Every finding on record at Forest Hills Care Center

Based on observation, record review, and interview during the Recertification Survey conducted from 06/04/2025 to 06/11/2025, the facility failed to maintain the residents' rights to a safe, comfortable, and homelike environment. This was evident in 3 (Units 1, 2, and 3) of 3 units observed. Specifically, 1.) The cover for the clean linen carts in Units 1 and 2 were soiled and heavily worn. 2.) The high back of Resident #41's wheelchair was in disrepair. The findings include: The facility policy titled Linen Cart Cover dated 02/2025 documented, Covers should be free of tears, holes or damage that may compromise their integrity. Cart covers shall act as a physical barrier to prevent contamination from dust, debris and airborne pathogens. During multiple observations from 06/04/2025 to 06/10/2025, between 7:00 AM and 1:00 PM, the blue mesh cover of the clean linen cart in Unit 1 was torn, tattered, and heavily worn with brownish crusty stain. Additionally, the blue mesh cover of the clean linen cart in Unit 2 was heavily frayed and encrusted with yellowish substance. On 06/11/2025 at 9:31 AM, Certified Nurse Assistant #2 was interviewed and stated they do not pay attention to the condition or cleanliness of the covers for the clean linen carts. They stated the housekeeping department takes care of the linen cart covers. On 06/11/2025 at 9:37 AM, the Director of Housekeeping was interviewed and stated they are responsible for ensuring the cleanliness of the building. They stated they do not look at cart covers and expects the staff on the unit to report issues of torn or soiled cart covers. The Director of Housekeeping stated the clean linen cart covers are changed when needed or when they received a report about its condition. They stated covers are important in keeping with infection control practices as this reduces or minimizes the amount of dust and dirt that can get into the clean linen carts. The facility's policy titled Preventive Maintenance for wheelchairs which was last revised on 03/2025 documented it is the practice of the facility to develop and implement a preventive maintenance program to ensure wheelchairs are maintained in a safe and operable manner. The policy also documented that all staff have a responsibility to ensure that wheelchairs in need of repairs are not used and are reported for repairs. On 06/04/2025 at 11:38 AM, Resident#41 was observed sitting in their wheelchair in the dining room having lunch. The high back of Resident #41's wheelchair was noted torn and was in disrepair. On 06/05/2025 at 10:34 AM and on 06/06/2025 at 9:59 AM, Resident #41 was observed sitting in their wheelchair, with the wheelchair's high back still torn and in disrepair. A review of the facility Maintenance logbook for Unit 3 did not reveal any entries for Resident #41's wheelchair needing repair. On 06/06/2025 at 10:19 AM, Certified Nursing Assistant #3 was interviewed and stated Resident #41 is not always in their assignment and they are not aware that the wheelchair needs repair. They stated if they observed a resident's wheelchair was torn or in disrepair, they would usually out a sheet on it. On 06/06/2025 at 10:29 AM, Registered Nurse #1was interviewed and stated they were not aware that Resident #41's wheelchair needed repair. They stated they tell the Rehabilitation Department when a wheelchair needs repair, and they would come and change it. On 06/06/2025 at 2:04 PM, the Director of Rehabilitation was interviewed and stated if a wheelchair needs repair, the staff reports the issue to the maintenance staff, the maintenance staff then would repair the wheelchair if possible. They stated they would have to order a new wheelchair if the back rest was ripped and the type of upholstery is outdated. On 06/11/2025 at 8:03 AM, the Director of Nursing was interviewed and stated there are maintenance books on each units and the staff must log and report any wheelchair that needs repair. The Director of Nursing also stated that if the wheelchair is torn as in Resident #41's case, then it should be repaired. On 06/11/2025 at 8:10 AM, the Maintenance Director was interviewed and stated they are responsible for repairing the wheelchairs. They stated there is a maintenance logbook on each unit that is being checked and signed off by a maintenance personnel once an issue has been addressed. The Maintenance Director stated they do not recall if they were told that Resident #41's wheelchair need repair. 10 NYCRR 415.5(h)(2)

Based on observation, record review, and interviews during the Recertification Survey conducted from 06/04/2025 to 06/11/2025, the facility did not ensure that services provided or arranged by the facility meet professional standards of quality. This was evident in 1 (Resident #46) of 1 resident reviewed for pain. Specifically, Resident #46 had physician orders for Lidocaine patch to be applied daily at 9:00 AM to bilateral shoulders for pain. Licensed Practical Nurse #2 had signed off Resident #46's lidocaine patch order on the medication administration record as having administered it, although they did not apply the pain patch on Resident #46's shoulders. Cross Reference: F-697 Pain Management The findings are: The facility's policy and procedure titled Professional Standards of Practice for Licensed Nursing Staff (Registered Nurse and Licensed Practical Nurse) dated 01/25 documented Licensed Practical Nurses are expected to administer medication and treatment as ordered and within licensure limits and to document timely and accurately all care rendered. Resident #46 was admitted to the facility with diagnoses that included Primary Osteoarthritis of Right and Left Shoulders, Benign Prostatic Hyperplasia, and Chronic Kidney Disease. The quarterly Minimum Data Set assessment with a reference date of 03/05/2025 documented Resident #46 had intact cognition and required partial / moderate assistance in activities of daily living. The assessment documented that Resident #46 received scheduled pain medication regimen and that resident had indicated no pain during the pain assessment interview. A care plan for pain related to arthritis and joint pain was initiated for Resident #46 on 03/18/2022 and was last reviewed on 02/27/2025. The care plan documented that Resident had mild pain. The facility interventions included to administer medications as ordered, pain assessment as needed, and to evaluate effectiveness of the medication. A physician's order dated 08/20/2024 documented to apply Asperflex (lidocaine) 4% topical patch, apply 1 patch by topical route once daily at 9:00 AM to bilateral shoulders, and remove at 9:00 PM for unspecified pain. The Medication Administration Record for Resident #46 dated 06/05/2025 at 9:00 AM documented that Licensed Practical Nurse #2 administered the lidocaine patch. On 06/05/2025 at 11:18 AM, Resident # 46 was interviewed in their room and gestured with both hands, touching each shoulder and stated they have pain on both shoulders. Resident #46 stated pain patches are applied to each of their shoulders and that it provides soothing relief. The resident exposed both of their shoulders and there were no patches observed to either shoulders. Resident #46 stated they did not remove the patches, and they have to wait for the other nurse to apply the pain patches. On 06/05/2025 at 11:10 AM, Licensed Practical Nurse #1, who was the medication nurse, was interviewed and stated Resident #46 had a standing order for pain patch. They stated they have a memory of applying pain patches earlier today on Resident #46's shoulders, however, they did not sign off on the medication administration record as having applied the pain patches. They stated they notified Licensed Practical Nurse #2, who was the treatment nurse, that the pain patches were applied, and that Licensed Practical Nurse #2 will sign off on the medication administration record because it is considered a treatment. On 06/05/2025 at 11:24 AM, Licensed Practical Nurse #2, who was the treatment nurse, was interviewed and stated they are responsible for providing wound care treatments and pain patches to all residents. Licensed Practical Nurse #2 stated they did not apply Resident #46's pain patch but had signed off on Resident #46's lidocaine patch order on the medication administration record as having administered it. They stated Licensed Practical Nurse #1 told them they already applied the pain patches on the resident's shoulders, but they did not check if the lidocaine patches were actually applied. On 06/09/2025 at 11:34 AM, the Director of Nursing was interviewed and stated each unit has a medication nurse and there is a nurse assigned to all residents' units to perform wound care and treatments. The Director of Nursing stated Resident #46 is on pain patch because of joint arthritis which was effective. They stated standards of professional practice dictates that medications are to be given as ordered by a physician and must be signed off by the licensed nurse who administered it. 10 NYCRR 415.11(c)(3)(i)

Based on observation, record review, and interview during the Recertification Survey conducted from 06/04/2025 to 06/11/2025, the facility failed to ensure that pain management was provided to a resident consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. This was evident in 1 (Resident #46) of 1 resident reviewed for pain. Specifically, Resident #46 had physician orders for Lidocaine patch to be applied daily at 9:00 AM to bilateral shoulders for pain. During observation at 11:18 AM, there were no pain patches observed on Resident #46's shoulders. However, the Medication Administration Record for 06/05/2025 at 9:00 AM documented that the Lidocaine patch had been administered. The findings are: The facility policy on Pain Assessment and Management with a revised date of 03/2025 documented, The facility is committed to providing/maintaining the resident's highest level of pain control and comfort while achieving/maintaining the resident's highest level of Activities of Daily Living Function. Resident #46 was admitted to the facility with diagnoses that included Primary Osteoarthritis of Right and Left Shoulders, Benign Prostatic Hyperplasia, and Chronic Kidney Disease. The quarterly Minimum Data Set assessment with a reference date of 03/05/2025 documented Resident #46 had intact cognition and required partial / moderate assistance in activities of daily living. The assessment documented that Resident #46 received scheduled pain medication regimen and that resident had indicated no pain during the pain assessment interview. A care plan for pain related to arthritis and joint pain was initiated for Resident #46 on 03/18/2022 and was last reviewed on 02/27/2025. The care plan documented that Resident had mild pain. The facility interventions included to administer medications as ordered, pain assessment as needed, and to evaluate effectiveness of the medication. A physician's order dated 08/20/2024 documented to apply Asperflex (lidocaine) 4% topical patch, apply 1 patch by topical route once daily at 9:00 AM to bilateral shoulders, and remove at 9:00 PM for unspecified pain. The Medication Administration Record for Resident #46 dated 06/05/2025 at 9:00 AM documented that Licensed Practical Nurse #2 administered the lidocaine patch. On 06/05/2025 at 11:18 AM, Resident # 46 was interviewed in their room and gestured with both hands, touching each shoulder and stated they have pain on both shoulders. Resident #46 stated pain patches are applied to each of their shoulders and that it provides soothing relief. The resident exposed both of their shoulders and there were no patches observed to either shoulders. Resident #46 stated they did not remove the patches and they have to wait for the other nurse to apply the pain patches. On 06/05/2025 at 11:23 AM, Certified Nursing Assistant #1,who was the aide assigned to Resident #46, was interviewed and stated they did not observe any patches on the resident's shoulders when they assisted Resident #46 with shower today between 8:00 AM - 8:30 AM. On 06/05/2025 at 11:10 AM, Licensed Practical Nurse #1, who was the medication nurse, was interviewed and stated Resident #46 had a standing order for pain patch. They stated they have a memory of applying pain patches earlier today on Resident #46's shoulders, however, they did not sign off on the medication administration record as having applied the pain patches. They stated they notified Licensed Practical Nurse #2, who was the treatment nurse, that the pain patches were applied, and that Licensed Practical Nurse #2 will sign off on the medication administration record because it is considered a treatment. On 06/05/2025 at 11:24 AM, Licensed Practical Nurse #2, who was the treatment nurse, was interviewed and stated they are responsible for providing wound care treatments and pain patches to all residents. Licensed Practical Nurse #2 stated they did not apply Resident #46's pain patch but had signed off on Resident #46's lidocaine patch order on the medication administration record as having administered it. They stated Licensed Practical Nurse #1 told them they already applied the pain patches on the resident's shoulders but they did not check if the lidocaine patches were actually applied. On 06/09/2025 at 11:34 AM, the Director of Nursing was interviewed and stated each unit has a medication nurse and there is a nurse assigned to all residents' units to perform wound care and treatments. The Director of Nursing stated Resident #46 is on pain patch because of joint arthritis which was effective. They stated that medications are to be given as ordered by a physician and must be signed off by the licensed nurse who administered it. 10 NYCRR 415.12

