/23 documented, Impression: Acute angulated comminuted fracture of the distal left femoral shaft/metaphysis. The NP note dated 09/13/23 documented that the family is now agreeable to send the resident to the emergency room for evaluation of left distal femur fracture. The Hospital X-ray results dated 09/13/23 Concluded: Left femur fracture with angulations. The facility's internal investigation dated 09/13/23 concluded the following, the investigative review supports that there is no reasonable cause to believe that any alleged abuse, neglect, mistreatment, misappropriation of property or quality concerns has occurred. On 11/14/23 at 7:30 AM, Registered Nurse (RN) #1 was interviewed and stated that the Certified Nurse Aide (CNA) observed and reported to the unit nurse that the resident was experiencing pain to the left leg when moved. RN #1 also stated that they are the person responsible for conducting the investigation and that the team's weekly Medical Board Meetings together with the Medical Director conduct case reviews. RN #1 further stated that this case was reviewed and determined that abuse was ruled out due to the residents underlying medical diagnosis which included, severe osteoporosis. On 11/14/23 at 07:52 AM, the Director of Nursing (DON) was interviewed and stated that because this was an unwitnessed event which resulted in a fracture it should have been reported to the NYSDOH. The DON also stated that NYSDOH would have investigated the case to rule out abuse, neglect, or mistreatment. This case was an unwitnessed event which needed to be reported immediately within 2 hours. 415.4(b)(2)

Based on observations, interviews, and record review conducted during the Recertification survey from 11/08/2023 to 11/15/2023, the facility did not ensure that menus were followed. This was evident for 1 of 5 residents reviewed for Food out of 38 total sampled residents. Specifically, Resident # 18 received items that were listed on the allergies/preferences section of their tray ticket during mealtimes. The findings are: The facility policy titled Serving Food dated February 2023 documented resident preferences at mealtime are important to the satisfaction of the dining experience and the staff will call for alternative trays upon resident request. Food preferences will be indicated on tray cards meal. Resident #18 was admitted with diagnoses that included Anemia, Hypertension, and Malnutrition. The Admission Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #18 was cognitively intact and required set up and supervision with eating. Physician's Orders initiated 8/21/2023 documented No Added Salt diet, on 9/6/2023 Food consistency regular 8/22/2023 thin liquid 11/1/2023. During an interview on 11/08/2023 at 12:49 PM, Resident #18 was interviewed and stated that breakfast is the best meal and lunch, and dinner leaves a lot to be desired. The breaded meat tastes awful they are tasteless. The resident stated that they are supposed to get ginger ale and got milk. On 11/08/2023 at 12:47 PM, Resident #18 was observed with their lunch tray. The tray had breaded fish, mixed vegetables, mashed potato, chocolate ice cream, whole milk, apple juice. The tray ticket documented Diet No Added Salt (NAS), Supper Prefers juice, no veggie burger, no pasta, no breaded food. Resident #18 was noted picking off the breading from the fish. On 11/14/2023 at 01:02 PM, Resident #18 was noted with a lunch tray that contained breaded chicken. The Dietary Progress notes dated 8/21/2023 to 10/17/2023 documented resident food preferences include cold cereal, scrambled eggs, wheat bread, and whole milk. Food preferences were updated to include two servings of scrambled eggs, and dislikes turkey burger. Meal ticket was updated on 10/16/2023. During an interview on 11/14/2023 at 03:11 PM, the Food Service Director (FSD)/Registered Dietitian (RD) stated that whatever is on the menu and the alternate is printed on the ticket with an A is written on the ticket meaning an alternate item is offered and dietary provides food items to the residents. For the weekly menu staff go around and circle the items with the resident and make sure the food consistency is matched. The FSD/RD stated that they have reviewed food preferences with Resident #18, and they stated on 11/14/2023 when the resident received the breaded chicken they were not offered the turkey burger since it was not their preference and their ticket stated no turkey burger which was the alternate item. During an interview on 11/15/2023 10:13 AM, the Cook (Cook #2) was interviewed and stated when breaded fish is given, a non-breaded option is provided or other options such as egg or vegetable patty. Cook #2 also stated that grilled cheese sandwiches or beans may be offered. Cook #2 also stated that residents can ask for a sandwich (peanut butter, egg salad, bologna, and tuna) as alternate instead of breaded fish or chicken. During an interview on 11/15/2023 at 10:22 AM, FSD/RD stated that there every week residents are given the menu, and they choose what they want to eat. The FSD/RD also stated that the menu choices from last week for Resident #18 were no longer available. The FSD/RD further stated that they look at the tray line daily and food preferences are placed on the tray ticket and in Sigma also. If a resident asks for an alternate item their tray ticket is labeled with the letter A. For resident satisfaction, they honor likes and dislikes. The FSD/RD stated that they send extra alternates in the event someone needs it, and try hard to ensure menu choices to reduce call backs. During an interview on 11/15/2023 at 10:31 AM, the Dietary Aide (DA) # 2 was interviewed and stated they put items on the tray as part of assignment. They read the meal ticket and put food items on the tray accordingly. There is always an alternative regular chicken and some resident instead prefer the alternate which is a sandwich. We always have something to offer the resident if they want it. They have received training on reading the meal ticket and allergies are listed on the bottom of the ticket 415.14(c)(1-3)

Based on observations, record review, and interviews during the Recertification survey conducted from 11/08/2023 to 11/15/2023, the facility did not ensure that infection control practices were maintained. Specifically, (1) a Registered Nurse (RN #3) was observed using a blood pressure cuff (BPC), and pulse oximeter on multiple residents without sanitizing the BPC between residents and not performing consistent hand hygiene between residents (Resident # 282, Resident # 18, Resident #336, and Resident #337), and (2) the Wound Care Nurse was did not practice appropriate hand hygiene while performing a wound care treatment. The findings are: 1.The policy titled Cleaning and Disinfecting of Resident Care Items and Equipment last reviewed 10/2022 documented resident care equipment including reusable items and durable medical equipment will be cleaned and disinfected according to the Centers for Disease Control (CDC) recommendations for disinfection ad the OSHA Bloodborne Pathogens standards. During an observation on 11/08/2023 between 3:41 PM to 03:55 PM, RN #3 was observed in removing the blood pressure cuff (BPC) off the left upper arm