Every finding on record at Gurwin Jewish Nursing and Rehabilitation Center

Based on observation, interviews, and record review (Complaint #2698214), the facility did not ensure each resident environment remained as free of accident hazards as possible. This was identified for one (1) (Resident #473) of five (5) residents reviewed for Accidents. Specifically, Resident #473 required two (2) person assistance for transfers as per their plan of care. On 12/19/2025, the assigned Certified Nursing Assistant #5 transferred Resident #473 alone from the wheelchair to a shower chair, resulting in the resident sustaining multiple skin tears to the right hand, left hand, and left shin.The finding is:A facility policy titled Activities of Daily Living last revised 09/2022 documented Certified Nursing Assistants must review the Certified Nursing Assistant Taks List and Kardex to ensure adherence to the resident's plan of care. Care and services will be provided including transfer and ambulation; locomotion on/off unit; and walk in the corridor with the use of the safety and assistive devices.An undated facility policy titled Safe Transfers and Movement of Residents documented residents shall be transferred, repositioned, and assisted with mobility only in accordance with their current assessment and care plan, using appropriate assistive devise, proper body mechanics, and the required level of staff assistance. Transfers shall be performed in a manner that promotes resident safety, dignity, and comfort and minimizes the risk of injury to residents and staff.Resident #473 was admitted with muscle weakness, spinal stenosis (narrowing of spaces within the spine), and difficulty in walking. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 11, indicating the resident had moderate cognitive impairment. The Minimum Data Set assessment documented the resident had functional limitation in range of motion to the lower extremity on one side and was dependent (helper does all the of the effort. Resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) on staff with sit-to-stand mobility, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. The resident used a wheelchair as a mobility device. The resident did not have any falls since the prior Minimum Data Set assessment.An Occupational Therapy Communication Form dated 06/19/2025 documented the resident was dependent on two (2) person assistance for tub/shower transfer and toilet transfer.A Kardex -Certified Nursing Assistant Task (a summary of resident care instructions for Certified Nursing Assistants) for 12/2025 documented Resident #473 required two (2)-person assistance for transfers including chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer.A Comprehensive Care Plan titled Self-Care/Mobility Performance Deficit initiated on 12/03/2024 and last revised on 01/08/2026 documented interventions including perform tub/shower transfer as instructed on the Certified Nursing Assistant Task; perform toilet transfer as instructed on the Certified Nursing Assistant Task; and provide Occupational Therapy evaluation as per the physician's orders.A Nursing Progress Note dated 12/19/2025 documented Certified Nursing Assistant #5 reported Resident #473 sustained skin tears during a transfer from the wheelchair to the shower chair. Certified Nursing Assistant #5 instructed the resident to hold the grab bar. The resident stood up; however, was unable to turn. Certified Nursing Assistant #5 seated the resident back in the wheelchair and then attempted the transfer again. At that time, the Certified Nursing Assistant #5 observed Resident #473 was bleeding and immediately notified the nurse. The resident was observed with a skin tear on top of the right hand measuring 1 centimeter in length and 1 centimeter in depth; a skin tear to the left lateral (side) hand measuring 4 centimeters in length and 0.5 centimeters in width; and a skin tear to the left shin measuring 2 centimeters in length and 2 centimeters in width.An Accident and Incident Report dated 12/19/2025 documented at approximately 04:30 PM, Certified Nursing Assistant #5 reported Resident #473 having new skin tears after transferring Resident #473 from a wheelchair to a shower chair, to the nurse. The investigation determined the transfer was not performed in accordance with the resident's care plan, which required two-person assistance for all transfers.A Physician's Order Dated 12/19/2025 documented to cleanse the skin tears to the left lateral hand, right hand, and left shin with normal saline, apply Bacitracin external ointment topically, and cover with a dry protective dressing every day shift.An Investigative Summary dated 12/24/2025 concluded Resident #473 sustained multiple skin tears as a result of failure to follow the established plan of care during transfers by Certified Nursing Assistant #5.A Physical Therapy Communication Form dated 12/24/2025 documented the resident required two (2) person assistance for sit-to-stand and chair/bed-to-chair transfer. The resident did not use a mechanical lift and was not able to ambulate.During an observation and interview on 12/31/2025 at 11:08 AM, Resident #473 was observed with a dressing to their right hand and left forearm. Resident #473 stated recently (date not recalled) when they were getting out of the shower one staff member was helping them and they sustained skin tears.During an interview on 01/07/2026 at 11:24 AM, Licensed Practical Nurse #2 stated they do not recall Resident #473's transfer status as they are not regularly assigned to the resident. On 12/19/2025, they worked during the evening shift and at approximately 04:30 PM Certified Nursing Assistant #5 brought Resident #473 to the nursing station. The resident was observed with impaired skin on the left hand and left leg. Licensed Practical Nurse #2 stated they immediately called the nursing supervisor. Certified Nursing Assistant #5 said the resident sustained the skin tears during the shower. Licensed Practical Nurse #2 stated Certified Nursing Assistant #5 did not ask them for assistance with Resident #473 in the shower room.During an interview on 01/07/2026 at 12:31 PM, Registered Nurse #5 stated they were called to the unit by Licensed Practical Nurse #2 regarding Resident #473. The resident was assessed with superficial skin tears to both arms and left shin. Registered Nurse #5 stated Certified Nursing Assistant #5 acknowledged that they transferred the resident from the wheelchair to the shower chair by themselves and the resident sustained skin tears during the transfer. Registered Nurse #5 stated the resident required two (2) person assistance for transfers and that Certified Nursing Assistant #5 could not provide a reason for transferring the resident by themself. Registered Nurse #5 stated they informed the Chief Nursing Officer and Certified Nursing #5 was sent home.During an interview on 01/07/2025 at 01:06 PM, the Chief Rehabilitation Officer stated that Resident #473 was discharged from rehabilitation services in July 2025. The Chief Rehabilitation Officer stated as of 12/19/2025, Resident #473 required two (2) person assistance for tub/shower transfers as instructed on the Occupational Therapy Communication dated 6/19/2025. The Chief Rehabilitation Officer stated the resident should have been transferred with the assistance of two (2) staff members into the shower chair, and that a one (1) person transfer from the wheelchair to the shower chair was an unsafe transfer. During an interview on 01/07/2025 at 02:25 PM, Certified Nursing Assistant #5 stated they were regularly assigned to care for Resident #473. Certified Nursing Assistant #5 stated they typically did not check a resident's Kardex. Certified Nursing Assistant #5 stated on 12/19/2025 at approximately 04:00 PM to 04:15 PM they took Resident #473 to the shower room for a scheduled shower. Certified Nursing Assistant #5 stated they were alone in the shower room with the resident. They instructed Resident #473 to hold the grab bars in the shower room; however, they were not able to transfer the resident into the shower chair in the first attempt as the resident said, they needed a second. Certified Nursing Assistant #5 stated they again attempted to transfer the resident and were able to complete the transfer by grabbing the back of the resident's pants and pivoting the resident from the wheelchair into the shower chair. Certified Nursing Assistant #5 stated once they completed the transfer, they noticed the resident had skin tears and took the resident to the nursing station. Certified Nursing Assistant #5 stated they were aware Resident #473 needed two (2) person assistance with transfers and had no explanation or excuse as to why they transferred the resident alone. Certified Nursing Assistant #5 stated they did not ask for assistance from other staff prior to transferring the resident into the shower chair and did not perform a safe transfer for Resident #473 on 12/19/2025 as per the resident's plan of care.During an interview on 01/08/2026 at 09:12 AM, the Assistant Director of Nursing stated Resident #473's plan of care required two (2) person assistance for transfers. Certified Nursing Assistant #5 did not follow the resident's plan of care and unsafely performed the transfer alone, resulting in multiple skin tears to the resident's hands and left leg. The Assistant Director of Nursing Stated the resident was re-evaluated by rehabilitation services and it was determined that the resident continued to require two (2) person assistance with the transfers During an interview on 01/08/2026 at 11:15 AM, the Chief Nursing Officer stated Certified Nursing Assistant #5 should not have transferred Resident #473 alone because Resident #473 required two (2) person assistance for transfers. The Chief Nursing Officer stated Certified Nursing Assistant #5 should have sought assistance to transfer Resident #473 into the shower chair. The resident sustained superficial skin tears with no other injuries as a result. The Chief Nursing Officer stated Certified Nursing Assistant #5 was immediately removed from the schedule and on 12//22/2025 Certified Nursing Assistant #5 resigned from the facility. 10 NYCRR 415.12(h)(1)