Based on observation, record review, and interview during the Recertification Survey from 06/04/2025 to 06/11/2025, the facility failed to maintain infection prevention and control practices. This was evident in 1 (Resident #12) of 5 residents investigated for Pressure Ulcer out of 38 total sampled residents. Specifically, Licensed Practical Nurse #3 did not perform hand hygiene and glove changes during wound care observation. The findings include: The facility's policy titled Treatment Policy with a last reviewed date of 02/2025 documented that the facility will have a wound care program to prevent deterioration of pressure ulcers and the development of any infection and promote wound healing. The objectives include to educate all nursing staff regarding the importance of wound care treatment. The treatment procedure includes applying clean gloves to remove soiled dressing, discard dressing, wash hands and put on clean gloves. Resident #12 was admitted to the facility with diagnoses that include Non-Alzheimer's Dementia, Stage 3 Pressure Ulcer and Depression. The Minimum Data Set assessment dated [DATE] documented Resident #12's cognition as severely impaired, was dependent to staff on bed mobility, and had Stage 3 pressure ulcer/injury. A physician's order dated 06/07/2025 included Santyl 250 unit/gram topical ointment: cleanse sacrum with normal saline, pat dry. Apply ointment and Calcium Alginate dressing and combine pad to site daily and as needed, no adhesive around wound site. A physician's order dated 06/07/2025 documented to cleanse left buttock with normal saline, pat dry, and apply Xeroform dressing with combine pad to site daily and as needed. A comprehensive care plan for impaired skin integrity on the sacrum was initiated on 05/13/2021 and was last reviewed on 05/29/2025. The facility interventions include providing treatment as per physician's order, to observe for signs and symptoms of infection, keeping skin dry at all times, and pressure relieving device. A comprehensive care plan for impaired skin integrity on the left buttock was initiated on 05/07/2025. The goals include resident's ulcer will be free of signs and symptoms of infection. The facility interventions include treatment as per physician's order, weekly wound measurements weekly and as needed, and performing weekly wound rounds. A physician's note dated 06/05/2025 documented Resident #12 was evaluated for pressure ulcer. Resident #12 had stage 3 pressure ulcer on the sacrum and dermatosis on the left buttock. Recommendation was wound care as per wound team; the family was made aware. During a wound care observation conducted on 06/09/2025 at 10:58 AM, Licensed Practical Nurse #3 gathered their supplies, placed it on a disposable tray, donned gown and gloves, and entered Resident #12's room. Licensed Practical Nurse then introduced self, and with the assistance of the Certified Nursing Assistant #4 turned Resident #12 to their right side. Without changing gloves and without performing hand hygiene, Licensed Practical Nurse proceeded to open the gauze dressings, poured normal saline solution on some of the gauze, and then cleaned the wounds with the saturated gauze. Without changing gloves and without performing hand hygiene, the Licensed Practical Nurse then pat dry the wounds, placed the Santyl ointment on the gauze, and packed the wound with calcium alginate dressing. Licensed Practical Nurse #3 opened the Xeroform gauze dressing and placed it on the wound on the buttocks and covered both wounds with the combine pads. Licensed Practical Nurse and the Certified Nursing Assistant #4 removed the dirty linen from underneath the resident's sacrum, and the put on an adult brief for Resident #12. Licensed Practical Nurse failed to change their gloves and perform hand hygiene all throughout the wound care treatment, and did not change their gloves nor washed their hands after cleaning the resident's wounds. Further, Licensed Practical Nurse #4 did not utilize a protective drape under resident's sacrum during wound care. On 06/09/2025 at 11:24 AM, Licensed Practical Nurse #3 was interviewed immediately after dressing change and stated they are taught to use the protective drapes during wound care and to change their gloves after cleaning the wound. Licensed Practical Nurse #3 stated it was an oversight because they were not feeling well today. On 06/09/2025 at 11:32 AM, Registered Nurse #1 was interviewed and stated that licensed nurses were taught to wash their hands, before and after wound treatment preparation, and when they are about to start the wound treatment on the residents. Registered Nurse #1 also stated that hand hygiene must be performed after removing the soiled dressing and after cleaning the wound because the gloves are contaminated. They stated nurses were taught to wash their hands after and between dressing changes. On 06/11/2025 at 08:15 AM, the Assistant Director of Nursing was interviewed and stated that licensed nurses they should wash their hands before they prepare the wound treatment supplies, when they bring the supplies to the room, when they start the treatment, when they remove the soiled dressing, and must put on a new pair of gloves when they clean the wound. They stated licensed nurses must use the protective drape under the resident and remove any soiled material under the resident prior to dressing changes. On 06/11/2025 at 7:55 AM, the Director of Nursing was interviewed and stated that nurses are given in-service education to change their gloves and to wash their hands between dressing changes. They stated that nurses also had their competency on hand hygiene. 10 NYCRR 415.19(b)(4)

Based on observations and interviews conducted during the Recertification survey, the facility did not ensure that the survey results were posted in a place readily accessible to residents, family members, and legal representatives in areas of the facility that are prominent and accessible to the public. Specifically, the survey results were located in a corner with no signage in the area, and was not readily accessible to residents. The finding is: The facility policy and procedure titled Resident Right effective 11/2/2021and revised 10/4/2023 documented the facility will post reports with respect to any survey, certification and complaint investigation made respecting the facility during the 3 preceding years. It should be available for any individual to review upon request. During multiple observations of prominent areas and resident units in the facility, the survey results or information about the whereabouts of the survey results could not be located. On 12/19/2023 at 11:05 AM-12:08PM, during the Residents Council meeting 12 Residents were asked about the location of the survey result book. All residents indicated that they did not know where the survey results were located. During multiple observations between 12/18/23 to 12/21/23, the survey result were observed placed in a black binder with a small thin label. The binder was located in a black metal bin attached to the wall in a corner area of the lobby behind a clear plastic guard. There was a shredder bin placed right under the black bin holding the survey results which obstructed resident's access to the binder. In addition, there was no signage indicating the survey results could be located in this area. During multiple observations on resident Units 1 and 3 from 12/18/23 to 12/20/23 there were signs indicating that the survey results could be located in the lobby area. The signs were not at eye level for residents in wheelchairs and the print was difficult to read due to the print and design of the signs. There was no signage located on Unit 2 indicating where survey results could be found. On 12/21/2023 at 1:09 PM, the Administrator was interviewed and stated the survey results are located in the lobby near to the pay phone. The Administrator also stated that they always tell the residents during Resident Council meetings where the results can be located. 10 NYCRR 415.3(d)(1)(v)

Based on observation, record review, and interviews conducted during the recertification survey from 12/18/2023 to 12/21/2023, the facility did not ensure a clean, comfortable, and homelike environment was maintained. This was evident for 2 of 3 resident units. (Unit 2, and Unit 3) during review of the Environment. Specifically, 1) multiple resident rooms on Unit 2 were observed with multiple white colored streaks on the splash guard for the handwashing sink in the resident rooms and 2) overbed tables were noted with missing white paint on the bottom foot base bottom, multiple wall air conditioning and heater units were noted with dust on the outside and black colored debris on the inside top coils and top of the unit and air conditioning units were also noted with silver duct tape affixed to the edges and on surrounding wood based had silver duct tape, multiple resident rooms were noted with cracked or missing footboard veneer on there was cracked furniture in resident rooms Unit 3. This is evident for Environmental Task. The findings are: The policy and procedure titled Cleaning Maintaining Resident Room Equipment dated 11/20/2023 documented the facility will ensure that all equipment in the resident room is properly maintained, cleaned, and sanitized on a regular basis. Upon finding any malfunctioning of this equipment, immediately inform maintenance personnel for repair and new replacement. It is the responsibility of the maintenance department to monitor for monthly upkeep. During multiple observations on Unit 2 from 12/18/2023 to 12/21/23, Rooms 202, 203, 204, 205, 206, 207, 208, 209, 210, 211 the plastic covering on the wall between bathroom and sink was observed with multiple whitish streaks running up and down which were easily removed by the State Surveyor with wet paper towel. room [ROOM NUMBER] was noted with torn wallpaper, a large area of previously wall papered wall was covered with a large splatch of paint, and covered with and the radiator shell below the window had a chipped and raised top, and the night stand drawers had areas covered with cream colored duct tape. On 12/21/23 at 11:55 AM, Housekeeper #3 was interviewed and stated that they usually do special projects and was currently covering for the regularly assigned housekeeper who was on vacation. Housekeeper #3 also stated that they did not know how often the plastic covering on the wall has to be cleaned, because it's a special project that the regular housekeepers do not do as part of their daily routine. On 12/21/23 at 02:51 PM, the Director of Housekeeping was interviewed and that they do rounds twice a day throughout the units, checking nursing stations, shower rooms, dirty utility rooms, clean utility rooms and dining rooms. Each floor has one housekeeper. The housekeepers have a standard assignment of what to do, and they have to clean the rooms. The Director of Housekeeping also stated that all housekeepers are required to clean the walls, toilets, floors. 42101 During observations from 12/18/23 to 12/21/23, Rooms 301, 302, 303, 304, 305, 306, 307, 308, 309, 310 and 311 were observed with air conditioner units that had black debris, and had areas of duct tape covering parts of the unit. In addition, some bedside tables and footboards had chipped areas,there was peeling wallpaper and broken plastic wall coverings. During an interview on 12/20/23 at 03:53 PM, Housekeeper #2 stated that they look for dirt under bed, table, and furniture cleaning, to clean dust in room. Housekeeper #2 stated that they noticed the dusty AC units and will try to clean them. Housekeeper #2 further stated that they did not notice the chipped foot board and maintenance takes care of that and the bedside tables. During an interview on 12/21/23 at 10:04 AM, the Director of Housekeeping stated that air conditioner filters are cleaned but they keep no record of this. During a follow-up interview on 12/21/23 at 11:04 AM, Housekeeper # 1 stated that they look at the bedside table condition bottom to see if there are any droppings from food on it not to see if it needs to be painted. Housekeeper #1 also stated that AC units are cleaned one time a week and we clean and wipe the outside if there is any dust. Housekeeper #1 further stated that air conditioner units are duct taped regularly and the duct tape has been there less than 1 year. During an interview on 12/21/23 12:50 PM, the Director of Maintenance stated that the last time half the air conditioners on the 3rd floor were cleaned was in April 2023. They should be cleaned at least twice monthly or quarterly. 44472 During multiple observations from 12/18/23 to 12/21/23, Rooms 318, 319, 320 and 320 were observed with window blinds with open spaces, broken and loose slats. In addition, hallway windows near room [ROOM NUMBER], were observed with peeling of paint and gray duct tape on all sides. On 12/20/2023 at 12:15 PM, Resident in room [ROOM NUMBER] was interviewed and stated we do not like window blinds with broken loose slats, and we like our room to be a little darker but because there is a broken slats their room is still bright. On 12/21/23 at 12:04 PM, the Director of Maintenance was interviewed and stated lately they have noticed the blinds in the resident room were sagging, the materials used as slats were of poor quality. They have a plan of replacing all sagging and broken blinds. The Director of Maintenance further stated the maintenance staff will make frequent rounds to check all blinds and replace them as needed. The windows that have duct tape were temporary because we noticed some air coming in from outside so we just tape them but we have plan of fixing broken window sills and painting the window's wood area because some paint is peeling off especially in the second and third floor windows in the hallway. The Director of Maintenance also stated that air conditioner covers on some rooms in the third floor were dusty and with duct tape around, some heater have debris and is blackened so we will clean them up. The Director of Maintenance stated thzat they were aware of splash guards on some sink areas that are cracked, wall paper peeling off from the wall and bedside table that have chipped so they will be repainted. The Director of Maintenance also stated that the facility had construction going months ago but stopped and the Administration has plans of doing construction again. On 12/21/23 at 12:24 PM, the Administrator was interviewed and stated that because of the holidays, construction at the facility had stopped. The Administrator also stated that cleanliness must be observed on all rooms, and they are aware and frequently monitoring and repairing broken blinds, and fixing wall paper as soon as possible. The Administrator further stated that they will start with rooms that are vacant now and will eventually check all rooms. 10 NYCRR 415.5(h)(2)