of Resident #139 and removing the pulse oximeter off the resident's left second digit. RN #3 then proceeded to Resident #18 located in the same room, and assessed blood pressure on the resident's right upper arm and placed the pulse on their right second digit. RN #3 did not perform hand hygiene, and the blood pressure cuff and pulse oximeter were not cleaned between residents. RN #3 then proceeded to don a gown and gloves, approached Resident #336 in their room and placed the same blood pressure cuff on the left forearm and pulse oximeter on the left second digit. RN #3 then removed and cleaned the equipment, removed their gloves, and documented the vital signs. RN #3 donned clean gloves without performing hand hygiene and completed vital signs for Resident #337 who was located in the same room. RN #3 cleaned the BP cuff and pulse oximeter, removed their PPE, exited the room, and then applied alcohol based hand rub from the dispenser located in the hallway outside the resident's room. During an interview on 11/03/2023 at 04:49 PM, RN #3 stated that they noticed that they did not clean the BPC and pulse oximeter. RN #3 stated that they are supposed to clean the BPC and pulse oximetry between residents. RN #3 also stated that they did clean the equipment after use. RN #3 further stated that they know they should have done hand hygiene after changing their gloves. On 11/15/2023 at 12:34 PM, the Infection Preventionist (IP) was interviewed and stated they do rounds randomly. They look at how staff practice infection control and hand washing and if staff are following the facility protocol. The shared equipment (BPC and pulse oximetry) has to be cleaned with the appropriate wipes before and after use. The IP also stated that they do random infection control rounds and checks to make sure that the equipment is clean before it is used with other residents and so prevent cross contamination. The IP further stated that they do hand hygiene in-service regularly and they do one-on-one in-service for staff if needed. On 11/15/2023 at 01:08 PM, the Director of Nursing (DON) was interviewed and stated they do rounds in the morning and at least every 2 hours and when they are free in the facility. The DON also stated that hand hygiene should be done before touching a resident, and hands should be washed also. The BPC should be cleaned between use and staff should do hand hygiene with alcohol based sanitizer, use sink to wash hands and wear gloves after hand hygiene. The DON further stated that after staff touch things, remove gloves, and dispose of the gloves, they should do hand hygiene and can use sanitizing hand wipes for hands and the sanitizing wipes for the shared equipment. The DON stated that staff are in-serviced regularly and if they notice staff need correction they will do a one-on-one in-service to educate staff. 48937 2. The undated facility policy titled Handwashing/Hand Hygiene Policy documented that the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene procedures in preventing the transmission of healthcare associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors. The use of gloves does not replace handwashing/hand hygiene. Resident #101 was admitted with diagnoses that included Vascular Dementia unspecified Osteomyelitis of vertebra, and Pressure Ulcer of sacral region stage 4. The Quarterly Minimum Data Set assessment dated [DATE] documented that resident had one Stage 4 ulcer. The Physicians Order dated 11/09/2023 documented clean sacral wound with normal saline, pat dry, apply Calcium alginate and Zinc oxide to peri wound. Cover with DPD (dry protective dressing). On 11/14/2023 at 09:58 AM, a wound care observation was conducted with Registered Nurse (RN) #4. RN #4 washed their hands and placed a sterile drape on the overbed table. RN #4 then placed a Styrofoam tray on top of the drape sheet. In the tray they placed gloves and a zip-lock bag which contained zinc oxide. RN #4 also placed unopened gauze packets on top of the sterile drape. RN #4 then washed their hands with soap and water, donned gloves, removed the soiled dressing, and removed and discarded gloves. RN #4 did not perform hand hygiene and with ungloved hands began to open the gauze packets, placing the gauze on the Styrofoam tray below the zip-lock bag and gloves. RN #4 then poured normal saline onto the gauze pads, opened the dry protective dressing and treatment which they placed on the drape sheet. RN then donned gloves without performing hand hygiene and cleaned the wound and patted the wound dry. RN #4 then removed gloves and washed hands before applying the treatment and applying the dressing. RN #4 completed rest of dressing change with no additional concerns. On 11/15/23 at 11:14 AM, RN #4 was interviewed stated that they are the wound care nurse at the facility. RN #4 also stated that the procedure is after they prepare the supplies, they wash their hands before returning to care for the wound. RN#4 further stated that they were not aware that they had not washed hands after preparing supplies and before cleaning the wound. RN #4 also stated that it is their standard practice to open gauze unto the Styrofoam tray instead of unto the sterile drape sheet although they could not say how clean the tray was. RN #4 stated that they usually follow all infection control practices and must have made a mistake today. On 11/15/23 at 11:34 AM, the Infection Preventionist (IP) was interviewed and stated that they do rounds on all units every day to see if staff are following protocol and hand hygiene and they also check wound treatments. The IP also stated that they do observations of the Wound Care Nurse and check to make sure that they are doing hand hygiene and maintaining proper infection control procedures. The IP further stated that it is acceptable practice to moisten gauze over the sink or place gauze on the Styrofoam tray after it has been moistened there. On 11/15/23 at 11:53 AM, the Staff Development Coordinator (SDC) was interviewed and stated that they make rounds on all the units to see if there are any concerns or issues. Staff should be following infection control principles for hand hygiene, and bring only what is needed into the room for wound care. The SDC also stated that every time staff takes off gloves, they have to perform hand hygiene. Hand hygiene should also be performed after removing soiled dressing and after opening gauze at the overbed drape sheet as the outside packaging is not considered clean. The SDC stated that wound care competencies are done on hire and annually. 415.19 (a)(1-3),(b)(4)