Based on interviews and record review, the facility did not ensure the irregularities identified by the Pharmacist during the drug regimen review was documented on a separate, written report and the attending Physician documented in the resident's medical record that the irregularity identified by the Pharmacist had been reviewed and what action had been taken to address the recommendations. This was identified for one (1) (Resident #358) of five (5) residents reviewed for Unnecessary Medications. Specifically, Pharmacist #1 documented a medication regimen review recommendation in Resident #358's medical record on 12/2/2025 to review duplicate use of sleeping agents Melatonin (a sleep medication) and Ramelteon (a prescription sleep medication for adults with sleeping difficulty-a melatonin receptor). There was no documented evidence that a separate, written report of the recommendations was sent to the attending Physician, the Medical Director and the Director of Nursing Services. Additionally, Nurse Practitioner #1 discontinued the Melatonin on 12/9/2025 without documenting the rationale to discontinue the medication. The finding is: The facility's policy titled Medication Regimen Review dated 06/16/2023 documented all [pharmacy] recommendations which have the potential for immediate morbidity or mortality to a resident if left unaddressed will be communicated verbally to the appropriate medical staff. The communication will be documented in the electronic medical record document or pharmacy progress notes. All other recommendations may be transmitted verbally to the medical staff or by printing a medication regimen review form. The form will be placed in the appropriate medical staff's mailbox. The medical staff will respond to the written medication regimen review form within seven (7) days. The medical staff will acknowledge the recommendations and may either agree or disagree with the recommendation but must complete a written response on the form. All completed medication regimen review with the physician responses will be maintained and fully accessible in the pharmacy department, in addition to being scanned into each resident's permanent medical record. Resident #358 was admitted with diagnoses including dementia (a condition characterized by progressive or persistent loss of intellectual functioning), Parkinson's disease (a progressive neurodegenerative disorder of the central nervous system), and hypertension (the pressure in the blood vessel is too high). The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 11, which indicated the resident had moderately impaired cognition. The Minimum Data Set documented the resident reported trouble falling or staying asleep or sleeping too much for several days (2-6 days) in the past two (2) weeks. The current physician's order initially ordered on 02/05/2025 documented to administer Ramelteon oral tablet 8 milligrams one (1) tablet by mouth at bedtime for Insomnia (difficulty falling asleep). A physician's order first ordered on 02/14/2025 documented to administer Melatonin oral tablet 3 milligrams one (1) tablet by mouth at bedtime for sleep wake cycle. The order was discontinued on 12/09/2025. The Comprehensive Care Plan for Insomnia last revised on 07/17/2025 documented the resident was being treated for insomnia. Interventions included to provide medications as per physician's order and monitor for effectiveness; encourage/facilitate a regular bedtime routine, and to monitor for possible negative sign and symptoms of use of insomnia medications. The monthly Medication Regimen Review progress note, written in the electronic medical record, dated 12/02/2025, signed by Pharmacist #1 documented that Resident #358 was on Melatonin and Ramelteon, a duplicate treatment for sleep. There was no physician response, signature, or date in the medication regimen review progress note to acknowledge, agree or disagree with the recommendations. There was no documented evidence that the identified irregularity was reported to the attending Physician, the Medical Director or the Director of Nursing Services. A review of Resident #358's medical record from 12/02/2025 to 01/06/2026 revealed there was no medication regimen review form for Resident #358 related to the pharmacy recommendation made on 12/2/2025. During an interview on 01/06/2026 at 12:43 PM, Pharmacist #1 stated they reviewed Resident #358's medication regimen at least monthly and notified the medical provider of any recommendation through a Health Insurance Portability and Accountability Act compliant electronic communicating channel; the physician would respond to their recommendations through the electronic communication channel. Pharmacist #1 stated they documented their monthly medication regimen review in the resident's progress note. Pharmacist #1 stated that they were not informed that the monthly medication regimen review had to be documented on a separate written report, in addition to the progress note. Pharmacist #1 stated they did not write a separate report of their recommendations to provide to the attending Physician, Medical Director or the Director of Nursing Services on 12/02/2025. During an interview on 01/06/2026 at 1:23 PM, the Chief Pharmacy Officer stated they were responsible for developing the Medication Regimen Review policies and in-serviced the pharmacy staff of the task requirements. The Chief Pharmacy Officer stated since August 2025, they have directed the pharmacy staff to communicate the medication regimen review recommendations to all medical providers via the Health Insurance Portability and Accountability Act- compliant electronic communicating channel. The Chief Pharmacy Officer stated they did not require the pharmacists to document any identified irregularities on a separate written report because the facility is not required to do so. The Physician respond promptly by using the electronic communication channel. The Chief Pharmacy Officer stated they expected the medical providers to document their rationale of agreeing or disagreeing with pharmacist's recommendation in the medical progress notes. The Chief Pharmacy Officer stated that not all the medication regimen review recommendations are sent to the Medical Director and the Chief Nursing Officer. The recommendations are only brought to the Medical Director or the Chief Nursing officer's attention when the physician do not appropriately address the recommendations. During an interview on 01/06/2026 at 2:29 PM, Nurse Practitioner #1 stated they discontinued the Melatonin medication after reviewing the pharmacist's medication regimen review recommendation via the electronic communicating channel. Nurse Practitioner #1 stated they did not receive a separate written report addressing the medication regimen review on 12/02/2025. Nurse Practitioner #1 stated they agreed with the recommendation to discontinue Melatonin; however, they did not document the agreement in the resident's medical record. Nurse Practitioner #1 stated they should have documented a response when they reviewed the pharmacist's recommendation to include what actions were taken to address the identified irregularity. During an interview on 01/07/2026 at 09:58 AM, Physician #1, who was Resident #358's attending Physician, stated Nurse Practitioner #1 was assigned to Resident #358 and was responsible for providing medical care, under their (Physician #1) supervision. Physician #1 stated that Nurse Practitioner #1 could review the Pharmacist's recommendations and decide to follow up on the recommendations on their (Physician #1) behalf. Physician #1 stated Nurse Practitioner #1 should have documented their review of the Pharmacist's recommendation and the rationale to discontinue melatonin for