Based on interview and record review conducted during the Standard survey completed on 12/21/2023, the facility did not ensure that it promoted and facilitated resident self-determination through the support of resident choice for two (Resident #18 and #67) of four residents reviewed. Specifically, the preferred number of showers per week were not obtained and not provided in accordance with Resident #18 's and Resident #67 's wishes. The finding is: The policy and procedure titled Bath and Shower revised 01/2023 documented all residents receive a daily bed bath. All residents receive a shower twice a week and per resident's choice it always can be adjusted. Shower schedule is kept on each floor (updated daily as residents are discharged and admitted . CNA will provide showers in accordance with a shower list. 1.Resident #18 had diagnoses which included End Stage Renal Disease, Major Depressive Disorder, and Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #18 was cognitively intact, required limited assist of one staff member with bathing, and there was no rejection of care. The Annual Quarterly Minimum Data Set assessment dated [DATE] further documented it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. During an interview on 12/18/2023 at 10:37 AM with a Spanish language interpreter, Resident #18 stated they received a shower on Mondays and Fridays. Resident #18 also stated that they wished it could be more often, but they were told they cannot have a shower every day, and they did not recall who told them that but that is the way it is. The Activities of Daily Living Comprehensive Care Plan for bathing created 2/10/2017 and revised 12/12/2023 documented interventions which included to bathe as schedule and as requested, encourage resident to bathe self, and allow resident ample time to complete task. The Certified Nursing Assistant Documentation Record dated 11/2023 and 12/2023 revealed that Resident #18 received a shower on Mondays and Fridays as indicated by the Certified Nursing Assistant's initials. During an interview on 12/21/23 at 11:27 AM, Certified Nursing Assistant #7 stated they do not speak Spanish and Resident #18 received showers on Mondays and Fridays. Certified Nursing Assistant #7 also stated that Resident #18 would request towels from staff and perform their own morning care in their room. Certified Nursing Assistant #7 further stated that Resident #18 had not asked to shower more often, because they knows their set shower days. Certified Nursing Assistant #7 stated that if a resident requested to receive more showers, they would have to report to the nurse, because the Certified Nursing Assistant Documentation Record documentations does not allow the staff to document extra shower days outside of the scheduled days. 2. Resident #67 had diagnoses which included Osteoarthritis, Hypertension, and Depression. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #67 was cognitively intact, required moderate assistance with hygiene and lower body dressing, and required maximum assist with upper body dressing and oral and personal hygiene. The Annual Minimum Data Set assessment dated [DATE] documented it is very important to choose between a tub bath, shower, bed bath, or sponge bath. The Activities of Daily Living Comprehensive Care Plan created 3/20/2021 and revised 10/03/2023 documented interventions which included to bathe as schedule and as requested, encourage resident to bathe self, and allow resident ample time to complete task. During an interview on 12/19/23 at 09:28 AM with a Spanish language interpreter, Resident #67 stated they received a bed bath two to three times a week, and would prefer to get a shower every day. Resident #67 also stated that showering everyday was not allowed at the facility and they felt like they had to follow the rules at the facility. Resident #67 further stated that they felt like they could not decide when to shower, and that was the way things were done at the facility. The Certified Nursing Assistant Documentation Record dated 11/2023 and 12/2023 revealed that Resident #67 received a shower on Thursdays and Sundays as indicated by the Certified Nursing Assistant's initials. During an interview on 12/21/23 at 11:48 AM, Certified Nursing Assistant #8 stated they do not speak Spanish, and sometimes they get help interpreting from other Certified Nursing Assistants for Resident #67. Certified Nursing Assistant #8 also stated that Resident #67's shower days are Thursdays and Sundays and if they wanted an extra shower, they would report to the nurse to have it scheduled. During an interview on 12/21/23 at 12:21 PM, Registered Nurse #2 stated that all residents have a showers prearranged, and every room has certain days and times for shower. Registered Nurse #2 also stated that showers are prearranged and they were not sure if anybody ever asked the residents what they preferred shower schedule to be. Registered Nurse #2 further stated that if a resident requested additional showers, they would notify the staff and it would be arranged. During an interview on 12/21/2023 at 12:35 PM, the Director of Nursing stated that when residents are admitted they are informed that they will be showered two days a week, usually three to four days apart. Residents are told the day and shift of the shower and if the resident prefers to shower at a different time, it can be changed for a different shift. The Director of Nursing further stated that if residents want to shower more frequently, staff has to arrange it. The Director of Nursing stated that they did not think that staff ever asked the residents when and how often they would like to have a shower. During an interview on 12/21/23 at 02:58 PM, the Administrator stated that when a resident is admitted we have a set schedule, so we ask if they prefer day or evening, or how frequently. The Administrator also stated that shower preferences are discussed by the nurses on the floor during the admission interview or the Social Worker may ask. The Administrator further stated they were not aware that resident's shower preferences were not being honored as they have had conversations with family members and accommodated more frequent showers for some of the residents. 10 NYCRR 415.5(b)(1-3)

Based on observation, record review, and interviews conducted during the Recertification survey conducted from 12/18/2023 to 12/21/2023, the facility did not ensure a person-centered Comprehensive Care Plan (CCP) was developed and implemented to address the resident's needs. This was evident for 1 (Resident #9) of 22 total sampled residents. Specifically, a Comprehensive Care Plan related to Resident #9's discharge plan was not developed and implemented. The findings are: The facility policy on Comprehensive Care Plan regarding Discharge Planning Procedure effective on 1/2022 and last reviewed 2/2023 documented a written Comprehensive Care Plan will be developed and implemented for each resident, in conjunction with the residents and or resident representatives. The policy also documented discharge planning and documentation begins at admission and is discussed at the weekly discharge planning meeting and at the initial care plan meeting within 21 days after admission and the primary goal is to continue the comprehensive care of the resident. Discharge planning is to be documented and addressed on the resident's Comprehensive Care Plan and updated accordingly by the social worker. Resident #9 was admitted on [DATE] with diagnoses that included Hypertension, End Stage Renal Disease, and Malnutrition. The Significant Change Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #9 had moderate cognitive impairment and required extensive assistance from staff to complete Activities of Daily Living (ADL). Section Q of MDS-Participation in Assessment and Goal setting, documented that Resident #9 was an active participant in assessment process and the family responded that they did want to talk to someone about the possibility of leaving the facility and returning to live and receive services in the community. On 12/19/23 at 11:56 AM, Resident #9 was observed sitting in the wheelchair talking to a family member. The family member identified themselves as the Health Care Proxy and stated they told the Social Worker that they wanted Resident #9 discharged home and nobody had given them any update regarding the discharge plan. There was no evidence a Comprehensive Care Plan for discharge was developed and implemented. On 12/21/23 at 10:11 AM, Certified Nursing Aide #1 was interviewed and stated Resident #9's family member always visits and they wanted Resident #9 to be discharge. Certified Nursing Aide #1 also stated that the family member would always tell them of their plans for Resident #9's return home. On 12/21/23 at 10:19 AM, Licensed Practical Nurse #1 was interviewed and stated a family member always comes to visit and talks about Resident #9 going home soon and they are waiting for the Social Worker to update them of the plan for Resident #9 to go home. On 12/21/23 at 10:27 AM, Director of Social Service was interviewed and stated Resident #9 family member told us last week that they want Resident #9 to be discharged soon. The Director of Social Service stated they did not start discharge planning because it was just last week and they did not know if the family would change their mind. The Director of Social Service also stated that they did not document the request for discharge. On 12/21/23 at 10:44 AM, Social Worker #1 was interviewed and stated they are aware of Resident #9's family member's request for discharge however they did not initiate the care plan for discharge, and that was on oversight. Social Worker #1 also stated that care planning for discharge should be initiated as early as possible to help the family settle the resident at home. On 12/21/23 at 11:48 AM, the Director of Nursing was interviewed and stated that they were only made aware of Resident #9's request for discharge a few days ago. The Director of Nursing also stated that planning for discharge should have been initiated as soon as the resident was admitted to the facility. The Director of Nursing further stated they will check to ensure that care plans for discharge are in place from now on. 10 NYCRR 415.11(c)(1)

Based on observations and interviews conducted during the Recertification survey from 12/18/2023 to 12/21/2023, the facility did not ensure that drugs and biologicals were safe and secure to protect from unauthorized access. Specifically, 1) authorized and unauthorized staff were noted entering the medication room with and without using the keypad on the door, and 2) medication was left unattended in resident areas. This is evident for the Medication Storage Task on Unit 3. The findings are: 1.The facility policy titled Medication Storage/Handling revised 11/20/2023 documented the facility will ensure all medications, in all forms, are stored and handled according to manufacturer's recommendations and best practice standards in order to maintain the integrity of the medication as well as reduce the risk of medication errors. Medication room (s) storage cabinet(s), refrigerator(s) and carts should always be locked when not in use. On 12/18/2023 between 11:33 AM and12:31 PM, the Director of Housekeeping Licensed Practical Nurse #6, Licensed Practical Nurse #5, and Resident Nurse #1 entered the medication room without using the keypad lock. On 12/18/2023 between 02:20 PM and 02:57 PM, Licensed Practical Nurse #5 knocked on the medication room door and then entered the room without using the keypad. In addition, Licensed Practical Nurse #6 was observed walking into the medication room without using the keypad lock. The medication storage room was observed to contain containing a double locked narcotic locker, locked refrigerated medications, emergency box with tamper proof seal attached, over the counter medications not in a locked compartment, diabetic testing supplies not in a locked compartment, treatment supplies, sodium chloride and heparin flush syringes in a carboard box on the right bottom side shelf of the medication room. On 12/18/23 at 03:42 PM, the Director of Maintenance was observed at the medication room working on the lock. On 12/19/23 at 11:13 AM, the Director of Maintenance was observed in the 3rd floor medication room. Staff was heard calling out the medication room code in a loud voice in the nurse's station. The Director of Maintenance removed a stuffed cotton like material from the door area for the lock and disposed of it in the trash in the nurse's station. On 12/19/23 at 11:03 AM, the 2022-23 - 3rd Floor Maintenance Book was reviewed and revealed documentation on 12/18/2023 the med room doesn't fully close adjusted and was signed with Director of Maintenance's initials. On 12/20/23 at 12:02 PM, Licensed Practical Nurse #6 was observed entering the medication room and closing the door. Upon exiting the medication room, the lock was heard engaging approximately10 seconds after Licensed Practical Nurse #6 exited the room. On 12/20/23 01:03 PM, Certified Nursing Assistant #4 was observed entering the lock code into the medication room keypad to allow an outside vendor to enter the room. The door was propped open and the vendor remained in the room unsupervised. At 01:06 PM, Licensed Practical Nurse #4 was observed at the door supervising the vendor. During an interview on 12/19/23 at 10:35 AM, Licensed Practical Nurse #4 stated that the medication room lock has been broken since last week on Sunday (12/17/23). Licensed Practical Nurse #4 also stated that the medication room should be secure because we have over the counter (OTC) medications, treatment supplies and narcotics in there. Licensed Practical Nurse #4 further stated that only nurses are allowed in the medication room and we have to make sure to pull in door before we leave or else the door will not be locked. During an interview on 12/19/23 at 10:44 AM, Licensed Practical Nurse #5 stated there has been no issue with the lock for the med room. Licensed Practical Nurse #5 also stated that only nurses have the code to get in the medication room. During an interview on 12/19/23 at 10:47 AM, Registered Nurse #1 stated that intermittently the medication room door does not close properly, and maintenance has to go and check it. The last time this was an issue was 3 months ago and an entry was made in logbook and any concerns should be written in the maintenance book. Registered Nurse #1 also stated that if the medication room is not secure anyone can have access. Registered Nurse #1 further stated only the med nurse has access to narcotics and medications. During an interview on 12/20/23 at 01:08 PM, Certified Nursing Assistant #4 stated they opened medication room door for the contractor. We have access to medication room because the hygiene soap is kept there. During an interview on 12/20/23 at 02:53 PM, Certified Nursing Assistant #5 stated they will go to the medication room if the nurse asks them to get something, and sometimes the nurses will give them hygiene supplies. They stated that they will ask to go into the medication room, and they are not ordinarily supposed to go in there because medications there in the medication room. The nurses should supervise them when they go to medication room for the hygiene supplies. During an interview on 12/20/23 05:18 PM, Licensed Practical Nurse #7 stated there are no issues with the medication room lock and all nurses have access to the medication room. Licensed Practical Nurse #7 stated that the Certified Nursing Assistant would ask for what supplies they need, but some Certified Nursing Assistants would go to the medication room on their own to get supplies needed. Licensed Practical Nurse #7 further stated that the medication room should be locked. During an interview on 12/20/23 05:22 PM, Certified Nursing Assistant #3 stated that they go into the medication room to get hygiene supplies for residents. Certified Nursing Assistant #3 also stated that they were informed of how to access the room from previous nursing staff. The medication room should be locked because we have residents who wander so it should be locked at all times. During an interview on 12/21/23 at 10:01 AM and 02:31 PM, the Director of Housekeeping stated they dropped off supplies on Monday and Thursdays in the medication room and they have automatic access to the room because supplies are stored in there. The Director of Housekeeping also stated that nursing gave them the code to the medication room. The Director of Housekeeping further stated the supply room is separate from medication room in other nursing homes, but at this facility the supplies and medication room are in the same room. During an interview on 12/21/23 at 02:26 PM, the Director of Nursing was interviewed and stated they do not know the code to access the medication rooms. The medication rooms have medications, treatment supplies and only a licensed nurse can go inside. If the CNA want something they should have to the ask licensed nurse. The Director of Nursing also stated that the supply person will ask if they can open the medication room and nursing should observe when supplies are delivered. The Director of Nursing further stated that they heard about issue with lock this week and staff need to inform maintenance that the door does not lock completely. 2. The facility policy titled Medication Storage/Handling revised 11/20/2023 documented that for discontinued and expired medications immediately remove from the cart and directly bring to the Director of Nursing office then return to pharmacy. Never leave the medication with resident name in the medication room. The facility policy and procedure Return/Disposal of Discontinued Medication documented all discontinued medication are immediately removed form cart and brought to Director of nursing office for proper disposal and prevention of any medications errors. Upon identification that a medication is discontinued/resident discharged from facility, it is the responsibility of the RN/LPN to immediately remove the medication from the cart. Send the cart to the first floor DNS office. On 12/18/23 from 03:17 PM to 03:29 PM, an anti-thyroid medication was left unattended by Registered Nurse #1. at the nurse's station in front of resident room [ROOM NUMBER]. During an interview on 12/19/23 at 10:47 AM, Registered Nurse #1 stated that the medications were discontinued so they removed them from the medication cart. Registered Nurse #1 also stated that they planned to give the discontinued medication to the Assistant Director of Nursing. Registered Nurse #1 further stated that they do not have a designated area to store discontinued medication, and they forgot to keep this medication in the medication room. 10 NYCRR 415.18(e)(1-4)