Based on interviews, observations and record reviews made during an abbreviated survey(NY00291816) the facility failed to allow a resident's designated representative to exercise the resident's rights to the extent those rights are delegated to the representative. This was evident for 2o 5 residents reviewed. Specifically, the facility disenrolled the resident from a Medicare Advantage insurance program into traditional Medicare without the knowledge or consent of their representative. This was true in 2 of 5 residents sampled. The findings are: The facility's policy and procedure entitled Special Rules Regarding Selected Payors (undated) states that residents who are members of a managed care benefit plan that is under a contract with the facility to provide specified services will receive those services with full coverage so long as the resident meets eligibility requirements of the plan. 1) Resident #1 was admitted to the facility on [DATE]. The Minimum Data Set, dated dated dated [DATE] identified the resident's cognitive status as moderately impaired. The Minimum Data Set (MDS, a resident assessment tool) identified the resident with Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) score of 10/15 (00-7 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). The resident required extensive assist x 1 for bed mobility, transfers, locomotion, dressing, toileting and personal hygiene, and was independent in eating. On 12/15/2021 the resident was discharged to the community. A Cognitive Loss Care Plan was initiated for Resident #1 on 11/17/2021. Interventions: assess causative factors, engage resident and provide reality orientation at least once per shift, give simple directions using simple words and short sentences, make eye contact, modify approaches according to resident's ability and response levels, stand in line of resident's vision. A Psychiatry consult dated 11/23/2021 states Resident #1 was seen as a new admission, noted to be oriented x 3 with fair memory, insight and judgment, and had capacity to make medical and financial decisions. A Social Work note dated 12/15/2021 states Resident #1's family member requested resident be discharged back to The Arbors Assisted Living Facility, where the resident had lived prior to admission to the facility. Resident was discharged home the following day. The resident's Physical Therapy discharge summary dated 12/15/2021 states resident had become independent in bed mobility, able to transfer with supervision and able to walk 200 ft. with a Rollator with supervision. Initial authorization was obtained for the resident's stay in the facility from Empire Blue Cross Blue Shield, authorization #UM23972755, initial approval level 2 from 11/17-23/2021. A handwritten note (undated and unsigned) was obtained from the resident's finance folder and stated that the Finance Coordinator spoke with family member (who was Power of Attorney) regarding copayments after Day 20 of placement, continued authorization process, and wrote, Wants to stay with Blue Cross Blue Shield, not interested at this time in disenrollment. A Notice of Medicare Non-Coverage dated 12/13/2021 (NOMNC) states Resident #1's Medicare coverage in the facility will end on 12/14/2021 and that resident will be discharged on ,d+[DATE]. The NOMNC was signed by the social worker as verbally reviewed with the resident's family member. The NOMNC did not state that the resident had Empire Blue Cross Blue Shield insurance and the NOMNC was issued by the facility, not by Empire Blue Cross Blue Shield. 2) Resident #2 was admitted to the facility on [DATE]. The Minimum Data Set, dated dated dated [DATE] identified the resident's cognitive status as severely impaired. The Minimum Data Set (MDS, a resident assessment tool) identified the resident with Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) score of 2/15 (00-7 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). The resident required total dependence x 1 for locomotion; extensive assist x 2 for bed mobility, transfers and toileting; and extensive assist x 1 for dressing, eating and personal hygiene. The resident was discharged to another facility on 02/24/2022. A Cognitive Loss Care Plan was initiated for Resident #2 on 12/26/2021. Interventions: assess causative factors, give simple directions using simple words and short sentences, make eye contact, modify approaches according to resident's ability and response levels, stand in line of resident's sight. A copy of Resident #2's face sheet with a handwritten note (undated and unsigned) states a finance representative spoke with resident's son on 12/27/2021 regarding copayments after Day 20 of placement, Medicaid application, process of obtaining authorizations for managed care insurance. Note stated, Son wants to stay with Blue Cross Blue Shield. A Psychiatric consult dated 12/28/2021 states Resident #1 was seen as a new admission, appeared alert, calm, confused, oriented x 1 with decreased memory, insight and judgment poor, stated that resident had no capacity to make medical or financial decisions at present time. A Social Work note dated 02/23/2022 states family requested transfer packet be sent to another nursing home for long-term care. Social worker documented that transfer packet was sent and Resident #1 was approved medically for transfer but would require authorization from insurance. Family member was notified. Social worker updated new facility that auth was requested and new facility confirmed that bed would be held pending auth. A Social Work note dated 02/24/2022 states authorization for the new nursing home was received and transmitted. Resident #1's family member was notified and agreed with transfer. Resident #1 was discharged to new facility at 7:15 PM. Resident #1's facility bill was reviewed and revealed that Empire Blue Cross Blue Shield covered the resident throughout December 2021, January 2022 and February 2022 without interruption in the facility. The Admissions Director was interviewed on 03/04/2022 at 1:51 PM and stated that when a resident has managed care, authorization must be obtained prior to admission. Each insurance company has its own rules but generally the hospital will get an initial authorization number, the level and the initial approval date through the case manager. After the initial period the facility sends updated Physical Therapy and Occupational Therapy notes to the case manager and are given continued authorizations. With traditional Medicare, authorization is not needed. The facility does not favor one type of admission over the other. Admissions Directed stated to not know which plans had bigger daily rates and stated to have never spoken with any residents or family about disenrolling from a managed plan. The facility accepts a wide variety of plans Blue Cross Blue Shield, Aetna, Humana, Elder Plan, VNS, United Health Care and [NAME]. Resident #2's family member was interviewed on 03/04/2022 at 12:27 PM and stated to be familiar with Resident #1's insurance because they were the resident's Power of Attorney. The resident was approved by Blue Cross to be admitted to the facility for subacute rehab, but out of the blue someone phoned and asked to disenroll the resident from Blue Cross into traditional Medicare. Complainant stated to not recall this person's name. Complainant stated that they would not disenroll because the resident had the managed plan through a former employer and paid no premiums. In early January someone from the facility phoned regarding a Medicaid application for a supplemental pharmacy plan. The complainant was again unsure of the name of the person who spoke with them. Because the complainant felt the resident would not have needed a supplementary pharmacy plan if they were covered by Blue Cross, they phoned Blue Cross and learned that the resident had been disenrolled into traditional Medicare. The facility