Resident #358. During an interview on 1/7/2026 at 11:57 AM, the Medical Director stated they were involved in developing the Medication Regimen Review policy. The Medical Director stated they were notified of some pharmacy recommendations through the Health Insurance Portability and Accountability Act- compliant electronic communicating channel. The Medical Director stated they were aware that most pharmacy irregularities were communicated through this forum and not in a separate written report. The Medical Director stated that the medical providers can provide more efficient responses using the communication system instead of responding to written reports. The Medical Director stated they expected medical providers to document their review of the Pharmacist's recommendations in the progress notes and what action had been taken to address the identified irregularities. The Medical Director stated they do not receive all pharmacy recommendations in a separate written report and that the facility should comply with the regulatory requirement and ensure all Medication Regimen Reviews are documented in a separate, written report. During an interview on 01/08/2026 at 8:43 AM, the Chief Nursing Officer stated they were notified of some pharmacist recommendations through the Health Insurance Portability and Accountability Act- compliant electronic communicating channel. The Chief Nursing Officer did not receive any written reports and was not aware that pharmacist recommendations must be sent to them in a separate, written report. The Chief Nursing Officer stated that the facility should comply with the regulatory requirement and ensure all pharmacy recommendation are documented in a separate, written report. The Chief Nursing Officer stated that medical providers should document when a pharmacy irregularity was reviewed and addressed. 10 NYCRR 415.18(c)(2)

Based on observation, record review, and interviews the facility did not ensure that it maintained an infection prevention and control program designed to help prevent the development and transmission of infectious diseases. This was identified for one (1) (Resident #432) of nine (9) residents reviewed for Infection Control. Specifically, Resident #432 had a physician's order for contact isolation precautions for a diagnosis of shingles (blistering skin rash caused by the reactivation of the varicella-zoster virus). Certified Nursing Assistant #1 was observed in Resident #432's room making the resident's bed without wearing appropriate personal protective equipment.The finding is: The facility policy titled Transmission Based Precautions dated 04/28/2024, documented transmission-based precautions are a group of infection prevention and control practices that are used in addition to standard precautions for residents who may be infected or colonized with infectious agents that require additional control measures to prevent transmission effectively. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. Resident #432 was admitted with diagnoses including chronic obstructive pulmonary disease (a progressive lung condition causing airflow obstruction, making breathing difficult), and gastrostomy Status (a surgically created opening into the stomach for long term feeding, medications, or drainage). The admission Minimum Data Set assessment dated [DATE], documented a Brief Interview for Mental Status score of 12, indicating the resident had moderate cognitive impairment. A physician's order dated 12/28/2025 documented Contact Precautions, left flank rash/presumed shingles. A comprehensive care plan titled Resident has an infection Herpes Zoster (Shingles) dated 12/29/2025 and resolved on 01/02/2026 documented interventions that included to maintain contact isolation precautions. During an observation on 12/31/2025 at 11:41 AM, a contact precaution signage was on the doorway of Resident #432's room. The signage indicated staff must put on gloves and a gown before entering the room. Certified Nursing Assistant #1 was inside Resident #432's room and had gloves on. Certified Nursing Assistant #1 was not wearing a gown and was observed touching and shaking the blankets and bedsheets to lay smoothly on Resident #432's bed. During an interview on 12/31/2025 at 11:18 AM, Certified Nursing Assistant #1 stated the signage on Resident #432's door indicated the resident was on contact precautions. Certified Nursing Assistant #1 stated they took off their gown after providing care to Resident #432, changed their gloves and then proceeded to make the resident's bed. Certified Nursing Assistant #1 stated they thought they did not need a gown when making the resident's bed. They were only required to have the gown on before entering the resident's room and when providing care for the residents who were on contact precautions. During an interview on 12/31/2025 at 12:23 PM, the Infection Preventionist stated staff should wear gloves and a gown when they enter a resident room with contact precautions. Certified Nursing Assistant #1 should not have shaken the blankets and linen when making Resident #432's bed and should have put on the appropriate personal protective equipment, including a gown, when in contact with the resident's environment. During an interview on 01/07/2026 at 8:02 AM, the Chief Nursing Officer (Director of Nursing Services) stated staff should follow the contact precautions directions and wear appropriate personal protective equipment. The Chief Nursing Officer stated if a staff member goes into a contact isolation room without the proper personal protective equipment, they could spread the infection to other residents and staff. 10 NYCRR 415.19(a)(1-3)

Based on observations, interviews, and record review, the facility did not ensure that each resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. This was identified for one (1) (Resident #30) of three (3) residents reviewed for Activity of Daily Living. Specifically, Resident #30 had limited range of motion for both hands and required assistance with hand hygiene. The resident was observed with accumulation of moisture and brown sticky substance with a strong odor in the resident's hands. The assigned Certified Nursing Assistant #8 acknowledged not providing hand hygiene to the resident due to not being able to open the resident's hands.The finding is: The facility Activity of Daily Living policy revised on 09/2025 documented care and services will be provided for activities of daily living such as bathing. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, personal, and oral hygiene. Resident #30 was admitted with diagnoses including cerebral infarction (brain tissue death caused by a blocked artery, cutting off oxygen and nutrients), dysphagia (difficulty swallowing), and dementia (decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, and behavior). The Annual Minimum Data Set assessment dated [DATE] documented the resident had severely impaired cognition and was rarely/never understood. The resident was dependent on staff with all activities of daily living and had impairment to both upper and lower extremities. The care plan for self-care/mobility performance deficit initiated on 10/12/2023 and revised on 10/02/2025 documented interventions including shower/bathe (as per Certified Nurse's Assistant task); monitor and report any signs and symptoms of immobility such as contractures forming or worsening, or skin-breakdown. During an observation on 01/07/2026 at 10:30 AM, Resident #30 was lying in their bed. The resident's hands were observed to be contracted with closed fists. During an observation on 01/07/2026 at 10:35 AM, Certified Nursing Assistant #8 opened Resident #30's hands. There was a strong foul-smelling odor, and the resident's palms were observed with an accumulation of moisture and brown sticky substance. Certified Nursing Assistant #8 scraped out the accumulated sticky substance and discarded the residue in the garbage. During an interview on 01/07/2026 at 10:55 AM, Certified Nursing Assistant #8 stated they were the full time Certified Nursing Assistant for Resident #30. The resident receives a shower twice a week and a bed bath five times a week. Certified Nursing Assistant #8 stated Resident #30 was unable to perform any self-care tasks. Certified Nursing Assistant #8 stated they did not wash Resident #30's palms because it is difficult to open the resident's hand and clean. Certified Nursing Assistant #8 stated they had notified the unit nurses (could not recall the name) about the difficulty in opening the resident's hands. The resident used to use the gauze roll for their palms; however, the gauze roll was discontinued because the resident did not like using the gauze roll. The resident was supposed to get passive range of motion exercises daily. Certified Nursing Assistant #8 stated they provided the passive range of motion to the resident's hands daily; however, they did not pay attention to the resident's palms and did not clean the