Based on observations, interviews and record review conducted during the Recertification survey 12/18/2023-12/21/2023, the facility did not promptly notify the ordering physician, physician assistant, nurse practitioner or clinical specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies, and procedures for notification of a practitioner. This was evident for 1 of 4 residents reviewed for Pressure Ulcer/Injury out of 21 sampled residents. (Resident #4) Specifically, there was no evidence the facility promptly notified the Medical Director of a contaminated urine culture report received on 12/15/2023 that required resubmission due to contamination. The findings are: The facility policy and procedure titled Urine Specimen Collection, revised 2/2023, documented that upon receiving laboratory results/called by the lab for urine contamination, the Doctor should be immediately informed, and a telephone order written to recollect the urine. The procedure titled Nursing Standing Laboratory Test/Order, revised 4/2023, documented that laboratory test results are to be reported to the Physician as soon as they are in. Resident #4 was admitted to the facility with diagnoses that included Lymphoma, Hypertension and Diabetes Mellitus. A Urine Culture Report, (a urine test that identifies the specific bacteria that is causing a Urinary Tract Infection (UTI), documented that a urine sample was collected on 12/15/2023 at 3:58 PM. The final results of the Urine Culture were reported on 12/15/2023 at 5:37 PM and documented growth found. Final Result. Three or more organism isolated, probably contaminated. Please resubmit. Record review on 12/21/2023 revealed no documented evidence that the urine culture had been repeated. On 12/21/2023 at 1:57 PM, the Medical Director was interviewed and stated that a contaminated urine culture should have been repeated immediately. On 12/21/2023 at 2:41 PM, Registered Nurse #2 was interviewed and stated that the urine culture report with the request to resubmit the urine sample was received by the facility on 12/18/2023 but not viewed until today (12/21/2023) after the State Surveyor's inquiry. Registered Nurse #2 also stated that the facility Physician was not notified, a repeat urine sample was not submitted, and a repeat urine culture was not performed. Registered Nurse #2 further stated that the test results should have viewed, and the urine sample repeated on the same day that the contaminated results were received by the facility. On 12/21/2023 at 2:49 PM, the Director of Nursing was interviewed and stated that contaminated laboratory results are reported to the facility by phone. The notification is reviewed by the Registered Nurse Supervisor, documented in a book and the Medical Director or Nurse Practitioner is notified and a follow up order obtained immediately. The Director of Nursing also stated that the Medical Director or Nurse Practitioner should be notified of abnormal/contaminated laboratory results as soon as the report is received. After the Medical Director or Nurse Practitioner signs the laboratory report, a signature is entered indicating that the report has been reviewed. The Director of Nursing further stated that laboratory reports are also found on the dashboard in the resident's Electronic Medical Record. The Director of Nursing stated that every shift of nurses should check for laboratory reports and contact the Medical Director or Nurse Practitioner right away with abnormal or contaminated results. 10 NYCRR 415.20

Based on observation, interviews, and record review conducted during the Recertification survey of 12/18/2023 through 12/21/2023, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, staff was observed not washing hands or wearing gloves before handling food for the resident. This was evident during the Dining observation. The facility's policy titled Infection Control: Meal services in Dining Room revised 01/2023 documented to never touch any prepared food items i.e. muffins bread with bare hands. On 12/18/23 at 12:11 PM, Certified Nursing Assistant #12 was observed during lunch time in the 2nd floor dining room assisting Resident #21 with their meal. Certified Nursing Assistant #12 removed bread from the plastic wrapping and spread butter on it while holding the bread with their bare hands. During an interview on 12/20/2023 2:29 PM, Certified Nursing Assistant #12 stated they have to wash or sanitize their hands prior to opening the bread wrapping and they are not supposed to touch the bread with their hands. They can leave the bread in the wrapping or let the resident butter their own bread. Certified Nursing Assistant #12 also stated that they did not remember if they opened the bread correctly during the lunch time observation but recalled that they were nervous being observed by the State Surveyors. During an interview on 12/21/2023 at 01:55 PM, Registered Nurse #2 stated that the Certified Nursing Assistants are not supposed to touch the bread with their bare hands and should use some sort of barrier, either the wrapping or gloves. Registered Nurse #2 stated that they go into . the dining room to observe that the Certified Nursing Assistants are doing what they should in the dining room. During an interview on 12/21/2023 at 12:35 PM, the Director of Nursing stated that Certified Nursing Assistants re not supposed to touch the bread with bare hands when they open it for resident. The Director of Nursing also stated that the nurses are supposed to supervise the Certified Nursing Assistants while they are in the dining room. 10 NYCRR 415.14 (h)

Based on observation, record review, and interviews conducted during the Recertification survey from 12/18/2023 to 12/21/2023, the facility did not ensure infection control practices were maintained. This was evident for 1 (2nd Floor) of 3 Units observed for dining. Specifically, a Certified Nursing Assistant did not perform hand hygiene between assisting residents with hand hygiene. The findings are: The policy and procedure titled Infection Control: Meal services in Dining Room revised 01/2023 documented hand hygiene must be performed by the nursing staff prior, during and after meal service. On 12/18/23 at 12:11 PM, Certified Nursing Assistant #12 was observed during lunch time in the 2nd floor dining room assisting two residents (Resident #60 and #63) with hand hygiene by using hand wipes before meal service. Certified Nursing Assistant #12 cleaned Resident #60's resident's hands and then cleaned Resident #63's before leaving the dining room to wash their hands. after she finished the task for both residents. Certified Nursing Assistant #12 did not perform hand hygiene between the residents. During an interview on 12/20/2023 at 2:29 PM, Certified Nursing Assistant #12 stated they are supposed to clean the hands for each resident and clean their own hands in between. Certified Nursing Assistant #12 stated they did not remember if they washed their hands between cleaning each resident's hands, because they were nervous because State Surveyors were making observations in the dining room. During an interview on 12/21/2023 at 01:55 PM, Registered Nurse #2 stated that the nurses give Certified Nursing Assistants sanitizing hand wipes and they are supposed to help the residents clean their hands before meals. Registered Nurse #2 also stated that Certified Nursing Assistants can clean their hands in between the residents with sanitizing wipes or wash their hands. Registered Nurse #2 further stated that nurses go to the dining room to observe that the Certified Nursing Assistants are doing what they should be doing in the dining room. During an interview on 12/21/2023 at 12:35 PM, the Director of Nursing stated that if the Certified Nursing Assistants are cleaning hands for several residents, they have to clean their hands in between. The Director of Nursing also stated that the nurses are supposed to supervise the Certified Nursing Assistants while they are in the dining room. 10 NYCRR 415.19(b)(4)

Based on observations and interviews conducted during the Recertification survey, the facility did not ensure that a safe, functional, and comfortable environment was provided for residents, staff, and the public. Specifically, staff bathrooms in the nursing station was observed in disrepair. This was observed on the 3rd floor and basement level of the facility. The finding is: On 12/20/2023 at 11:34 AM, 12/21/2023 at 11:01 AM, the staff bathroom located in the 3rd Floor nursing station area was observed with a discolored radiator with a rusty brown colored stain on it, and peeling paint. In addition, an opening was observed in the corner between the wall and the floor. On 12/20/23 at 01:15 PM, the the basement bathroom by physical therapy the bathroom noted with dirty corners with black colored residue on left and right edges of the 2-inch tiles in entry way. The hand washing sink was noted with a missing seal to right and left edge of sink connected to the wall. On 12/21/2023, at 11:07 AM, Registered Nurse #1 was interviewed and stated that maintenance was aware of the bathroom and they were told that this is an old building. Registered Nurse #1 also stated that the rusty brown color on the bathroom radiator has been there for a while. On 12/21/2023 at 11:26 AM, Housekeeper #1 assigned to the 3rd floor was interviewed and stated that the bathroom is cleaned 2-3 times a day and the condition of the radiator had been observed. Housekeeper #1 gave no response when asked about the rusty brown colored stain radiator on the radiator. On 12/21/23 at 12:04 PM, the Director of Maintenance was interviewed and stated that the facility had construction going on months ago but it was stopped and the administration does have plans of continuing construction. On 12/21/23 at 12:24 PM, the Administrator was interviewed and stated that construction was stopped because of the holidays. The Administrator stated that construction will resume but will focus on empty resident rooms before moving to other areas. 10 NYCRR 415.29