denied having done so. Complainant then phoned CMS, which assisted in re-enrolling the resident in Blue Cross Medicare. Resident #1's family member was interviewed on 03/07/2022 at 2:32 PM and stated to be the resident's Power of Attorney. They stated to have never received a disenrollment form from the facility but to have received written notice from Blue Cross on 12/14/2021 that Resident #1 had been disenrolled as of 12/01/2021. Complainant then called their Medicare advisor who stated to be able to re-enroll the resident as of 01/01/2022. However, complainant decided against this and continued the resident in traditional Medicare. The Finance Coordinator was interviewed on 03/07/2022 at 11:14 AM and stated that Finance reaches out to the resident or family to verify demographics upon admission, then obtains the clinicals to get authorizations from the managed care company. They talk to patients on options for copayments and let them know there will be charges after day 20. They generally also discuss possible application for Medicaid. They do not usually mention disenrollment from a managed plan. Some families want the resident to continue with coverage once the managed program denies coverage, so in that care they guide them through the process of disenrolling from a managed plan if that's what the family wants. The Coordinator stated that there was no disenrollment form for Resident #1 because the resident was admitted under one authorization from Blue Cross and left the facility under the same authorization without interruption, never having disenrolled. There was no NOMNC because the resident was not discharged to the community. The Center for Medicare Services (CMS) Representative was interviewed on 03/21/2022 at 10:46 AM and stated that they had documentation proving that Resident #1 was disenrolled from their Medicare Advantage program as of 12/01/2021. The CMS Representative stated that when this change occurs there is potential for a resident to be directly charged a significant copayment. Further contact with the Finance Coordinator was made on 03/21/2022 at 1:04 PM. They stated to have not been aware of the CMS documentation and reaffirmed that they had never disenrolled the resident from a Medicare Advantage program into traditional Medicare. 415.3(c)(1)(iii)

Based on observation, record review and interview conducted during the recertification and abbreviation survey (NY 315) , the facility failed to maintain an infection prevention and control program to prevent the development and transmission of COVID-19. Specifically, the facility did not take additional measures and precautions, per NYS Epidemiology and Centers for Disease Control and Prevention (CDC) recommendations, to prevent ongoing transmission of COVID-19 during a facility outbreak with uncontrolled transmission of COVID-19. There were 66 COVID-19 cases identified in the facility from 9/18/21 to 10/21/21 on all units. The facility did not cease indoor visitation when the outbreak spread to more than one unit per NYS guidance. Residents residing on units with positive cases were not put on transmission-based precautions to prevent further spread. Unvaccinated newly admitted residents are placed on quarantine for 10 days instead of 14 days per CDC recommendations. This was evident for 5 of 5 units observed for Infection Control and Prevention (Units 1, 2, 3, 4, and 5). The findings include but are not limited to: The CDC recommendations titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated Sept. 10, 2021, documents, Fully vaccinated residents who have had close contact with someone with [CONDITION(S)]-CoV-2 infection should wear source control and be tested as described in the testing section. Fully vaccinated residents and residents with [CONDITION(S)]-CoV-2 infection in the last 90 days do not need to be quarantined, restricted to their room, or cared for by HCP using the full PPE recommended for the care of a resident with [CONDITION(S)]-CoV-2 infection unless they develop symptoms of COVID-19, are diagnosed with [CONDITION(S)]-CoV-2 infection, or the facility is directed to do so by the jurisdiction ' s public health authority. In addition, the recommendations specify, In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of quarantine for fully vaccinated residents and work restriction of fully vaccinated HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction ' s public authority recommends these and additional precautions. The CDC recommendations further document, In general, all unvaccinated residents who are new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. Facilities located in counties with low community transmission might elect to use a risk-based approach for determining which unvaccinated residents require quarantine upon admission. Decisions should be based on whether the resident had close contact with someone with [CONDITION(S)]-CoV-2 infection while outside the facility and if there was consistent adherence to IPC practices in healthcare settings, during transportation, or in the community prior to admission. The Centers for Medicare & Medicaid Services (CMS) QSO-20-39-NH memo, revised 4/27/21, documents: Facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission. These scenarios include limiting indoor visitation for: Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated, until they have met the criteria to discontinue Transmission-Based Precautions; or Residents in quarantine, wether vaccinated or unvaccinated, until they have met criteria for release from quarantine. During an outbreak of COVID-19, indoor visitation can occur if outbreak testing shows the outbreak is contained to a single area. If the initial or subsequent rounds of outbreak testing identify one or more additional COVID-19 cases in other areas/units of the facility, the the facility should suspend visitation for all residents (vaccinated and unvaccinated), until the facility meets the criteria to discontinue outbreak testing. The Executive Order #202.1 dated March 12, 2020 documented the following: Any guidance issued by the New York State Department of Health related to prevention and infection control of COVID-19 at nursing homes and adult care facilities, including but not limited to guidance on visitation, shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The NYS Department of Health advisory titled, Health Advisory: Revised Skilled Nursing Facility Visitation, dated July 8, 2021, documents, In accordance with CDC and CMS guidance, facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited to compassionate care situations due to a high risk of COVID-19 transmission. These scenarios include limiting indoor visitation for: Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated, until they have met the criteria to discontinue Transmission-Based Precautions; or Residents in quarantine, wether vaccinated or unvaccinated, until they have met criteria for release from quarantine. During an outbreak of COVID-19, indoor visitation can occur if outbreak testing shows the outbreak is contained to a single area. If the initial or subsequent rounds of outbreak testing identify one or more additional COVID-19 cases in other areas/units of the facility, the the