resident's hands. During an observation and interview with Licensed Practical Nurse #4 on 01/07/2026 at 11:04 AM, Resident #30 was lying in their bed with both their palms half opened. Some of the moist brown sticky substance was still present in the resident's palms. Licensed Practical Nurse #4 stated Resident #30's palms were dirty and appeared they have not been washed properly. Licensed Practical Nurse #4 stated Certified Nursing Assistants were responsible to provide grooming and hygiene to each resident on their assignment. During an interview on 01/07/2026 at 1:00 PM, Wound Care Nurse #1 stated the brown sticky substance was a buildup of sweat and debris and were a result of the hands not being washed properly for a while. Wound Care Nurse #1 stated after they observed the condition of the resident's hands, they called the Physician and obtained an order to cleanse the resident's palms with hydrogen peroxide and normal saline one time only. Wound Care Nurse #1 stated the residue came off from the resident's palms. Wound Care Nurse #1 stated the resident's hand hygiene should have been maintained to keep the skin intact and prevent infections. The physician orders dated 01/07/2026 documented to cleanse bilateral palms and in between fingers with 1/2 Hydrogen Peroxide 3% and normal saline one time only for Dry flaky skin for one (1) day. Apply Zeasorb-AF Powder 2 % (an antifungal) to bilateral hands topically, every day and evening shift for moisture after cleaning with soap and water. During an interview on 01/08/2026 at 2:22 PM, Chief Nursing Officer stated Certified Nursing Assistants should provide grooming and hygiene care the residents including washing the residents' hands. 10 NYCRR 415.12(a)(3)

Based on observation, record review, and interviews the facility did not ensure the Minimum Data Set assessment was completed to accurately reflect each resident's status. This was identified for one (1) (Resident #11) of three (3) residents reviewed for Physical Restraints. Specifically, Resident #11's Minimum Data Set assessments dated 10/31/2025 and 11/11/2025 inaccurately documented that Resident #11 used physical restraint in a chair or out of bed daily.The finding is: The facility's policy titled Minimum Data Set Accuracy last revised on 09/2025, documented the Minimum Data Set Assessor will ensure the Minimum Data Set is coded accurately to reflect the resident's status. All Minimum Data Set assessments must be completed accurately and within the required timeframes. Minimum Data Set coding must be supported by clinical documentation in the medical record. Minimum Data Set entries must reflect the resident's status and services provided during the applicable look-back period. The Minimum Data Set discrepancies between documentation and Minimum Data Set coding are to be resolved prior to submission. Resident #11 was admitted with diagnoses that included [NAME] Syndrome (a rare severe skin reaction often triggered by mediations or infections causing flu like symptoms and rash), vascular dementia (a decline in thinking skills due to damaged blood vessels in the brain), and type 2 diabetes mellitus (the body does not make enough insulin). The Five (5) Day Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 12, which indicated the resident had moderately impaired cognition. The Minimum Data Set assessments dated 10/31/2025 and 11/11/2025 documented in Section P0100H that Resident #11 used other physical restraint in a chair or out of bed daily. The Centers for Medicare and Medicaid Services (CMS) form 802 (matrix used to identify pertinent resident care categories) dated 12/31/2025 documented Resident #11 had physical restraints. A review of Resident #11's medical record revealed there was no documented evidence that the resident utilized a physical restraint. During an observation on 01/07/2026 at 08:30 AM, Resident #11 was observed resting in bed with no physical restraints noted. Resident #11 declined to be interviewed. During an interview on 01/07/2026 at 08:46 AM, Registered Nurse Unit Manager #1 stated they were not sure why the use of restraints was checked on the matrix for Resident #11. Registered Nurse Unit Manager #1 stated they were responsible for completing the matrix for the unit and the use of restraints for Resident #11 must have been entered in error because the resident did not use any type of restraints. Registered Nurse Unit Manager #1 stated they were not sure why other restraints were indicated on the Minimum Data Set assessment tools. Registered Nurse Unit Manager #1 stated the Minimum Data Set coordinator was responsible for completing the Minimum Data Set assessment. During an interview on 01/07/2026 at 2:05 PM, Minimum Data Set Assessor #3 stated work per diem at this facility and were not too familiar with Resident #11. Minimum Data Set Assessor #3 stated they completed both the 10/31/2025 and the 11/11/2025 Minimum Data Set assessments for Resident #1 and erroneously entered that the resident utilized restraints, and it was an oversight on their part. During an interview on 01/07/2026 at 2:52 PM, the Chief Minimum Data Set Officer stated the facility uses a scrub program (specialized software for skilled nursing facilities that automatically audits resident assessments for errors, inconsistencies, and compliance issues before they are sent to the Centers for Medicare & Medicaid Services) to make sure the Minimum Data Set assessments are accurate. The Chief Minimum Data Set Officer stated they called the scrub program vendor and were told that Section P0100H is excluded from the audit for unknown reasons. The Chief Minimum Data Set Officer stated the Minimum Data Set assessor should have verified the accuracy of the data. During an interview on 01/08/2026 at 08:42 AM, the Chief Nursing Officer (Director of Nursing Services) stated the Minimum Data Set assessor should review the accuracy of the Minimum Data Set assessments before signing for completion. 10 NYCRR 415.11(b)

Based on observations, record review, and staff interviews during the recertification survey initiated on 5/15/2024 and completed on 5/23/2024, the facility did not ensure that a person-centered care plan for each resident that included measurable objectives and timeframes to meet the resident's needs was developed timely and implemented accurately. This was identified for one (Resident #210) of five residents reviewed for Respiratory Care. Specifically, Resident #210 had a physician's order for oxygen therapy at one liter per minute via nasal cannula. During three seperate observations, Resident #210 was observed receiving oxygen at three liters per minute. Additionally, there was no documented evidence that a comprehensive care plan for the resident's Respiratory Status was developed in a timely manner. The finding is: The facility's undated Comprehensive Care Plan policy and procedure documented that the resident's Comprehensive Care Plan must address the main reason for admission and that the Comprehensive Care Plan and Discharge Plan must be initiated within one week of admission and 14 days of an initial or significant change in resident's condition. The team must initiate a Comprehensive Care Plan using the Care Assessment Areas Summary Sheet as the guideline. Within 21 days of Admission, the Comprehensive Care Plan must be finalized and there must be evidence that the Care Assessment Areas instructions were used in formulating the resident's care plan. Resident #210 was admitted to the facility with diagnoses that included Pulmonary Hypertension, Congestive Heart Failure, Non-Alzheimer's Dementia, and Atrial Fibrillation. The Admission Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 3, which indicated severely impaired cognition. Section O of the Minimum Data Set assessment documented the resident received continuous oxygen on admission and while a resident. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident received oxygen therapy while a resident. Resident #210 was observed lying in bed, awake and responsive, on 5/15/2024 at 11:20 AM. The resident was receiving oxygen from an oxygen concentrator at 3 liters per minute via a nasal cannula. A Physician's order dated 10/10/2023 and last reviewed on 5/2/2024 documented to administer oxygen at one liter per minute via a nasal cannula every shift for shortness of breath. The Treatment Administration Record dated 10/2023 and 11/2023 documented the resident was receiving oxygen at one liter per minute via nasal cannula for Shortness of Breath as indicated by the nurses' signature. The current Treatment Administration Record dated 5/2023 documented the resident was receiving oxygen at one liter per minute via nasal cannula for Shortness of Breath until 5/23/2024 when the Physician's order was changed to 2 liters per minute titrating up to 3 liters per minute. Resident #210 was observed on 5/23/2024 at 8:53 AM. Resident #210 was lying in bed and was receiving oxygen from an oxygen concentrator at 3 liters per minute via nasal cannula. Resident #210 was observed on 5/23/2024 at 8:58 AM with Licensed Practical Nurse #3. Resident #210 was lying in bed and was receiving oxygen from an oxygen concentrator at 3 liters per minute via nasal cannula. Licensed Practical Nurse #3 confirmed that the oxygen flow rate was set at 3 liters per minute. A Review of the medical record was conducted on 5/23/2024 and revealed that the care plan for the resident's Respiratory Status was not initiated until 5/23/2024. A Comprehensive Care Plan initiated on 5/23/2024 documented altered Respiratory Status and difficulty breathing related to shortness of breath. Interventions included administering medication as ordered; nebulizer treatments and oxygen therapy as ordered, and maintaining oxygen settings as per the Physician's order. During an interview with Registered Nurse #2 on 5/23/2024 at 1:11 PM, they stated that on admission the admitting Registered Nurse is responsible for initiating the care plans for the resident. Registered Nurse #2 stated when Resident #210 was admitted to the facility, a care plan for the need for oxygen therapy should have been initiated. During an interview with the Director of Nursing Services on 5/23/24 at 2:39 PM, they stated that the nurses should have ensured that Resident #210 received oxygen therapy as per the physician's order. The Director of Nursing Services stated if the resident needed a higher oxygen flow rate than what was ordered by the Physician, then the Physician should have been contacted to obtain a new order. The Director of Nursing Services stated that a care plan for oxygen use should have been initiated by the admitting Registered Nurse; however, the care plan can also be initiated by any Registered Nurse Manager or Supervisor. The Director of Nursing Services further stated that the comprehensive care plan for each resident must be completed before the initial care plan meeting is held. 10 NYCRR 415.11(c)(1)

Based on observations, record review, and interviews during the Recertification Survey initiated on 5/15/2024 and completed on 5/23/2024, the facility did not ensure that the facility's medication error rate was not five percent or greater. This was identified for three of the 27 medications observed during the medication pass observation, resulting in an 11.11% medication error rate. Specifically, during a medication pass observation Resident #155 did not receive three of their 8:00 AM physician-ordered medications until 11:46 AM on 5/15/2024. The finding is: The Facility's Policy for Administering Medications revised on 1/12/2024 documented that medications should be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal). Resident #155 was admitted with diagnoses that include Dementia and Hypertension. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13, indicating the resident had intact cognition. The active Physician's Orders for May 2024 for Resident #155 documented to administer the following medications at 8:00 AM: -one Escitalopram Oxalate 10 milligram tablet by mouth once a day for Depression at 8:00 AM; -one Apixaban Oral 2.5 milligram tablet by mouth every 12 hours for history of venous Thromboembolism (blood clotting) at 8:00 AM; 2 oral puffs of Albuterol Sulfate Hydrofluoroalkane Aerosol Solution 108 (90 Base) micrograms/actuation pressurized inhalation four times a day for Chronic Obstructive Pulmonary Disease at 8:00 AM. During the medication administration task observation on 5/15/2024 at 11:46 AM, Registered Nurse #4 was observed administering one Escitalopram Oxalate 10 milligram tablet, one Escitalopram Oxalate 10 milligram tablet, and 2 oral puffs of Albuterol Sulfate Hydrofluoroalkane Aerosol Solution 108 (90 Base) micrograms/actuation pressurized inhalation to Resident #155 which were due to be administered at 8:00 AM as per the physician's orders. The medications were administered 2 hours and 46 minutes beyond their prescribed time. Registered Nurse #4 was interviewed on 5/15/2024 at 11:48 AM and stated that they were administering Resident # 155's 8:00 AM medications late because they got busy with other things. Registered Nurse #4 stated they should have administered the medications before 9:00 AM since the medications can be administered one hour before or one hour after the prescribed time. The Chief Nursing Officer was interviewed on 5/23/2024 at 2:37 PM and stated that Resident #82's medications were administered late on 5/15/2024, which is not acceptable. The Chief Nursing Officer stated they expected the nurses to administer medications as per the facility policy which is one hour before and one hour after the scheduled time. Nurse Practitioner #1 was interviewed on 5/23/2024 at 3:06 PM and stated that it was not acceptable to administer the medications later than one hour past the prescribed time. Nurse Practitioner #1 stated Registered Nurse #4 should have notified Nurse Practitioner #1 about the delayed medications to determine if the time change was appropriate. 10 NYCRR 415.12(m)(1)

Based on observations, record review, and interviews during the recertification survey conducted 5/15/24-5/23/24, the facility did not ensure each resident was provided a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs, taking into consideration the preferences of each resident. This was identified for one (Resident #36) of five residents reviewed for Nutrition. Specifically, Resident #36 verbalized disliking the food served to them and requested a burger as a preferred meal. The facility did not honor the resident's preference and only provided a burger meal once in three weeks. Finding include: The facility policy Nutritional Services revised in January 2024 documented that Residents are interviewed regarding food/beverage and meal preferences to provide an individualized and personal dining experience. These food/beverage and meal preferences are updated regularly. Food/beverage and meal preferences may include religious, ethnic, cultural, and/or usual eating patterns. Preferences will be honored and recognized by all staff and implemented in the best interest of the resident. The facility policy Resident food preferences revised in January 2018 documented Residents' individual choices are obtained that incorporate religious, cultural, and ethnic needs and preferences. Residents are served meals that offer choices, including portion size, and comply with food preferences. Choices of food substitutions are provided when the resident refuses the meal items served and should be of equal nutritional value to the planned menu item. The Dietitian/Designee would interview the resident within 24-48 hours of admission (not to exceed 72 hours over a weekend); obtain food and dining preferences, dislikes, allergies, and cultural, religious, and ethnic preferences; record the information in the resident's nutrition file, update preferences regularly, minimally quarterly. Resident # 36 has diagnoses including Liver Cirrhosis. The 4/11/2024 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status score of 13 indicating the resident had intact cognition. The resident had no behaviors and had a significant weight loss. The resident was interviewed during the initial screening on 5/15/2024 at 11:45 AM and stated they only eat breakfast and dislike all other food. A review of the resident's weights from 2/22/2024 to 5/12/2024 revealed the resident had a significant weight loss (more than 10 percent in 6 months). On 2/22/2024 the resident weighed 219 pounds and on 5/12/2024, the resident weighed 191 pounds indicating a 24.9% weight loss. The comprehensive care plan (CCP) for Advanced Directive revised 7/13/2023 documented the resident is capable of making their own decisions regarding medical decisions and has assigned (family member) as their decision maker. The comprehensive care plan (CCP) for Nutrition revised 5/2/2024 documented Resident #36 has the potential for weight changes & Dehydration related to cardiac status, edema with diuretic treatment, morbid obesity, Cirrhosis, significant weight loss, poor oral intake, noncompliant with recommended diet. Interventions include Nutrition /Nursing to provide cultural/religious, food/fluid, and mealtime preferences. The resident's dietary preference sheet documented the resident's preferences as follows: cheese quiche, grilled American sandwich on white bread, green steamed peas, Mediterranean stuffed peppers vegetarian, and burger beef on bun patty. The alternate menu offered to the resident included: Dairy Meal: tuna salad sandwich, egg salad sandwich, cheese sandwich, cottage cheese and fruit plate, and baked fish. The Meat Meal: turkey sandwich, chicken salad sandwich, bologna sandwich, salami sandwich, tuna salad sandwich, egg salad sandwich, roasted chicken, daily bread options include challah, kaiser, tortilla, wheat, white, and rye bread. A Nutrition/Dietary Note dated 4/26/2024 at 3:01 PM documented Resident #36 requested to speak to the writer (Registered