Based on observation, interviews, and record review conducted during the Recertification and Complaint survey, the facility did not ensure food was prepared in accordance with professional standards of food safety. Specifically, staff were observed not washing hands prior to and during food preparation, not washing hands after disposing of trash, refrigerator temperatures were not maintained, dishwasher temperatures were not in accordance with manufacturer guidelines, food was not labeled and dated in the kitchen storeroom. The findings are: Dietary Policy and Procedure titled Storage/Distribution (undated) states utilize proper personal hygiene practices (ex. Proper hand washing and appropriate use of gloves) to prevent contamination of food. Dietary Policy and Procedure titled Storage/Distribution (undated), under Storage section, Procedure: all products will be labeled, dated with a date gun and rotated upon delivery using FIFO method. Any food that has reached its use-by date, will be thrown out. Inspect cans for dents, severe damage, expiration date, and smell. any food that has reached its use-by date, will be thrown out. On 10/26/21 at 11:03 AM the Cook was observed coming out of storeroom and putting on gloves without washing hands. On 10/26/21 at 11:07 AM the Cook was observed coming out of the storeroom with gloves on, who then took them off, put margarine into vegetables and then put on gloves. On 10/26/21 at 11:08 AM Dietary Aide #1 put on gloves without prior hand washing, and went on tray line to serve. On 10/26/21 at 11:11 AM the Cook was observed opening a garbage can with gloved hands and then put tray food into a steamer. On 10/26/21 at 11:25 AM Dietary Aide #2 was observed coming out of the storeroom and did not take off dirty gloves, did not wash hands and did not don new gloves. Review of Meal Temperatures Log dated October 2021, reflects omission of temperatures for the breakfast meal for October 1st through October 26th, 2021 as well as temperatures for the lunch meal for October 4th, 16th, 17th, 2021. On 10/25/21 at 9:20AM Spice containers were observed with black dust on the lid of the containers, as well as no use-by date on the meat side of kitchen. On 10/26/21 at 09:43AM Dietary Aide #1 observed with mask down on chin. On 10/26/21 at 10:01AM the Cook was observed wearing a mask not covering the nose. On 10/26/21 at 11:21AM Dietary Aide #2 was observed wearing face mask below the mouth and covering the chin. On 10/28/21 at 09:04AM the Rabbi was observed wearing face mask below the mouth and covering the chin. On 10/25/21 at 9:20AM it was observed that the 2-door dairy refrigerator - exterior unit thermometer documents def. Temperature log was not posted on the refrigeration unit. The internal thermometer documents 48 degrees F. On 10/25/21 at 9:25AM the Food Service Director (FSD) stated staff had been in and out of the box recently. On 10/25/21 at 10:36 AM it was observed that the 2-door dairy refrigerator exterior unit thermometer documentsdef. Internal thermometer documents 42 degrees F. Refrigerator temperature should be between 35-41 degrees. On 10/26/21 at 11:17 AM, Dietary Aide #3 was observed running the meat dish machine in use with wash temperature at 130 degrees Fahrenheit. Dish washer temps log for the month of October meat side, indicates wash temperature of 150 degrees Fahrenheit. Several dates have omissions (October 1, 5, 8, 11, 15, 2021). The manufacturer's temperature guide posted on meat dish machine is 155-160 degrees Fahrenheit. The dish machine PPM log for dairy side, October 2021, reflects monitoring of ppm for breakfast, and wash/rinse temperatures for dinner. No signatures/initials are recorded for the breakfast record. For dinner temperatures, there are several omissions (October 1, 6 9, and 18, 2021). The record indicates 120, which, if a temperature, falls below the manufacturers recommended wash temperature of 155-160 degrees Fahrenheit. On 10/27/21 at 12:28 PM the kitchen store room was observed. there were items dated with a sticker from a date gun. Three 64-ounce bottles of prune juice and 2 bottles of lemon juice were not dated. An open bottle of red cooking and white cooking wine were open with a date sticker but no use-by-date. On 10/27/21 at 12:28 PM the State Agent (SA) toured the storeroom with FSD and Food Service Manager (FSM). Two plastic bins were observed in the 2-door dairy refrigerator. FSD identified product as homemade pesto. There was no date or name of product on the container. FSD states a date gun is used to date food items during delivery and when taken out of a case pack. A package of Oreo type cookies in plastic wrap, 3- 64 oz. bottles prune juice, and 2 bottles lemon juice observed not dated. As per Dietary Policy and Procedure titled Dented, Damaged and/or Bulging Food Cans (undated), dented, damaged or bulging cans will be set aside on a shelf and labeled as follows: DENTED CANS. During kitchen tour, no such shelf was observed. Dented cans were found on the can rack. 415.14(h)

Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure infection control practices were maintained. Specifically, 1- oxygen tubing was observed touching the floor; and, 2- recreation staff were observed not wearing Personal Protective Equipment (PPE) before entering a resident's room on contact/droplet precautions. This was evident for 2 of 2 residents reviewed in the area of Respiratory Care. (Resident # 236 and # 389) The findings are: 1). Resident # 236 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility policy titled Oxygen Therapy dated 5/21 documented oxygen tubing must be changed every week and the Certified Nursing Assistants (CNA) are responsible for checking that the oxygen is functioning properly. The Physicians Order dated 10/21/2021 documented Resident #236 was to receive continuous oxygen via nasal cannula at a rate of 3 liters per minute (lpm). The Nursing Progress Notes dated 10/21/2021 documented Resident #236 was admitted and was receiving oxygen via Nasal Cannula at 3lpm. The Physician History and Physical dated 10/23/2021 documented Resident #236 was status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/25/21 at 10:13AM, Resident #236 was observed lying in bed. An oxygen concentrator was observed to be on and at bed side. Oxygen tubing allowing for the flow of oxygen from the concentrator to the Nasal Canula (NC) in resident's nostrils was observed to be undated and on the floor. On 10/26/21 at 09:26AM, the resident was observed lying in bed while License Practical Nurse (LPN #1) was at bedside administering medications. The oxygen concentrator was observed to be and at bedside. The oxygen tubing connecting the concentrator to the NC in the resident's nostril was looped under the resident's bedside table and was touching the floor. The LPN #1 administered the medications and exited room without addressing the oxygen tubing. Further observations of the oxygen tubing on the floor were made on 10/27/21 at 08:39AM and 10/28/21 at 09:10AM. On 10/28/21 at 11:54 AM, an interview was conducted with LPN#1 who stated rounds are done every morning and this includes observing oxygen tubing to ensure it is not on the floor. The LPN also makes observations of oxygen tubing when administering medications. LPN #1 did not see the oxygen tubing on the floor when administering medications to Resident #236 on 10/26/21. If oxygen tubing is on the floor, it is to be discarded. On 10/28/21 at 12:31 PM, an interview was conducted with Registered Nurse (RN) #2 who stated dates for the oxygen tubing should be placed on the concentrator in the room. Oxygen tubing is changed weekly and as needed if soiled. Oxygen tubing is not supposed to be on the floor and, if found on the floor, must be discarded, and changed right away. I and the LPNs on the unit make rounds in the morning and throughout the day to monitor residents and ensure oxygen tubing is not on the floor. On 10/28/2021 at 4:39 PM, an interview was conducted with Infection Preventionist (IP) who stated rounds are made continuously throughout the day. Resident receiving oxygen are monitored to ensure the tubing does not touch the floor. 2). Resident #389 was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility policy titled Droplet Precautions revised 03/2021 documented droplet precautions should be implemented for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking. PPE use includes gown, face mask (or face shield in place of goggles) should be worn. Gloves should be donned, and hand hygiene performed before and after touching the patient and after contact with respiratory secretions and contaminated objects/materials. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was ordered to receive continuous oxygen via NC at 2lpm daily. Oxygen tubing is to be replaced every Sunday and as needed. On 10/25/2021 at 09:44AM, Resident #389 room door was observed with a droplet precaution sign that read: Use Proper Personal Protective Equipment (PPE) before entering room. The PPE documented on the sign included gown, mask or respirator, goggles or face shield, and gloves. On 10/25/2021 at 12:19PM, the Director of Recreation (DOR) was observed wearing a face mask and entering the resident's room. The DOR did not don a gown, gloves, or face shield upon entering the resident's room. The DOR then assisted Resident #389 with sitting up in bed by holding onto the resident's arm with ungloved hands. The DOR went to the kitchen to retrieve a soda for the resident. The DOR then returned with a soda, donned gloves, opened the soda for the resident, doffed gloves, and then washed their hands. On 10/25/2021 at 12:40PM, Resident #389 was observed sitting up in bed and oxygen tubing connecting the resident's NC to the oxygen concentrator on the ground. At 12:47PM, DOR enters the resident's room wearing a surgical mask. The DOR was not wearing a gown or face shield and the resident was not wearing a face mask. At 02:36PM, oxygen tubing was observed to still be touching the floor. On 10/28/2021 at 10:50 AM, 12:10PM, and 02:21PM, Resident #389 was observed sitting up in bed and oxygen tubing was touching the floor. On 10/25/2021 at 02:13PM, The Director of Recreation was interviewed and stated they are aware Resident #389 has a contact/droplet precaution sign on their door. The DOR was aware that a gown should be donned when entering the resident's room but was distracted at the time of the observation. PPE wearing is part of infection control and is important to stop the spread of COVID-19. On 10/28/2021 at 02:50PM, Certified Nursing Assistant (CNA #3) was interviewed and stated infection control inservice was provided within the last 3 months. Oxygen tubing should not be touching the floor because it is dirty. There are times a resident is put in bed and the tubing ends up on the floor. If the tubing becomes soiled, the CNA informs the nurse. On 10/28/2021 at 02:58PM, Licensed Practical Nurse (LPN #2) was interviewed. LPN#2 stated that rounds are done of the entire unit hourly and during medication pass. If tubing is found on the floor, it should be removed and changed. The tubing is long, so it does not restrict the resident's mobility. Tubing should be off the floor to promote infection control. An interview was conducted with the Director of Nursing (DON) on 10/28/2021 at 04:28PM and 10/29/2021 at 11:52AM. The DON stated rounds are done in the morning for all units. The oxygen tubing for Resident #389 is long because the resident moves around and requires CNA assistance when walking to the bathroom. Oxygen tubing cannot touch the ground for infection control reasons. Resident #389 is on contact precautions and anyone going inside the resident room should wear PPE, including a gown. Staff providing direct care should wear a face shield as well. Inservices and reminders in the facility daily morning meeting are provided to staff re: proper PPE use and residents on contact precautions. On 10/29/2021 at 11:59AM, RN #2 was interviewed and stated hourly rounds are done to ensure staff are wearing the correct PPE when entering the room of a resident on contact/droplet precautions. The PPE to be worn includes a face mask, gown, gloves, and goggles or shield. RN #2 has provided education to staff re: how to properly don and doff PPE. Resident #389 has refused the COVID-19 vaccine and is noncompliant with wearing a surgical mask. 415.19(b)(4) 415.19(a)(1-3), 400.2