facility should suspend visitation for all residents (vaccinated and unvaccinated), until the facility meets the criteria to discontinue outbreak testing. The facility policy titled Cohorting Residents-Admission and Re-admitted d 03/12/20, last revised 09/18/21, documented: Newly admitted residents with known COVID-19 positive will be placed in an isolation room and put on appropriate Transmission-Based precaution (TBP) on a designated COVID-19 unit. COVID-19 positive admissions will have no testing within 90 days an be quarantined for a minimum of 10 days. If residents remain symptomatic, they will remain on the unit and continue TBP; if symptom improved, within 24 hours with no use of [MEDICATION(S)] medication and symptoms appeared at least 10 days ago, then the resident may be moved to a non-COVID unit. If asymptomatic at least 10 days passed, may be moved to another non-COVID-19 unit. The policy further documented that the new admission with known negative results are placed on the designated admission unit for monitoring at least for 10 days quarantine. Testing may be done within 7 to 10 business days upon admission, and if resident tested negative and asymptomatic, may be moved to a non-Covid-19 unit after completion of quarantine. The fully vaccinated residents do not required quarantine, but they are monitored for 10 days for signs and symptoms of COVID-19. The policy did not specify quarantine for unvaccinated new admissions. The COVID-19 positivity rate was 2.69% in the community and 1.6% in Queens County at the time of the survey. 1) The List of Staff and Patients COVID Positive submitted by the facility to NYS Epidemiology documented positive results received from 9/17/21 through 10/6/21. The listing documented 56 positive cases were identified in the facility. Positive residents were identified on more than one unit as early as 10/4/21. There were 6 cases on Unit 3, 10 cases on Unit 1, and 4 cases on Unit 4. Other positive cases listed did not include the resident's location when they became positive. NYSDOH Epidemiology conducted an onsite visit on 9/22/21 and a virtual walk-through on 10/11/21. An email was sent by NYS DOH Epidemiology to the Director of Nursing (DON), Administrator, and Nursing Supervisor on 10/11/21 with recommendations following the virtual visit. Recommendations from 10/11/21 included putting exposed residents on quarantine with contact and droplet precautions in addition to testing and conducting more contact tracing and investigation of each positive to see if the cause of the transmission and those at risk could be identified. The facility was also informed that there were concerns that the multiple positive cases were identified on more than one unit. The facility was informed that given the situation, roommates and possibly whole hallways or units may need to quarantine. The survey team requested a list of residents who tested positive for COVID-19 from 9/18/21 to present. Initially, the facility submitted a list of 40 residents diagnosed with COVID-19 at the facility. On 10/20/21, the facility submitted an updated list with 66 residents who tested positive for COVID-19 in the current outbreak from 9/18/21 to 10/20/21. Positive residents were identified on units 1, 3, 4, and 5. Unit 2 is the COVID-19 positive unit. There were inconsistencies in the vaccine records provided. On 10/21/21, the facility also provided to the state agency (SA), a list of fully vaccinated residents containing 68 residents and 35 unvaccinated residents. The Director of Nursing (DON) stated that there were still some residents whose vaccination status was unconfirmed. The DON stated they are currently working on it. On 10/25/21, the DON provided a list of residents who received COVID vaccines at the facility. The list contained 156 residents with no dates. The DON stated that some of the residents on the list had received 1 dose and some were fully vaccinated. The DON stated it would take longer to specify, so they gave the information they had so far. Vaccination status should be considered when effectively and accurately cohorting residents, assessing risk when exposed, and putting residents on the appropriate precautions. room [ROOM NUMBER], a 4-bed room, had two residents that tested positive for COVID-19. Resident #89 tested positive for COVID-19 on 10/6/21, and Resident #58 tested positive on 10/11/21. Resident #159, a fully vaccinated roommate, remained in the room and was not placed on quarantine related to the exposure. A resident in room [ROOM NUMBER], Resident #53, tested positive for COVID-19 on 10/18/2021. Resident #53 was moved to the COVID-19 unit on 10/19/2021. Resident #245, the exposed roommate, was not placed on quarantine and remained in the room. The facility did not follow the recommendations to quarantine exposed residents or units/hallways in an attempt to control transmission. There was no documented evidence that the facility conducted more thorough contact tracing. 2) Resident #389 was admitted to the New Admission unit on 10/02/21 to room [ROOM NUMBER]B. Resident #389 was fully vaccinated with the Johnson and Johnson vaccine on 4/30/21, per hospital records. On 10/11/21, 9 days after admission, the resident was transferred from 105B to 303A. On 10/11/21, the resident was diagnosed with COVID-19 and transferred from the 3rd floor to the 2nd floor COVID-19 unit. The facility did not implement their policy to observe vaccinated residents for at least 10 days upon admission. In addition, Resident #389 received an unvaccinated roommate (Resident #390) on 10/7/21 during their time on the New admission unit. 3) Resident #390 was admitted to the New Admission unit on 10/7/21 to 105A. Resident #390 was not vaccinated for COVID-19. On 10/11/21, 4 days after admission, the resident was moved to the 5th floor, in 504B. Resident #390 tested positive for COVID-19 on 10/13/21 and was moved to the COVID unit. The facility admitted an unvaccinated resident to a room with a roommate. In addition, Resident #390 was not placed on quarantine for 14 days as per CDC recommendations for unvaccinated new admissions. 4) The facility had full visitation in progress on all units even though new COVID-19 cases were identified on all non-COVID units. From 10/17/21 to 10/21/21, the survey team observed visitors riding the elevator to all units throughout survey. The Visitors' Log documented that the facility had 183 visitors from 9/17/21 to 10/21/21. Visitors went on all Units, including the quarantined units, Unit 1 (New Admission unit) and Unit 2 (dedicated COVID-19 unit). The DON stated there is no restriction for visitors, however, the visitors are screened for COVID-19 symptoms questioners and they check their temperatures before going into the unit. On 10/20/2021 at 2:18 PM, an interview conducted with the 3rd floor Charge Nurse, Licensed Practical Nurse (LPN#2). LPN #2 stated visitors have to wear face shields and masks on the unit, and the visitors are escorted to the resident rooms. LPN #2 stated that the residents on the unit are allowed to have visitors in the room, and the last new COVID-19 positive resident on the 3rd floor was identified on 10/19/21 in room [ROOM NUMBER]B. The positive resident did not have a roommate at