Dietician) to discuss food quality and poor intake. The resident has had significant weight loss related to poor appetite and food dislikes. The resident stated food had no flavor. The resident was encouraged to ask the family to bring in seasoning shakers to add flavor. The resident refused. The resident discussed liking a burger with sliced onion and pudding with sugar. Pudding added to dairy meals with bedtime snacks. The menu profile updated and will discuss options with the kitchen staff to determine the availability of the beef burger. The resident was re-interviewed on 5/22/2024 at 12:00 PM and stated they stopped eating the facility's food. I only eat 2 hard-boiled eggs daily. They know my preferences and they do not provide it. They tell me to have my brother bring in food, I dislike the alternates. They want to give me drugs to stimulate my appetite but I refuse to take them. I am provided- tuna fish, cheese sandwich, and bologna that I cannot eat. I should have more choices to choose from. If they were to give me the food that I like, I would would eat it. During an observation on 5/22/2024 at 1:00 PM, Resident #36 was provided with a falafel sandwich meal. The resident disliked the sandwich and returned the tray with the Certified Nurse Assistant #2. The resident was re-interviewed on 5/23/2024 at 12:30 PM and stated they disliked the Falafel sandwich that was served on 5/22/2024 and could not eat it. They have no appetite and the food served at the facility does not stimulate their appetite. If they were given the food they liked, they would eat it. The resident further stated they had requested hamburgers as a preference over three weeks ago and they were offered the burger only once in the last three weeks. Dietician # 1 was interviewed on 5/22/2024 at 1:12 PM and stated Resident #36 disliked the food and had significant unplanned weight loss. Burgers are not on the alternate list and are only served once in the last few weeks. The day Resident #36 requested a burger they got the burger. Dietician # 1 stated they did not know if burgers could be provided to the resident more often and they did not ask food services to determine the availability. Clinical Nutrition Manager #1 was interviewed on 5/22/2024 at 3:13 PM and stated the facility can not serve meat on a dairy meal day. Every Wednesday and Friday the Lunch meal is always meat and the Dinner is always dairy, except on Wednesdays and Fridays. Clinical Nutrition Manager #1 stated that the dietician told them about the resident's preference for burgers and they called the kitchen and got the burger for the resident that day (could not recall when). Food Service Director # 1 was interviewed on 5/22/2024 at 3:17 PM and stated the facility follows kosher guidelines, No dairy for 6 hours after meat meal and no meat after dairy meal x 1 hour. Food Service Director # 1 stated they were not aware of the resident's preference for the burger. The last burger meal served was approximately two weeks ago. No one from the dietary department requested the availability of burgers for Resident # 36. We cannot serve meat during a dairy meal or dairy during a meat meal; however, we can provide meat to a resident at any time if they request. Chief Operating Officer #1 was interviewed on 5/23/2024 at 11:25 AM and stated the resident refuses to eat and has a poor appetite and the facility has to abide by kosher requirements. Chief Nursing Officer # 1 was interviewed on 5/23/2024 at 2:00 PM and stated nursing staff monitors the resident's weight and notifies the Dietician if the resident refuses to eat, offers alternate meals, and if the resident refuses the alternate meal then the nurse/Dietician should contact the kitchen to see if other options are available. If there are no other options then we see if the resident wants to order out. Chief Nursing Officer # 1 stated many residents here do not like the facility's food because of its kosher status. 10 NYCRR 415.14

Based on observation, record review, and interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 00321973) initiated on 5/15/2024 and completed on 5/23/2024, the facility did not ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments. This was identified for one (Resident #90) of two residents reviewed for abuse. Specifically, Resident #90 was involved in a resident-to-resident altercation on 8/11/2023 and sustained a 4-centimeter by 4-centimeter Hematoma (bruise) to their left forearm. The comprehensive care plan for Resident #90 was not reviewed or revised to reflect the altercation. The finding is: The facility's undated Comprehensive Care Plan policy documented to ensure the timeliness of each resident's person-centered comprehensive care plan and ensure the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and their needs. Following the annual or significant change Minimum Data Set (MDS 3.0) assessment, the care plan is updated to reflect the resident's status and the Interdisciplinary Team (IDT) will document that each care plan has been reviewed and revised, if applicable, and that all changes identified by the Quarterly Minimum Data Set 3.0 must be documented in the comprehensive care plan. Resident #90 was admitted to the facility with diagnoses that included Bipolar Disease, Hypertension, and Coronary Artery Disease. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 10, which indicated the resident had moderately impaired cognition. The resident had no behavioral symptoms. The resident required limited assistance of one staff for walking on the unit and extensive assistance of one staff for locomotion on the unit. A Quarterly Minimum Data Set assessment dated [DATE] documented the resident had short and long-term memory problems and had moderately impaired skills for making decisions. An annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 14 which indicated the resident had intact cognition. The resident had no behavioral symptoms and utilized a walker and wheelchair. A Comprehensive Care Plan dated 6/29/2023 documented that Resident #90 was involved in a resident-to-resident interaction. Interventions included staff encouraging peers to be in a different area on the unit and support to be provided to ensure the resident feels safe and not at risk of negative interaction with other residents. A Behavior note dated 8/11/2023 documented that Resident #90 was self-propelling their wheelchair up the hall, and as they passed Resident #148 was also self-propelling their wheelchair down the hall, Resident #148 began to hit Resident #90 with a rubber-soled shoe in the left arm. This act was witnessed by the charge nurse, and both residents were immediately separated. A Hematoma measuring four centimeters in length, four centimeters in width, and one centimeter in depth was observed. Ice was applied to Resident #90's left forearm. A review of the resident's care plan for resident to resident altercation was conducted on 5/23/2024 and there was no documented evidence that the care plan was reviewed and revised at the time of the Quarterly care plan review for the 12/7/2023 and the 2/29/2024 assessments. An interview was conducted on 5/23/2024 at 1:55 PM with Social Work #1, and they stated that the Social Workers or nurses can update the care plans. Social Work #1 stated that either discipline should have updated the care plan to reflect the resident-to-resident altercation. An interview was conducted on 5/23/2024 at 2:50 PM with the Director of Nursing Services, they stated the care plan should have been revised by any Registered Nurse who was assigned to the resident's unit or by the Registered Nurse Risk Manager. The Director of Nursing Services stated the care plan should have been updated to reflect the altercation and any changes that were made to the plan of care. The Director of Nursing Services further stated that the care plan also should have been reviewed and updated after each Minimum Data Set assessment. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 5/15/2024 and completed on 5/23/2024, the facility did not ensure that each resident who needs respiratory care is provided such care consistent in accordance with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #210) of five residents reviewed for Respiratory Care. Specifically, Resident #210 had a Physician's order for oxygen to be administered at one liter per minute via nasal cannula. On three separate occasions, the resident was observed receiving oxygen at three liters per minute. The finding is: The facility's oxygen policy and procedure dated 7/2023 documented to check the physician's order for the rate of flow and type of mask used. The policy also documented adjusting the liter flow gauge as per the physician's order. The facility's Physician Order policy dated 6/2023 documented that physician's orders must be entered in the Electronic Medical Record by the medical staff. Nurses will review and confirm the new orders and obtain clarification as needed. Resident #210 was admitted to the facility with diagnoses that included Pulmonary Hypertension, Congestive Heart Failure, Non-Alzheimer's Dementia, and Atrial Fibrillation. The Admission Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 3, which indicated severely impaired cognition. Section O of the Minimum Data Set assessment documented the resident received continuous oxygen on admission and while a resident. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident received oxygen therapy while a resident. Resident #210 was observed lying in bed, awake and responsive, on 5/15/2024 at 11:20 AM. The resident was receiving oxygen from an oxygen concentrator at 3 liters per minute via a nasal cannula. A Physician's order dated 10/10/2023 and last reviewed on 5/2/2024 documented to administer oxygen at one liter per minute via a nasal cannula every shift for shortness of breath. Resident #210 was observed on 5/23/2024 at 8:53 AM. Resident #210 was lying in bed and was receiving oxygen from an oxygen concentrator at 3 liters per minute via nasal cannula. Resident #210 was observed on 5/23/2024 at 8:58 AM with Licensed Practical Nurse #3. Resident #210 was lying in bed and was receiving oxygen from an oxygen concentrator at 3 liters per minute via nasal cannula. Licensed Practical Nurse #3 confirmed that the oxygen flow rate was set at three liters per minute. A Comprehensive Care Plan dated 10/10/2023 and last updated on 2/29/2024 documented the resident has Congestive Heart Failure. Interventions including to check breath sounds; monitor and document labored breathing; monitor vital signs as per the Physician's order; and notify the Physician of significant abnormalities. There was no documented evidence of the resident's use of oxygen included in the care plan. A Comprehensive Care Plan initiated on 5/23/2024 documented altered Respiratory Status and difficulty breathing related to shortness of breath. Interventions included administering medication as ordered; nebulizer treatments and oxygen therapy as ordered and maintaining oxygen settings as per the Physician's order. During an interview with Licensed Practical Nurse #3, the medication nurse, on 5/23/2024 at 9:05 AM, a review of the resident's physician's order was conducted by Licensed Practical Nurse #3. The physician's order indicated to administer oxygen at one liter per minute. Licensed Practical Nurse #3 stated at the start of their shift, they checked on Resident #210 and observed that the resident was receiving oxygen at three liters per minute via nasal cannula. Licensed Practical Nurse #3 stated they did not check the physician's order. Licensed Practical Nurse #3 stated they should have checked the physician's order to ensure the resident was receiving oxygen at the flow rate ordered by the Physician. During an Interview on 5/23/2024 at 9:15 AM with Registered Nurse #2, they stated that Licensed Practical Nurse #3 should have verified the physician's order to ensure Resident #210 was receiving the correct oxygen flow rate as per the physician's order. Registered Nurse #2 stated that the resident should have been receiving oxygen at one liter per minute. During an interview with the Education Coordinator on 5/23/2024 at 10:10 AM, they stated nurses are expected to administer oxygen as per the physician's orders. If the resident required three liters of oxygen instead of one liter, then the nurses should have notified the physician and obtained a new order. The Education Coordinator stated that the nurses are in-serviced upon hire, annually, and as needed regarding checking and following the physician's orders. During an interview with the Director of Nursing Services on 5/23/2024 at 2:39 PM, the Director of Nursing Services stated that the nurses should have confirmed the physician's order when administering oxygen therapy. The Director of Nursing Services stated that if there was a concern with the oxygen flow rate, the nurses should have called the Physician, verified the order, and followed the physician's order as written. During an interview with Nurse Practitioner #1 on 5/23/2024 at 3:15 PM, they stated the nurses are expected to follow the physician's order as written; however, if there were concerns with the order the nurses should verify the order with the Physician or the Nurse Practitioners. 10 NYCRR 415.12(k)(6)

Based on observations, record review, and interviews during the Recertification Survey initiated on 5/15/2024 and completed on 5/23/2024 the facility did not ensure that all drugs were labeled and stored in accordance with professional standards including the expiration dates. This was identified for 1) one (medication cart on Unit 2) of thirteen medication carts observed during the medication storage task, and 2) one (Unit 4 medication room) of seven medication rooms reviewed for the medication storage task. Specifically, 1) On 5/22/2024, Unit 2's medication cart was observed with an expired Fluticasone inhaler. The label on the inhaler had Resident #371's name with an expiration date of 5/15/2024. 2) On 5/22/2024, Resident #350's 50 cubic centimeter bag of intravenous antibiotic solution (Normal Saline with 1 gram of Ceftriaxone) was observed in the medication room refrigerator with an expiration date of 5/20/2024. The findings are: The Facility's policy titled, Dispensing Medication, revised 7/20/2022 documented that manufacturer's expiration date and package insert expiration rules apply for medications that are dispensed in original manufacturer packaging and an auxiliary label is placed on the original packaging with the new expiration date. The manufacturer's packaging insert for the Fluticasone inhaler documented the inhaler is good for six weeks once opened. The insert package suggested writing the discard date on the label. 1) Resident #371 was admitted with diagnoses including Anemia, Acute Respiratory Failure, and Asthma. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating the resident had intact cognition. A Physician's order for Resident #371 dated 4/02/2024 documented to administer Fluticasone Furoate-Vilanterol Inhalation Aerosol powder breath activated 100-25 micrograms. One inhalation a day for Asthma. During the medication storage task with Licensed Practical Nurse #1 on Unit 2 South on 5/22/2024 at 11:56 AM, a Fluticasone inhaler was observed in the medication cart with an expiration date of 5/15/2024. The inhaler had a label with Resident #371's name. Licensed Practical Nurse #1 was interviewed on 5/22/2024 at 12:00 PM and stated the expired Fluticasone inhaler should not be stored in the medication cart. Licensed Practical Nurse #1 stated they would discard the expired inhaler and request a new Fluticasone inhaler for Resident #371 from the Pharmacy. Licensed Practical Nurse #1 stated the expiration date on the Fluticasone inhaler was 5/15/2024 and admitted to administering the inhaler medication to Resident #371 on 5/22/2024 from the expired inhaler. Licensed Practical Nurse #1 stated they should have checked the expiration date before administering the medication to the resident. The Assistant Pharmacy Director was interviewed on 5/22/2024 at 12:17 PM And stated the manufacturer's expiration date on the Fluticasone inhaler was 11/2025; however, the label added by the in-house Pharmacist indicated an expiration date that was 45 days from when the inhaler was first opened. The manufacturer requires that the inhaler be discarded 45 days after it was first opened. The Pharmacist had filled the medication order on 4/2/2024 when the resident was first admitted to the facility. The Pharmacy had only supplied one Fluticasone inhaler since the resident was first admitted to the facility which expired on 5/15/2024. The Chief Pharmacy Officer was interviewed on 5/22/2024 at 2:04 PM and stated when an inhaler is taken out of the original packaging, the inhaler should be discarded 45 days after opening as per the manufacturer because there of the potential contamination issue. The Chief Pharmacy Officer was re-interviewed on 5/23/2024 at 3:31 PM and stated the 4/02/2024 date on the label is when the Fluticasone inhaler was dispensed from the pharmacy to the nursing Unit. No other inhalers were dispensed for this resident after 4/2/2024 until 5/22/2024 when the expired inhaler was discovered. The Chief Nursing Officer was interviewed on 5/23/2024 at 2:38 PM and stated the medication nurse should have checked the expiration date before administration of the inhaler. The medication nurse should have discarded the medication and the resident should not have received the inhaler medication after the expiration date of 5/15/2024. 