Based on observation, record review, and interview during the Re-certification survey, the facility did not ensure a resident was treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, Resident # 35 was observed on 2 occasions wearing inappropriate clothing, one occasion wearing a pajama pant and a different pajama top, then on another occasion, wearing a cotton like short pant and a t-shirt, and a blanket on the wheelchair, in the dining room, This was evident for 1 of 2 residents reviewed for Dignity (Resident #35) The findings are: The facility Policy and Procedure (P&P) titled Dignity, revised 09/13, documents; Dignity defined is that the facility must promote care for residents' in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his/her individuality. Respecting a resident's preferences, choices, and routines: grooming, that residents should be appropriately dressed, with proper footwear, for the time of day and for the weather. The undated facility P&P titled Donation Clothing, documents; It is the policy of Forest Hill Care Center to ensure that all residents have appropriate clothing to maintain dignity. If the resident does not have appropriate clothing, nursing will notify the Social Worker and Recreation and residents will be asked permission if donation clothing is acceptable. If the resident is in agreement with receiving donation clothing, all clothing will be labeled with resident's name. Resident #35 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #35 was cognitively intact, and had no behavior issues. On 10/26/21 at 10:16AM, Resident #35 was observed out of bed sitting in a wheelchair wearing pajama pants and a different pajama top. Resident #35 stated they don't have any clothes, and Resident #35 gets cold in the dining room, so he/she doesn't like to go to the dining room to eat. Resident also stated that the staff knows he/she doesn't have any clothing. On 10/26/21 at 02:29PM, Resident #35 was observed sitting outside their room wearing the same mismatched clothing. On 10/27/21 at 12:30 PM, Resident #35 was observed wearing a cotton like shorts and a t-shirt in the dining room. Resident #35 stated that they were cold and that staff put them in the dining room without appropriate pants on. Resident #35 was observed with a blanket draped on the back of the wheelchair. On 10/28/21 at 12:48PM, Resident #35 was observed in bed asleep, wearing a sweatshirt. The Comprehensive Care Plan (CCP) titled Dressing, created on 03/10/21, and CCP titled - Activities of Daily Living (ADL) Functional/Rehabilitation Potential dated 3/10/21 documented that the resident required extensive assist of 1 person, related to weakness, cognitive deficits, as evidenced by impaired ability to put on / take off clothing and unable to reach lower extremities. Goals included that resident will be dressed appropriately, comfortably daily X 90 days. Interventions included to encourage the resident to participate in dressing and praise accomplishment. Social Worker Notes dated 10/28/21 documented the Social Worker (SW) made aware on 10/27/2021 that Resident #35 did not have appropriate clothing for the weather change. The SW immediately reached out to the resident's APS (Adult Protective Services) caseworker, however was unable to reach them and left a voicemail. Resident #35 stated he/she would be ok with wearing donation clothing. Recreation and SW were able to find clothing, and most were labeled and brought to the resident's room. SW will monitor and remain available as needed. SW encouraged resident and staff to inform them of any concerns noted. During an interview on 10/27/21 at 2:39 PM, a Certified Nurse's Aide (CNA #1}, stated to the State Surveyor (S.A) they were sorry that the resident did not have on appropriate clothing in the dining room, and Resident #35 only had shorts and t-shirts. The blanket was given in case the resident was cold. CNA #1 stated that they went down to collect donated clothing and got clothes for the resident, for the rest of the week. On 10/29/21 at 10:32AM, a follow-up interview was conducted with CNA #1 who stated that when a resident has no clothing, it is reported to the Nurse or the Social Worker. Normally, the Social Worker would get the donated clothing, but nursing staff can also go get the donated clothes. Resident #35 was admitted with only one long sleeved shirt, one pair of pants, and the rest of their clothing was shorts and t-shirts. CNA # 1 went to get some donated clothes, but did not find any since Resident #35 only likes loose clothes. when? They told the Social Worker and the Recreation Therapist that day about resident's clothing status, but the RN Supervisor wasn't aware. CNA #1 said that the resident was given a blanket while in the dining room, in case they got cold, since CNA #1 knew that the clothing was inappropriate. CNA #1 later went down to the basement to collect donated clothing for the resident for the rest of the week. On 10/28/21 at 11:54AM, an interview was conducted with CNA #2 who stated that the resident was on their assignment today and 10/27. CNA #2 stated Resident #35 doesn't have much clothing. The CNA also stated that they told Resident #35 to tell their family to bring clothing before, and the nurses know the resident needs clothing. If the resident does not have appropriate clothing, then donated clothing stored in the basement, can be used. CNA #2 stated that there was no need to get clothing downstairs before since summer just ended, and Resident #35 had shorts and t-shirts. If the resident voiced that they were cold, a blanket or sheet would be provided. On 10/28/21 at 12:03PM an interview was conducted with Registered Nurse Supervisor (RNS), who stated the Staff said that the resident was cold, so they put a blanket around the resident's back. RNS stated that the resident was complaining that they were cold and was wearing shorts, and the Director of Recreation went down to get them pants. It was inappropriate for Resident #35 to be wearing shorts if it was cold. They weren't aware that the resident needed clothing, and if the RNS had known, they would have called the family to bring in clothes. If clothing was needed immediately, Staff would go downstairs and get the donated clothes. The Social Worker would be informed and follow-up with the family On 10/27/21 at 12:37 PM an interview was conducted with the Director of Recreation who brought up clothing for Resident #35. The Director of Recreation stated that they spoke to the resident's brother about clothing for the resident, but no clothes were sent to the facility for the resident. The resident should not have been in the dining area with short pants and a t-shirt as it is colder in there, and as soon as they were notified, the Director of Recreation obtained appropriate clothing. The facility has donated clothes in the basement, and if there is a need for clothes, it can be provided. On 10/28/21 at 04:05PM an interview was conducted with Director of Social Services (DSS), who stated that they were not aware that the resident needed clothes. On 10/27, the CNA assigned to Resident #35 said Resident #35 needed clothing. The DSS called Resident #35's family and left a message requesting clothing. If a resident needs clothing immediately, they ask the resident if they want to wear donated clothes. Once permission is given, clothes are given to the resident. As the weather gets cold, the resident should be dressed appropriately. 415.3(c)(1)(i)

Based on record review and interviews conducted during re-certification and complaint survey, the facility failed to ensure the resident's right to be free from neglect. This deficient practice resulted in harm to the resident. Specifically, The Comprehensive Care Plan (CCP) for the resident 10/24/17, stated that the resident requires two persons, and the use of an assistive device (Hoyer Lift), to transfer from bed to wheel chair. A Certified Nurse Assistant (CNA) willfully neglected to implement the CCP. The CNA attempted to transfer the resident by herself, and without the use of the Hoyer Lift. This negligence resulted in the resident falling during the transfer and sustaining a [MEDICAL CONDITION] hip. This was evident for one (1) out of three (3) residents reviewed for abuse out of the total sample of 18 residents. The Finding is: Complaint #NY 927 The Facility's Policy & Procedure (P&P) on Abuse, Neglect & Mistreatment of [REDACTED]. The P&P states its purpose is to ensure the safety of all residents by protecting them from abuse, neglect, and mistreatment. The policy states that each resident has the right to be free from abuse, mistreatment, neglect exploitation, & misappropriation of property. No one may subject residents to abuse including but not limited to facility staff, other residents including consultants, volunteers, staff or other agencies servicing the resident, family members or legal guardians, friends or other individuals. It also states that the facility maintains systems to prevent instances of abuse, neglect or mistreatment of [REDACTED]. Under the definitions of abuse, in the neglect category, it is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to attain or maintain their highest practicable level of physical, mental and psychosocial well being. Resident #20 is [AGE] years old and was originally admitted to the facility on [DATE]. The resident's most recent re-admission was 12/14/17. Diagnosis: [REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the resident's cognition is severely impaired and the resident is total dependent of two persons for physical assistance/transfers. All resident care needs must be anticipated since her cognitive ability is severely impaired as a result of her Alzheimer's/Dementia status and she has physical Limited Range of Motion. The Nurses Admitting Record of 04/13/15 documented the resident as wheelchair bound. The Comprehensive Care Plan(CCP) dated 10/24/17 included interventions required for this resident during transfers including the use of a mechanical (Hoyer) Lift for transfers to be done by two persons. Occupational/Physical Therapy Screening Form dated 10/16/17 -10/31/17, specifies, Transfer Status: Hoyer Lift with 2 persons assist. Monthly physician's orders [REDACTED]. The Resident's CNA Documentation Record (CDR) guides the CNAs on tasks performed and is used to record the care provided to residents. Record review for November 2017 and December 2017, revealed CNA#1, documented by signing her initials on the CDR, that she transferred the resident with 2 persons and the Hoyer Lift, during her shift, 7:00 AM to 3:00PM daily, except for 12/8/17, the date of the incident, where she neglected to follow medical orders and care plan directives for transfers with mechanical device and two person assist. Facility Incident/Investigation Report dated 12/8/17 and completed on 12/11/17 by an RN, revealed the CNA admitted to transferring without following resident transfer orders and did not ask for assistance from other staff members. X-rays were ordered on [DATE] and revealed the resident sustained [REDACTED]. The resident required a hospital admission on 12/9/17. It reveals the CNA was counselled and suspended indefinitely. On 12/26/17 at 9:30AM an interview with the resident's spouse was conducted. He stated he was not present when the incident happened on morning of 12/08/17 and was informed by staff. He said the Certified Nurse Aide (CNA) admitted she made a mistake by transferring without Hoyer Lift or assistance and said that the wheel chair brake had given way, the resident was assisted to the floor by aide, an evaluation was done and it was determined by x-ray, she had a fracture in the right hip and was sent to the hospital on [DATE]. He stated he advocated for the CNA to stay caring for his spouse since the resident has Alzheimer's and the CNA is familiar with her and the CNA had never done anything to harm the resident before. He said he felt the facility's disciplinee and in-service was sufficient and was happy she could return to care for his spouse. He commented that the CNA made a mistake on that day and accidents happen but her overall performance with his spouse is great and he insisted she stay. The facility took his request into consideration and allowed her to return. On 12/26/17 An interview with the Certified Nurse Aide(CNA#1) was conducted. The CNA stated, I made a stupid choice. I don't know why I did not get assistance or use Hoyer Lift. CNA stated she always cared for the resident and always asked for assistance for two persons transfer with Hoyer Lift but on 12/08/17, she took it upon herself to have her stand and transfer from bed to chair. The CNA stated she checked the wheel chair, secured the wheel chair brake but it gave way on the right side during transfer. She assisted the resident to slide to the floor, notifying the nurse immediately. The resident was evaluated by the nurse and later sent to the hospital after x-rays were done. The CNA stated she received 5-day suspension and was in-serviced again on all topics and allowed to return to work after the residents' spouse requested it. The incident occurred at approximately 6:45am during shift change with sufficient staff on the Unit on all shifts. Records reveals the staffing numbers per shift were as follows: 7-3pm shift: RN-1, LPN-2, CNA-5 3-11pm RN-1, CNA-4, 11pm-7AM LPN-1 and CNA-2. On 12/26/17 A brief interview with Director of Nursing Services(DNS) was conducted. The DNS stated the CNA was suspended after not following resident care plan for transfer. She was re-instructed and the spouse requested the CNA remain performing resident care since her overall health depended on it. On 12/28/17 at 10:52 AM an interview with the Rehabilitation Director (RD)was conducted. The RD stated the resident was a Hoyer Lift, two-person transfer, prior to the fall. She stated the resident was on a standing program in rehab, but the resident could not pivot. The resident had a fall on 12/08/17 when transferred by the CNA and was sent to the hospital on [DATE]. Resident was re-assessed by Physical Therapy/Occupational Therapy OT/PT after her return 12/14/17. Reported that now resident is on a skilled Physical Therapy/Occupational Therapy program: goal was to safely move in bed without pain. The goal was attained on 12/29/17. New Goals are for wheel chair positioning and return to a standing program. The Resident was on a Geri reclining chair until pain resolved, now is on a standard wheel chair since she attained that goal. Resident is Non-weight bearing on right leg, and has a bending ortho consult. Residents Pain Management therapy/short wave diathermy last day was 12/29/17, and re-evaluate for standing program. Resident has improved. She no longer requires two persons to assist in bed mobility. She is now moving in bed with the assistance of one person. Two person Hoyer Lift for transfers will remain. On 12/29/17 at 11:22 AM a second interview with the Director of Nursing(DNS) was conducted. The DNS stated she investigated the incident immediately and that all records demonstrated that the CNA was in-serviced prior to accident/incident. The DNS stated the CNA was in-serviced on all topics again after the 12/8/17 incident. The DNS has worked in the facility for [AGE] years. She stated that when she reported to work on 12/8/17 she was informed about the incident. The DNS immediately interviewed the CNA who said, I made a big mistake, saying the CNA was crying when she spoke to her. The DNS said that many residents voiced they liked the quality of her work and care and that she was a person without any previous incident. She also stated that the CNA could return to the facility after the residents' spouse advocated for her to continue working with resident but would have been terminated otherwise. A review of the Employee File/Records for the CNA revealed in-services and attendance sheets were identified for the following dates and topics: Abuse/Neglect/Mistreatment:01/05/17 & 6/30/17, Accountability: 4/17, Falls Precautions, Safety and Transfers: 5/8/17, Dementia/Behavior problems and pain: 6/21/17, Nail care: 7/17, Elopement, Toileting: 11/17, Active Shooter/bomb threats: 12/12/17. The facility provided all paperwork required, including criminal background check and certifications without prior history of any disciplinary actions or abuse. On 12/29/17 at 11:37 AM an Interview with Registered Nurse Supervisor (RNS #1) for the day shift was conducted. RNS#1 stated an accident/incident(A/I) report was completed by the out by the night supervisor, the resident was lifted off the floor with Hoyer Lift and put to bed, assessed by RNS #2, who notified the MD and orders for x-rays were obtained. RNS #1 was able to describe how A/I are reported by staff according to policy and procedures. Morning report is used as re-education and reminders to staff to follow all plan of care and used to address questions and concerns staff may have. The RNS #1 described her role on the unit and her function in ensuring staff follow plan of care including how she provides daily reminders and re-enforcements. Risk Management and In-services are also done by the Assistant Director of Nursing or the Director of Nursing. RNS #1 commented that it was a lack of judgement on the CNA's part when she chose to transfer without assistance or the Hoyer Lift device. 415.4(b)(1)(i)