the time of diagnosis. On 10/20/2021 at 2:45 PM, an interview conducted with LPN #1, the 4th Floor Charge Nurse who stated visitors fill out forms and have a rapid COVID test in the lobby before coming to the unit. Visitors have to wear a mask and eye protection, and extra PPE is kept on the unit in case it is needed. An escort brings the visitor to the resident's room if they are wandering looking for the room. One resident on the 4th floor came down with COVID-19 last week on Wednesday, and the resident was moved to the COVID unit. That resident did not have a roommate. On 10/25/2021 at 5:09 PM, an interview conducted with the Director of Recreation who stated a few days ago, the facility implemented a visiting schedule where visitors have to call in advance for the 1st and 2nd floors. Prior to that, visitors to all units could visit any time during visiting hours. Visitors for the 1st and 2nd floors need to call 12 hours in advance. All visitors sign-in at the front desk, have their temperature taken, and write their name, number on the contact tracing form. The resident they are visiting is also recorded so that they know which room the visitor is going to. A designated person usually escorts them to the unit. The escort turns the visitor over to the CNAs or radios ahead on the walkie-talkie to let them know someone is coming up. On units 3, 4 and 5, people can visit any time during visiting hours -- 9:30 to 11:30, 2:45 to 4:30 and 6:30 to 8:00. The rationale is that only one elevator is working right now, and the facility doesn't want any cross contamination during meal service and room changes. The elevator is sanitized after meal service and each visiting period. Recreation staff are responsible for putting in the care plans for Personal and Compassionate Visiting. Every resident has a Compassionate Visiting Care Plan, not just residents who are at end of life. On 10/20/21 at 01:49 PM, an interview conducted with the Medical Director (MD) who stated the protocol for COVID-19 changes case by case. Usually, COVID-19 positive residents are isolated, monitored, and they make sure they are not aerosolizing the COVID. Residents are tested based on the positivity rate and per DOH guidelines and the infectious disease nurse. Residents admitted with COVID-19 are isolated with quarantine precautions and monitored for the appropriate time. The MD stated he believes residents are isolated for 14 days unless the immunologist at DOH tells the facility otherwise. The MD stated they could not generalized because guidelines change daily. Residents exposed to COVID-19 are isolated and re-tested . The MD stated hew would have to check with the DON regarding the policy for new admissions. The MD stated, let's face it, every patient that comes from the outside is an exposed patient. New admissions are quarantined and put in the general patient population after 14 days or maybe 10, they need to check the policy. The MD is a member of the QA Committee, and there are no medical concerns that the MD is aware of. The MD stated they communicate with the Administrator and DON daily. During an interview on 10/20/2021 at 1:44 PM, the Director of Nursing (DON) who is also the Infection Control Preventionist was interviewed. The DON stated that residents admitted with COVID-19 are placed on the 2nd floor COVID-19 unit for 10 days. Symptomatic residents are placed in a private room, and asymptomatic positive residents can be cohorted with another positive resident. After 10 days of isolation, COVID-19 positive residents are no longer considered infectious. COVID-19 positive residents are not tested again for COVID until 90 days after admission, per the CDC recommendations, and they are moved to a regular unit in a semi-private room after clearance from the doctor. COVID-19 positive residents have to be asymptomatic and no longer infectious. There is no cohorting in the facility based on vaccination status. The facility has had some residents who tested positive for COVID-19 after admission. Contact tracing is done with a resident tests positive. The CNAs and nurses assigned to the COVID-19 unit and the 1st floor new admission unit are dedicated and do not float, but the IV nurses work on all units and adhere to infection control protocols. The facility is currently doing outbreak testing for staff and residents twice per week. The DON stated the facility is open for indoor visitation, especially on the non-COVID units. The two isolation units have had some visitors also. On 10/25/21 at 05:20 PM, the DON was interviewed again. The DON stated that the facility previously had an Infection Control Preventionist consultant who is no longer used. The DON stated the 2nd Floor COVID-19 unit was created on 9/23/21 in response to an outbreak per CDC recommendations. The only unit on quarantine prior to the outbreak was the Unit 1 New admission unit. The DON stated that exposed unvaccinated residents who never had COVID-19 are placed on isolation, but residents who recovered from COVID-19 within 90 days and vaccinated residents do not need to be on isolation. The DON reported NYSDOH Epidemiology recommended a dedicated COVID-19 area and no blowers in the hallway. Epidemiology also recommended cohorting vaccinated residents with vaccinated residents and unvaccinated with unvaccinated residents, and the DON is curious about the reason for the recommendation because the DON has not found any guidelines about that. On 10/20/21 at 11:40 AM, an interview was conducted with the Administrator who stated that positive residents are admitted to the 2nd floor, which is a dedicated COVID-19 floor with dedicated staff. In general, residents are not tested for COVID-19 unless they are having symptoms, however, some residents requested to be tested and we honored that. At times, the facility conducts serial testing for COVID-19 just to make sure infections are not spreading all over. The Administrator stated once a COVID-19 positive resident is asymptomatic and moved off the COVID unit, they do not have to be quarantined again, especially if vaccinated. The facility reports COVID-19 positive new admissions from the hospital and COVID-19 positive in-house cases to HERDS. Asymptomatic COVID-19 positive residents are quarantined for 10 days, and symptomatic COVID-19 positive residents are quarantined for 14 days or more, depending on the situation. The Administrator stated that they are using the CDC symptom-based strategy. Those residents who are immunocompromised with more symptoms can be quarantined for 14 days, and the physician will review prior to moving the resident off of the 2nd floor COVID unit. The Administrator also stated that facility staff work diligently calling the families to reach out to them for proof of vaccination. She stated that the facility infection surveillance conducted a review and concluded that the infection rates are up due to the fact that residents go out to appointments and have contact with people in the community. The facility also had visitors coming everyday, and they can't stop them. The Administrator stated the good thing is that many of the positive residents are asymptomatic. On 10/25/21 at 05:00 PM, a follow-up interview was conducted with the Administrator