Based on record review and interviews conducted during a re-certification and complaint survey the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents Specifically, 1)(Complaint #NY 927) The Comprehensive Care Plan (CCP) for Resident #20 documented that the resident requires two persons, and the use of an assistive device (Hoyer Lift), to transfer from bed to wheel chair. A Certified Nurse Assistant (CNA) willfully neglected to implement the CCP. The CNA attempted to transfer the resident by herself, and without the use of the Hoyer Lift. This negligence resulted in the accident with the resident falling during the transfer and sustaining a [MEDICAL CONDITION] hip. 2) Facility staff did not provide adequate supervision for a resident assessed at high risk for falls. Resident #78 had seven falls over a 4 month period. After the noted falls facility staff did not provide adequate interventions, and monitoring to prevent falls for the resident who attempted to transfer several times without assistance. This was evident for two out of three residents reviewed for supervision and prevention of accidents out of a total sample of 18 residents. The Findings are: 1) The Facility's Policy titled Transfer of Resident with a revision date of 11/01/2016 documents that it is the policy of the facility to conduct all transfers in accordance with the physician's orders [REDACTED]. The policy notes That a two person transfer requires 2 people. Hoyer Lift transfers always require 2 people. The procedure instructs that wheel chairs should be checked for safety and locked before beginning transfer. Resident #20 is [AGE] year-old with original admitted as 01/22/15 and most recent re-admission date of [DATE]. Diagnosis: [REDACTED]. All of the resident care needs must be anticipated since her cognitive ability is severely impaired because of her Alzheimer's/dementia status and her limited range of motion. The initial Nurse's Admission assessment dated [DATE] documented the resident as ambulating by wheelchair with assistance of one person. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented that the residents' cognition is severely impaired, and the resident is total dependent of two persons for physical assistance/transfers. The Comprehensive Care Plan(CCP) dated 10/24/17 included interventions required for this resident during transfers including the use of a mechanical Hoyer Lift for transfers to be done by two persons. Occupational/Physical Therapy Screening Form dated 10/16/17 -10/31/17 documented the resident's transfer status: Hoyer Lift with 2 persons assist. Monthly physician's orders [REDACTED]. The Resident's CNA Documentation Record (CDR) guides the CNAs on tasks performed and is used to record the care provided to residents. Record review for November 2017 and December 2017, revealed CNA#1, documented by signing her initials on the CDR, that she transferred the resident with 2 persons and the Hoyer Lift, during her shift, 7:00 AM to 3:00PM daily, except for 12/8/17, the date of the incident, where she neglected to follow medical orders and care plan directives for transfers with mechanical device and two person assist. Facility Incident/Investigation Report dated 12/8/17 and completed on 12/11/17 by RN, revealed the CNA admitted to transferring without following resident transfer orders and did not ask for assistance from other staff members. X-rays were ordered on [DATE] and revealed the resident sustained [REDACTED]. The resident required a hospital admission on 12/9/17. It reveals the CNA was counselled and suspended indefinitely. On 12/26/17 at 9:30 AM an interview with the spouse of Resident #20 was conducted. He statedthat he was not present when the incident happened on morning of 12/08/17 and was informed by staff. He said the Certified Nurse Aide (CNA) admitted she made a mistake by transferring without Hoyer Lift and that the wheel chair brake had given way, the resident was assisted to the floor by aide, an evaluation was done and it was determined by x-ray, she had a fracture in the right hip and was sent to the hospital on [DATE]. He stated he advocated for the CNA to stay caring for his spouse since the resident has Alzheimer's and the CNA is familiar with her and the CNA had never done anything to harm the resident before. He said he felt the facility's disciplinee and in-service was sufficient and was happy she could return to care for her. He commented that CNA made a mistake on that day and accidents happen but her overall performance with his spouse is great and he insisted she stay. The facility took his request into consideration and allowed her to return. On 12/26/17 An interview with the Certified Nurse Aide(CNA#1) was conducted. The CNA stated, I made a stupid choice. I don't know why I did not get assistance or use Hoyer Lift. CNA stated she always cared for the resident and always asked for assistance for two persons transfer with Hoyer Lift but on 12/08/17, she took it upon herself to have her stand and transfer from bed to chair. The CNA stated she checked the wheel chair, secured the wheel chair brake but it gave way on the right side during transfer. She assisted the resident to slide to the floor, notifying the nurse immediately. The resident was evaluated by the nurse and later sent to the hospital after x-rays were done. The CNA stated she received 5-day suspension and was in-serviced again on all topics and allowed to return to work after the residents' spouse requested it. The incident occurred at approximately 6:45am during shift change with sufficient staff on the Unit on all shifts. Records reveals the staffing numbers per shift were as follows: 7-3pm shift: RN-1, LPN-2, CNA-5 3-11pm RN-1, CNA-4, 11pm-7AM LPN-1 and CNA-2. On 12/26/17 A brief interview with Director of Nursing Services (DNS) was conducted. The DNS stated the CNA was suspended after not following resident care plan for transfer. She was re-instructed and the spouse requested the CNA remain performing resident care since her overall health depended on it. On 12/28/17 at 10:52 AM an interview with the Rehabilitation Director (RD)was conducted. The RD stated the resident was a Hoyer Lift, two-person transfer, prior to the fall. She stated the resident was on a standing program in rehab, but the resident could not pivot. The resident had a fall on 12/08/17 when transferred by the CNA and was sent to the hospital on [DATE]. Resident was re-assessed by Physical Therapy/Occupational Therapy OT/PT after her return 12/14/17. Reported that now resident is on a skilled Physical Therapy/Occupational Therapy program: goal was to safely move in bed without pain. The goal was attained on 12/29/17. New Goals are for wheel chair positioning and return to a standing program. The Resident was on a geri reclining chair until pain resolved, now is on a standard wheel chair since she attained that goal. Resident is Non-weight bearing on right leg, and has a bending ortho consult. Residents Pain Management therapy/short wave diathermy last day was 12/29/17, and re-evaluate for standing program. Resident has improved. She no longer requires two persons to assist in bed mobility. She is now moving in bed with the assistance of one person. Two person Hoyer Lift for transfers will remain. On 12/29/17 at 11:22 AM an interview with the Director of Nursing (DNS) was conducted. The DNS stated she investigation the incident immediately and that all records demonstrated that the CNA was in-serviced prior to accident/incident. The DNS stated the CNA was in-serviced on all topics again after the 12/8/17 incident. The DNS has worked in the facility for [AGE] years. She stated that when she reported to work on 12/8/17 she was informed about the incident. The DNS immediately interviewed the CNA who said, I made a big mistake, saying the CNA was crying when she spoke to her. The DNS said that many residents voiced they liked the quality of her work and care and that she was a person without any previous incident. She also stated that the CNA could return to the facility after the residents' spouse advocated for her to continue working with resident but would have been terminated otherwise. A review of the Employee File/Records for the CNA revealed in-services and attendance sheets were identified for the following dates and topics: Abuse/Neglect/Mistreatment:01/05/17 & 6/30/17, Accountability: 4/17, Falls Precautions, Safety and Transfers: 5/8/17, Dementia/Behavior problems and pain: 6/21/17, Nail care: 7/17, Elopement, Toileting: 11/17, Active Shooter/bomb threats: 12/12/17. The facility provided all paperwork required, including criminal background check and certifications without prior history of any disciplinary actions or abuse. On 12/29/17 at 11:37 AM an Interview with Registered Nurse Supervisor (RNS #1) for the day shift was conducted. RNS#1 stated an accident/incident(A/I) report was completed by the out by the night supervisor, the resident was lifted off the floor with Hoyer Lift and put to bed, assessed by RNS #2, who notified the MD and orders for x-rays were obtained. RNS #1 was able to describe how A/I are reported by staff according to policy and procedures. Morning report is used as re-education and reminders to staff to follow all plan of care and used to address questions and concerns staff may have. The RNS #1 described her role on the unit and her function in ensuring staff follow plan of care including how she provides daily reminders and re-enforcements. Risk Management and In-services are also done by the Assistant Director of Nursing or the Director of Nursing. RNS #1 commented that it was a lack of judgement on the CNA's part when she chose to transfer without assistance or the Hoyer Lift device. 2) The facility's policy on falls which was last revised on 07/2017 documented that the purpose of the policy is to provide a system whereby resident's falls are reported, their causes identified when possible and timely interventions are established to reduce the probability of repeated incidents. The care plan will be reviewed and updated upon each fall. It further states that if a frequent, or multiple faller is identified, the resident is placed on the frequent fall list and falling start program. The policy also documents that this resident should be assessed for resident's needs and determine the cause of behavior, for example: rule out pain, infection and to check for need to use the bathroom. Resident # 78 a [AGE] year old male admitted to the facility with [DIAGNOSES REDACTED]. On 12/27/2017 at 11:45 AM resident was observed in his room seated in his geri-chair,well- groomed. The Comprehensive Care Plan dated 8/22/17 identified that the resident was at risk for falls secondary to poor balance and cognitive impairment with non-compliant behavior. The Care Plan has chair and bed alarms as interventions. No specific frequency for monitoring noted. The CCP also identified that the resident required assistance for toileting, however there was no toilteing schedule included in the plan. the CCP documented resident requires total assist of two(2) person with use of Hoyer lift, should have call bell within reach, observe balance and safety awareness during transfer and observe any changes in transfer ability .There was no documented evidenced either in the nurses notes or CCP on the monitoring done on the resident to prevent or abate further falls. The medical records documented that the resident had a total of 7 (seven ) falls from August 2017 through December 23, 2017. The first fall was noted in the Nurse's progress notes dated 08/19/2017 at 6:25 AM, documented that the resident was found on the floor by the CNA ( certified nursing assistant ). No injuries noted. The resident was brought back to bed with 2 persons assist. The note further documented that the resident was asked what happened, and responded that he lost his balance as he was trying to put on his pants. No new interventions were put into place after this fall. In early September the resident was transferred from the rehab unit located on the first floor to the long term care unit on the second floor. The second fall was noted in the Nurse's progress notes dated 09/19/2017 at 7:30 PM. The CNA found the resident sitting on the floor in front of his wheelchair with a skin abrasion to the chin. The CNA alerted the Registered Nurse on duty (RN). The resident was transferred back to bed with 3 persons assist. The physician was notified. X-rays of the lumbar spine, bilateral hip, and pelvis area were ordered. The [MEDICAL CONDITION] was cleansed with nss ( normal saline solution ), and [MEDICATION NAME] ointment. Resident was referred to rehabilitation unit. X-rays were negative. The third fall was documented in the Nurse's progress notes dated 09/24/2017 at 10:15 AM. The resident was found on the floor in his room with no visible injuries. The nurses notes further documented significant decline in functional mobility requiring 2 persons transfers and inability to ambulate at this time. Resident was referred back to rehabilitation unit for evaluation. He was placed on skilled physical therapy to restore prior functional level and improve safety awareness. The MDS 3.0 ( minimum data set ) categorized as a Significant Change assessment was dated 09/27/2017. It identified the resident with a BIMS (brief interview for mental status) score of 6, indicating cognitive impairment. The resident was assessed as having the ability to usually understand and could be understood when when communicating. He was assessed as requiring extensive assist assistance of 2 plus person for transfers. The resident was assessed as continent of bowel and bladder, no toileting program was in place at this time. The resident required 2 plus persons for toileting. No walking activity noted on this assessment. The resident was assessed as not steady when trying to get on and off the toilet. The resident used a wheelchair for ambulation. There were no behaviors noted in the assessment. The fourth fall was documented in the Nurses progress notes dated 09/25/2017 at 6:30 PM. The resident was found sitting on the floor in front of his wheelchair by the sink in his room. Resident stated that he was talking with someone, and lost his balance. No visible injuries were noted. The care plan was updated to include floor mattress, bed alarm 2 1 /2 side rails and monitoring. No specific intervals or frequency for monitoring were noted. The fifth fall was documented in the Nurses progress notes dated 11/04/2017 at 1:10 PM. The resident was found on the floor on the second floor unit. The porter called charge nurse after he heard someone calling for help, and the noise of the bed alarm. No visible injuries noted. The sixth fall was documented in the Nurses progress notes dated 11/24/2017 at 6:50 PM. The resident was again found on the floor in front of his bed. No visible injuries were noted and was transferred back to bed with 3 persons assist. The seventh fall was documented in the Nurses progress notes dated 12/23/2017 at 9:20 PM. The staff responded to the bed alarm and found the resident on the floor. The resident was noted with redness on his right knee. The resident was transferred to bed with use of Hoyer Lift and 2 persons assist. The physician was notified. X-rays were taken with negative results. The Comprehensive Care Plans documented resident on total assist of two(2) with use of Hoyer Lift, call bell with in reach, observe balance and safety awareness during transfer and observe any changes in transfer ability. There was no documented evidenced either in the nurses notes or CCP on the monitoring done on the resident to prevent further falls. On 12/29/2017 at 11:30 AM the Assistant Director of Nursing (ADN ) was interviewed and stated resident during the early part of the year was able to ambulate and despite of instructions, he persist to do what he wants. Th DNS stated that when the resident was on the first floor, he was more closely supervised. When asked why, she responded it was because the unit was smaller, and the nursing staff was able to observe and see him when he goes to the bathroom. The DNS did not indicate that the resident was on a toilteting schedule when he resided on the first floor. The DNS stated that when the resident went to the second floor he continued to go to the bathroom when he wanted and self-ambulate. He was referred to the psychiatrist and rehabilitation. The DNS stated that the referral to the psychiatrist was made because most of this is behavioral. When the surveyor asked what has been done to address the behavior, she stated, I think that is what has not been added, and done. The monitoring and supervision which should include toileting. On 12/29/2017 at 1:46 PM CNA#2 was interviewed. She stated that the resident was able to walk by himself and go to the bathroom. She described the resident as very hyper. CNA#2 also stated that the resident started getting weaker. She said that one time she brought him to the bathroom, but he was shaky. She said that she reported this to the nurse several times, and even asked if a commode would be good for the resident. CNA#2 stated that she was off and when she came back she heard he fell down again. The CCP was not reviewed and revised to identify the resident's noted changes, such as increased weakness during toileting, shakiness as reported by CNA. Resident not able to follow instructions in regards calling for assistance by using call bell. The CCP did include interventions to anticipate resident's increase need for assistance particularly toileting. The CNA stated that she thought the resident would benefit from the use of a commode. There is no evidence that this intervention was discussed by the IDT. There was no increase in the monitoring and supervision for this resident to prevent falls. 415.12(h)(1)

Based on record review and interviews, the facility did not ensure that the resident's drug regimen was free from unnecessary medication. Specifically, there was a duplication in the transmittal of a resident's lab result. As a result the MD ordered, and the resident received an unnecessary increase in the dosage of [MEDICATION NAME]. This was evident for 1 of 6 residents reviewed for Unnecessary Medication (Resident #18). The findings are: Resident #18 is a [AGE] year-old with medical [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that resident had moderately impaired cognition. The Comprehensive Care Plan (CCP) for [MEDICAL CONDITION] last updated 6/12/2016 documented the resident at risk for abnormal [MEDICAL CONDITION] levels levels secondary to [MEDICAL CONDITION], The CCP goal was Resident's TSH will be wnl (within normal limits) x 90 days. The CCP interventions included: monitor labs as ordered . monitor weight monthly . monitor for weight loss . monitor appetite . monitor for mood and behavior changes . monitor for mental status changes. The Lab Results dated 6/22/2016, with a fax transmission date of 6/22/2016, documented TSH 7.080 H ([MEDICAL CONDITION] Stimulating Hormone- Reference range 0.470-4.680). The Physician (MD) Progress Note dated 6/28/2016 documented the plan to increase [MEDICATION NAME] to 75 mcg (micrograms) due to the resident's elevated TSH and to check the TSH/ Free T4 in 1 month. The MD Order dated 6/28/2016 documents: discontinue [MEDICATION NAME] 0.05 mg tab by mouth every morning at 6;30am . [MEDICATION NAME] 0.075mg (milligrams)1 tab by mouth every morning at 6:30am . TSH, Free T4, CBC with Diff, BMP please draw 7/28/2016. The Lab Report dated 6/29/2016, with a fax transmittal date of 6/29/2016, documented TSH 10.400 VH (Very High) (Reference range 0.470-4.680). A hand written note documented Change [MEDICATION NAME] to 88 mcg daily The MD order dated 6/29/2016 documented orders to discontinue [MEDICATION NAME] .075 mcg and start [MEDICATION NAME] 0.088 mg 1 tab by mouth every morning at 6:30 am. The MD Progress Note dated 7/19/16 documented the plan to continue [MEDICATION NAME] 88 mcg and check TSH in 4 weeks. The Lab report dated 6/22/2016 was retransmitted to the facility on [DATE], documented TSH 7.080 H (Reference range 0.470-4.680). A hand written note documented change [MEDICATION NAME] to 100 mcg. This was the same lab results reported to the MD on 6/22/16 resulting in the MD ordering an increase dosage of [MEDICATION NAME] to 75 mcg on 6/28/16. As a result the MD ordered an increase of the [MEDICATION NAME] on 7/20/2016 to 0.1mg (100 mcg). This is resulted in the resident receiving an unnecessary dosage of the medication. The resident's [MEDICATION NAME] was increased again based on an old lab value previously reviewed. The MD Progress Note dated 7/26/2016 documented the plan to continue [MEDICATION NAME] 100 mcg and check TSH in 3 weeks. The MD Progress Note dated 8/18/2016 documented plan to check TSH/Ft4 and continue [MEDICATION NAME]. The Lab report dated 8/19/2016 documented TSH 0.072 VL (Very Low). The Reference Range was 0.470-4.680 mcIU/ML (micro-international units per milliliter). The MD progress note dated 8/25/16 documented the plan to decrease [MEDICATION NAME] to 75 mcg. On 9/1/2016 at approximately 12:30 PM, the Registered Nurse Supervisor (RNS) was interviewed and stated lab results are faxed to the nursing office daily. She further stated it is the responsibility of the RNS to review the results, notify the MD, and obtain any new orders if the result is abnormal. She stated the lab is then flagged in the chart. The RNS stated that lab results are usually received the same day they are drawn unless it is a culture or something that will not come in until the next day. She stated that the RNS also reviews the labs in the chart to determine that abnormal labs are already addressed. She stated she could not remember if she knew the MD changed the [MEDICATION NAME] on 6/28/2016 the day before she called him with the result on 6/29/16. The RNS also stated the lab report dated 6/22/16 was initially sent with a missing Glycohemoglobin in progress. She stated that someone probably called the lab for the results again to get the Glcyohemoglobin and that's why the results were re-faxed and confused. On 9/1/2016 at approximately 1:00 PM, the Physician (MD) was interviewed and stated that he reviews labs and adjusts medications accordingly. He stated that he reviews normal and non-critical labs on his next visit, and the nurses call him if the lab results contain abnormal values. The MD stated that the medication was over corrected. He stated that the lab was called on 7/19/16 for the results of the Glycohemoglobin level and the entire report was retransmitted, including the elevated TSH level and he treated it again. On 9/2/2016 at approximately 2:30 PM, the VP of corporate development at the Laboratory was interviewed and stated that lab results are automatically faxed to the facility or transmitted to an IP printer. She stated that the lab report is sent in portions if all results are not available, and it is transmitted again when all results are available. She also stated that Critical Values are called in and printed automatically, and the lab report would indicate that the lab has already been reported. 415.12(l)(1)

Based on record review and interviews, the facility did not ensure that the Physician reviewed the resident's total plan of care. Specifically, a duplication in the transmittal of a resident's lab result was sent to the facility. As a result the MD ordered, and the resident received an unnecessary increase in the dosage of [MEDICATION NAME]. This was evident for 1 of 28 residents reviewed during Stage 2 (Resident #18). The findings are: Resident #18 is a [AGE] year-old with medical [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that resident had moderately impaired cognition. The Comprehensive Care Plan (CCP) for [MEDICAL CONDITION] last updated 6/12/2016 documented the resident at risk for abnormal [MEDICAL CONDITION] levels levels secondary to [MEDICAL CONDITION], The CCP goal was Resident's TSH will be wnl (within normal limits) x 90 days. The CCP interventions included: monitor labs as ordered . monitor weight monthly . monitor for weight loss . monitor appetite . monitor for mood and behavior changes . monitor for mental status changes. The Lab Results dated 6/22/2016 (with a fax transmission date of 6/22/2016) documented TSH ([MEDICAL CONDITION] Stimulating Hormone) 7.080 H ( Reference range 0.470-4.680). The Physician (MD) Progress Note dated 6/28/2016 documented the plan to increase [MEDICATION NAME] to 75 mcg (micrograms) due to the resident's elevated TSH and to check the TSH/ Free T4 in 1 month. The MD Order dated 6/28/2016 documents: discontinue [MEDICATION NAME] 0.05 mg tab by mouth every morning at 6;30am . [MEDICATION NAME] 0.075mg (milligrams)1 tab by mouth every morning at 6:30am . TSH, Free T4, CBC with Diff, BMP please draw 7/28/2016. The Lab Report dated 6/29/2016, with a fax transmittal date of 6/29/2016, documented TSH 10.400 VH (Very High) (Reference range 0.470-4.680). A hand written note documented Change [MEDICATION NAME] to 88 mcg daily. This lab result was not signed by the physician. The MD order dated 6/29/2016 documented orders to discontinue [MEDICATION NAME] .075 mcg and start [MEDICATION NAME] 0.088 mg 1 tab by mouth every morning at 6:30 am. The MD Progress Note dated 7/19/16 documented the plan to continue [MEDICATION NAME] 88 mcg and check TSH in 4 weeks. The Lab report dated 6/22/2016 was retransmitted to the facility on [DATE], documented TSH 7.080 H (Reference range 0.470-4.680). A hand written note documented change [MEDICATION NAME] to 100 mcg. This was the same lab results reported to the MD on 6/22/16 resulting in the MD ordering an increase dosage of [MEDICATION NAME] to 75 mcg on 6/28/16. As a result the MD ordered an increase of the [MEDICATION NAME] on 7/20/2016 to 0.1mg (100 mcg), resulting in the resident receiving an unnecessary dosage of the medication. The dosage of [MEDICATION NAME] was increased based on a previously reviewed lab value. The MD Progress Note dated 7/26/2016 documented the plan to continue [MEDICATION NAME] 100 mcg and check TSH in 3 weeks. The MD Progress Note dated 8/18/2016 documented plan to check TSH/Ft4 and continue [MEDICATION NAME]. The Lab report dated 8/19/2016 documented TSH 0.072 VL (Very Low). The Reference Range was 0.470-4.680 mcIU/ML (micro-international units per milliliter). The MD progress note dated 8/25/16 documented the plan to decrease [MEDICATION NAME] to 75 mcg. On 9/1/2016 at approximately 12:30 PM, the Registered Nurse Supervisor (RNS) was interviewed and stated lab results are faxed to the nursing office daily. She further stated it is the responsibility of the RNS to review the results, notify the MD, and obtain any new orders if the result is abnormal. She stated the lab is then flagged in the chart. The RNS stated that lab results are usually received the same day they are drawn unless it is a culture or something that will not come in until the next day. She stated that the RNS also reviews the labs in the chart to determine that abnormal labs are already addressed. She stated she could not remember if she knew the MD changed the [MEDICATION NAME] on 6/28/2016 the day before she called him with the result on 6/29/16. The RNS also stated the lab report dated 6/22/16 was initially sent with a missing Glycohemoglobin in progress. She stated that someone probably called the lab for the results again to get the Glcyohemoglobin and that's why the results were re-faxed and confused. On 9/1/2016 at approximately 1:00 PM, the Physician (MD) was interviewed and stated that he reviews labs and adjusts medications accordingly. He stated that the nurses call him if the lab results contain abnormal values and he reviews the labs on his next visit. The MD stated that the residents condition was over corrected. He stated that the lab was called on 7/19/16 for the results of the Glycohemoglobin level and the entire report was retransmitted, including the elevated TSH level which resulted in his treating the resident for the same condition twice. 415.15(b)(2)(iii)