who stated that the facility is still having full visitation. On Friday, 10/22/21, the facility implemented visitation by appointment. Before 10/22/21, no appointments were needed for visits. Visitors are allowed on all units. Visitors are screened and escorted upstairs. The visitors then meet with the nurses who arrange for the visitor to meet with the resident in the room one at a time. There are no designated spaces for visits outside of resident rooms because the facility does not have enough space. The visitors log indicates who the person visited, and the facility can trace them when doing contact tracing. Visitors are offered a mask and face shield, and they are given a gown if visiting on Units 1 and 2. The Administrator stated that all the residents are on compassionate care, no argument about that. The Administrator stated that compassionate care is no longer strictly for people with Hospice care or end of life. Residents in the nursing homes are going through psychological problems. If the facility stops visitation and does Facetime, the facility would get a lot complaints. The Administrator stated, We make sure we have to have compassionate care to cover it. Who am I to argue it. The Administrator stated they were not aware of NYSDOH Epidemiology recommendations because they were not present when Epidemiology visited. The Administrator stated that there was a memo received from NYSDOH dated 05/03/21 the documented residents who recovered from COVID-19 within the last 90 days do not need to be tested or quarantined. Also, the decision to discontinue precautions can be made using the symptom-based strategy. 415.19(b)(4)

Based on observation, record review, and staff interview during the recertification survey, the facility did not maintain an effective pest control program so that the facility is free of pests. Specifically, multiple flies were observed in resident rooms and the hallway area. This was evident for 42 residents on 1 of 5 units observed for the Environment (Unit 5). The finding is: The undated facility policy, titled pest control program, documented that the facility will maintain an effective pest control to eradicate and contain common household pests and rodents (for example: bed bugs, lice, roaches, ants, mosquitoes and rats). The policy also documented that the facility will provide comprehensive pest control services on a regular and scheduled basis. Observations were made on 10/18/21 on Unit 5 between the hours of 10:00 AM and 2:30 PM,. Flies were observed in the hallway and in rooms # 507, #508, #510 and #520. These rooms were occupied with residents. Unit 5 is a 20-bed unit with 42 residents. During an interview on 10/18/21 at 10:30 AM in room 507, Resident #17 stated that flies are everywhere. Resident #17 stated the facility does not care about them, and no one ever came to speak to Resident #17 regarding the flies concern. The flies never go away, and Resident #17 has never seen any exterminator coming to their room. During an interview, in Room 520, on 10/18/21 at 10:40 AM, flies were observed in the room. Multiple flies were seen on Resident #143's bed and flying around the room. Resident #143 stated This is very annoying and disgusting, and no one is talking about it. Resident #180 stated that the management is aware of these flies, and Resident #180 has not seen any exterminator coming to the building or spoken to management to address their concerns about the flies. Resident #180 was not happy about it. The pest-control service reports were reviewed. On 10/13/21, the service reports revealed that the facility was treated for flies, but Unit 5 was not listed as being treated. This was the only treatment for flies documented prior to the survey. The facility pest control services were not adequate. On 10/19/21 at 10:31 AM, an interview conducted with the Certified Nursing Assistant (CNA #5). CNA #5 stated that they started seeing flies in the unit a month ago. The flies used to follow a former resident on the unit, and the Housekeeping manager is aware of it. CNA #5 stated that the exterminator comes but the flies never go away. On 10/18/21 at 12:04 PM, an interview was conducted with a 5th floor Housekeeper. The Housekeeper stated they started seeing flies a few week ago, and they could not figure out where the flies came from. The Housekeeper stated the exterminator once per week, and it will take some time. During an interview on 10/25/2021 at 01:04 PM, the Director of Facility ( DF) stated they became aware of the flies on the unit 3 weeks ago. The exterminators came in and treated the area. The exterminators came in on Wednesday to inspect and treat the areas, specifically the rooms with complaints (rooms 514 and 520). The DF was informed by the staff via the radio that there were flies in the room. The exterminator comes once per week, and the treatment is working well. The DF also stated that the facility does not have a pest control log, but there are several avenues we report incidents like this. There is a group chat, and staff also communicate on the radios as well. On 10/25/21 05:00 PM, an interview conducted with the Administrator. She stated that there was a resident who was admitted with some skin problems on the foot. The resident had maggots on the leg and flies came into the facility with the resident. The administrator further stated that the resident was noncompliant, and the facility tried there best to accommodate. The exterminator comes once a week, and the treatment is effective. 10 NYCRR 415.29(j)(5)

Based on record review and interviews conducted during the Recertification and Abbreviated survey (NY 452), the facility did not ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly,and comfortable interior were provided. Specifically, a resident's chest of drawers was in disrepair with rot and holes. This was evident for 1 of 5 units observed for the environment (Units 3). The findings are: 1) On 10/19/21 at 11:30 AM, Resident #434 in room 314 was interviewed. Resident #434 complained that they do not have a place to put personal belongings because the bedside dresser drawer is broken. The surveyor opened the 3 dresser drawers and observed the drawers were in disrepair and rotten with holes in them. On 10/25/21 at 01:04 PM, a further interview conducted with the Director of Facility, The DF stated that that he started overseeing facility operations in July 8, 2021. The DF stated no one ever informed them about the broken dresser drawers in Room 314. The DF was aware of dresser drawers in disrepair in Rooms 412 and 413. The DF stated that the staff usually call them on the radio to report maintenance concerns, and there is no maintenance log. 10NYCRR415.5(h)(2

Based on observation, record review, and interview conducted during the Recertification survey, the facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. Specifically, a resident with hand contractures, was not wearing splint devices as ordered. This was evident for 1 of 1resident reviewed for Limited Range of Motion (Resident #1). The finding is: Resident #1 was was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE]documented the resident had severely impaired cognition. The resident required extensive assist of 2 for bed mobility, total assist of 2 for transfer and extensive assist of one for dressing and personal hygiene.Furthermore, the Resident has functional limitation in Range of Motion on both upper and lower extremities. On 10/17/2021 at 10:28 AM and 10/19/2021 at 11:34 AM, Resident #1 was observed in bed with contractures on both hands. No hand splint was in place. Resident #1 has an order to wear splint on both hands at all the time. Splint is to be removed during hygiene and exercise. The OT progress note dated 3/8/2021 documented Resident #1 was provided with maximum verbal and tactile cues during an occupational therapy session with bilateral hand splints. As per OT progress notes dated from 3/8/21 to 10/13/21, Resident's wrist and hands were developing a contracture. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/19/2021 at 12:33 PM, the Certified Nursing Assistant (CNA #3) was interviewed and stated that she positioned Resident #1, but she did not see any splint to put on the resident. On 10/19/2021 at 12:30 PM, the Occupational Therapist (OT #8) was interviewed and stated that rehab gave an in-service about the splints to the nurses. Resident #1's splints should be placed on everyday and removed for hygiene and skin checks. On 10/21/2021 at 10:01 AM, the Licensed Practical Nurse Charge Nurse (LPN #3) was interviewed and stated that the splint was sent to the laundry to be washed and was never brought back to the unit for Resident #1 to wear. It was found in the rehab department's closet. On 10/25/2021 at 12:03 PM, the Director of Nursing (DON) was interviewed and stated that it is not acceptable for the Resident not to have the device on. The DON stated they will give an in-service to the staff about the Resident's devices. 415.12(e)(2)

Based on record review and interviews conducted during the Recertification and Abbreviated survey (NY 100), the facility did not ensure the resident environment remained as free of accident hazards as possible. Specifically, the Licensed Practical Nurse (LPN) left controlled subtances unlocked and unattended on the medication cart in the hallway, leaving them accessible to residents. A resident took two narcotic blister packs from the medication cart narcotic box. ([MEDICATION(S)] 10/325mg tablets -16 tablets and Oxycodone 5mg tablets -16 tablets) and ingested some of the medication. This was evident for 1 out of 35 sampled residents (Resident #484). The findings include: The Facility Policy and Procedure tilted Controlled Substance with last revised date 10/22/2019 states that only authorized practitioners and licensed nursing and pharmacy personnel shall have access to Schedule II Controlled substance in the facility. The policy further states that during Med-Pass, controlled substances are stored in the medication cart's inner storage bin. Both inner storage bin and medication cart are locked at all times unless medications are being taken out. Resident #484 was admitted to the facility on [DATE] with diagnoses which include Opioid Dependency, Chronic pain, Anxiety disorder, and Hypertension. The Minimum Data Set, dated dated dated [DATE] identified Resident # 484 cognition as moderately impaired with a Brief Interview for mental Status Score of 12. Resident #484 requiresd one-person physical assistance with locomotion on and off the unit. The Facility's Loss of Controlled Substance Report dated 06/20/2021 documented that Registered Nurse Supervisor #1 (RNS #1) reported at 7:40 AM that two narcotic blister packs were identified missing from the 5th floor. [MEDICATION(S)] 10/325mg tablets -16 tablets and Oxycodone 5mg tablets -16 tablets missing. Upon reviewing the camera, Resident # 484 took two blister packs from the medication cart narcotic box. The Facility Occurrence Review and Investigation dated 06/20/2021 documented that the day nurse spoke to Resident # 484, and the resident handed 16 tablets back to the day nurse. The 16 tablets returned had 10/325 labels on each tablet. Resident # 484 then showed a small bag with green-colored pills to the day nurse and the nursing supervisor, but instead of handling it to the nurse, the resident swallowed the pills in front of the nurses. Resident # 484 was transferred to the hospital for evaluation and returned the same day. A review of the [MEDICATION(S)] narcotic sheet revealed that 16 tablets of Oxycodone/APAP ([MEDICATION(S)]) 10/325mg were on the blister pack on 06/19/2021 at 8:00 PM. A review of the Oxycodone narcotic sheet revealed that 16 tablets of Oxycodone 5mg were on the blister pack on 06/20/2021 at 6:00 AM. A review of the LPN statement dated 06/20/2021 revealed that the medication cart was left unattended during 6:00 AM medication administration. Two medication blister packs were identified missing while counting with the morning medication. A Nurse's Progress Note dated 06/20/2021 at 9:51 PM documented that Resident #484 returned from the hospital in no apparent distress, no vomiting, no distress noted. A Physician Progress Note dated 06/21/2021 at 11:36 AM, documented that Resident # 484 was seen for follow-up after return from the hospital. It is documented that as per Resident # 484 explained that many antihypertensive pills were ingested to keep staff from taking the pills. The resident was monitored for psych and medicine in the emergency department plan and returned to the nursing home the same day. Monitor for acute changes and notify MD. A review of the facility's in-service attendance record revealed no documented evidence that the night shift LPN received a prior in-service on handling-controlled substances. During an interview on 10/19/2021 at 3:00 PM, Registered Nurse Supervisor #1 (RNS #1) stated that the night nurse from the 5th floor called around 7:30 AM said some narcotics were missing. RNS #1 went to the floor immediately with the morning supervisor and checked the medication room and the medication carts, and they could not find the missing narcotics. The Director of Nursing ( DON) was informed and reviewed the surveillance video and saw that Resident # 484 took two blister packs from the medication cart narcotic box. Resident # 484 had some tablets in hand, showed them to the nurse, and then swallowed them in front of the nurses. The doctor was informed, and the resident was transferred to the hospital for evaluation. During an interview on 10/25/2021 at 9:42 AM, the Director of Nursing (DON) said that RNS #1 informed the DON immediately they noticed that the narcotics were missing. Two blisters' packs of medication were missing during shift change. The medication room and the medication cart were searched thoroughly, but they could not find them. The DON reviewed the camera and saw that Resident # 484 took the narcotics blister packs from the med cart. The med cart was left open while the nurse went to a resident room. Resident # 484 gave the morning nurse 10/325mg white 16 tablets out of the blister pack. The resident also showed 16 green tablets out of the blister pack to the nurse but did not give them to the nurse and swallow them in front of the nurse. The resident was sent to the hospital immediately for a possible drug overdose. The LPN was suspended and was going to be terminated but did return to work. 415.12(h)(2)