44925 2) The facility's policy titled Drug Storage revised on 1/12/2024 documented that nursing staff will check for pharmaceutical expiration dates and if expired, will return to the pharmacy for proper disposal or utilize the approved pharmaceutical waste disposal services. Resident #350 was admitted to the facility on [DATE] with diagnoses including Acute Pancreatitis, Cholangitis (an inflammation of the bile duct system), and Essential Hypertension. The Annual Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 11, indicating the resident had moderately impaired cognition. A Physician's order for Resident #350 dated 5/16/2024 documented Ceftriaxone Sodium Solution Reconstituted 1 gram; Use 1 gram intravenously every 24 hours for Urinary Tract Infection for seven Days from 5/16/2024 to 5/22/2024. On 5/22/2024 at 12:06 PM, Unit 4 North's medication storage room was observed with Licensed Practical Nurse #5. A bag containing 1 gram of Ceftriaxone Sodium Reconstituted Solution for intravenous use was observed in the medication storage refrigerator with an expiration date of 5/20/2024. Licensed Practical Nurse #5 stated they check for expired medication daily, but they did not notice the expired Ceftriaxone Sodium intravenous bag in the refrigerator. Licensed Practical Nurse #5 stated if they knew, they would have notified the Pharmacy to pick up the expired medication. Registered Nurse Manager #2 was interviewed on 5/23/2024 at 2:24 PM and stated that all nurses are responsible for removing expired medications from the medication storage room, including the refrigerator, and that the expired medications should not be stored in the unit refrigerator. The Assistant Pharmacy Director was interviewed on 5/22/2024 at 2:04 PM and stated that expired medications should not be in the medication room refrigerator. The Assistant Pharmacy Director stated they were not notified of an expired intravenous antibiotic medication bag on Unit 4 North. The Chief Nursing Officer was interviewed on 5/23/2024 at 3:00 PM and stated expired medications should not be stored in the refrigerator. The Chief Nursing Officer stated the facility has an in-house pharmacy in the building and always has medications available if needed. 10 NYCRR 415.18(e)(1-4)

Based on record review and staff interviews during the Recertification Survey and Abbreviated survey (NY 941 and NY 891) initiated on 8/15/2022 and completed on 8/22/2022, the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents. This was identified for 2 (Resident #394 and Resident #35) of 7 residents reviewed for Accidents . Specifically, 1) Resident #394 required bilateral Ankle-Foot Orthoses (AFO) and Darco shoes (special orthopedic shoes) and two-person assistance for transfers from one surface to another. On 9/8/2021 Certified Nursing Assistant (CNA) #3 transferred Resident #394 without using the AFO and the Darco shoes and without the assistance of a qualified staff member to transfer the resident from the wheelchair to the bed. Subsequently, Resident #394 twisted their knee and fell resulting in left tibia, fibula and ankle fractures. 2) Resident #35 had a Physician's Order for bilateral padded upper siderails when in bed. Resident #35 fell out of bed when their bed was replaced with another bed that did not have bilateral padded upper siderails. Subsequently, Resident #35 fell out of bed and sustained a laceration under the left eye; a hematoma to the right forearm and the left forehead; and skin tears to the right elbow and to the right thigh. This resulted in actual harm to Resident #394 that is not Immediate Jeopardy. The findings are: 1) Resident #394 was admitted with diagnoses including Arthritis, Difficulty in Walking, and Unspecified Fracture of the Fifth Lumbar Vertebrae. The 6/28/2021 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The MDS documented that the resident required extensive assistance of two staff members for transfers. The Physician History and Physical dated 6/24/2021 documented that the resident was admitted from the hospital with multiple fractures involving the lumbar spine and bilateral pelvis. A Comprehensive Care Plan (CCP) dated 7/1/2021 titled the resident has an ADL self-care performance deficit related to impaired balance, limited mobility, and multiple fractures, documented interventions including but not limited to transferring the resident as per the CNA tasks. The CCP did not provide specific directions related to assistance and devices required to transfer Resident #394 from one surface to another. A rehabilitation note dated 8/26/2021, written by a Physical Therapy Assistant and co-signed by a Physical Therapist, documented Resident #394 was issued bilateral AFOs to prevent knee buckling A rehabilitation note dated 8/26/2021, written by a Physical Therapy Assistant and co-signed by a Physical Therapist, documented Resident #394 requires a Lumbar Sacral Orthotic and bilateral AFOs and Darco (shoes) donned (put on) for all Out of Bed (OOB) activities. The resident no longer utilizing a Mechanical Lift. A physician's order dated 8/26/2021 documented bilateral ankle-foot orthoses (AFO) with bilateral Darco shoes when out of bed (OOB) and remove as needed for skin checks and hygiene. The Kardex Report (CNA task instructions-directions provided to CNAs how to provide care to the resident) as of 9/7/2021 documented to transfer Resident #394 with extensive assistance of two staff members, Thoracic-Lumbar-Sacral Orthosis (TLSO), and bilateral AFOs with Darco shoes. A nursing progress note written by Registered Nurse (RN) #1, unit RN, dated 9/8/2021 at 9:15 PM documented the writer (RN #1) was requested by the Resident Care Assistant (RCA) #1 at 5:15 PM to assist CNA #3 in Resident 394's room. Upon arrival the resident was noted crouched on CNA #3's knees with CNA #3's hands under the resident's arms. RN #1 and CNA #3 attempted to bring the resident up but were unable to do so. RN #1 and CNA #3 then lowered Resident #394 to the floor on the resident's buttocks and straightened the resident's legs out. Resident #394 complained of left lower extremity pain when the legs were being straightened out. The resident stated their leg was twisted when crouched down. The physician was made aware, and x-rays were ordered. X-ray results showed acute fracture of the medial malleolus (ankle) and distal fibula and tibia. The resident was transferred to the hospital [9/8/2021]. A Physician's order dated 9/8/2021 documented do not get Resident #394 out of bed until Lower Extremity x-ray results are done. Radiology Report Results dated 9/8/2021 documented acute fractures of the left distal tibia and fibula and acute fracture of left medial malleolus and lateral malleolus. A Physician's order dated 9/9/2021 [after return from hospital] documented Non-Weight Bearing (NWB) left lower extremity every shift. A nursing progress note dated 9/9/2021 documented Resident #394 returned from the hospital. Diagnoses included multiple fracture to left tibia, fibula, left bilateral malleolar ankle. Resident #394 returned with a soft cast and an ace wrap to the left lower extremity and was NWB to the left lower extremity and a knee immobilizer to the right lower extremity. An orthopedic consultation note dated 9/23/2021 documented Resident #394 sustained a left ankle fracture on 9/8/2021. The plan included to continue NWB status to the left ankle. A review of the Accident and Incident (A/I) report dated 9/8/2021 prepared by the Assistant Director of Nursing Services (ADNS)/Risk Manager documented after conducting interviews and performing re-enactments, it is unclear if CNA #3 used RCA #1 for the transfer. Despite all attempts CNA #3 and RCA #1 continued to have different accounts of the incident. Either way, the transfer was not done correctly. A written statement from CNA #3 in the 9/8/2021 A/I report documented CNA #3 asked the resident to allow them (CNA #3) to transfer the resident back to bed using a lift. Resident #394 used a walker and two people and did not want the lift; however, the resident wanted to go to bed because they (Resident #394) were tired. RCA #1 was in the room and CNA #3 asked RCA #1 for help transferring the resident. CNA #3 wrote that they (CNA #3) were not aware that the RCAs could not assist with transfers. As CNA #3 and RCA #1 stood the resident from their wheelchair, Resident #394 said their (Resident #394) knees started to buckle. The resident started to go down to the floor and RCA #1 then went to get the nurse. A written statement from RCA #1 in the 9/8/2021 A/I report documented RCA #1 and CNA #3 were in the resident's room. Resident #394 was insisting on being put back to bed. CNA #3 was going to use the Hoyer lift (mechanical lift) but the resident insisted they (Resident #394) can be transferred with a walker. CNA #3 pulled the resident's walker over and then asked RCA #1 to assist after the resident was already standing up. Resident #394 stated their legs were giving up. RCA #1 ran over and assisted CNA #3 to hold the resident up. Resident #394 started screaming that they (Resident #394) were going to fall. RCA #1 went to get the nurse. A written statement from Resident #394 in the 9/8/2021 A/I report documented CNA #3 and RCA #1 helped them (Resident #394) up from the wheelchair. When Resident #394 started to get up their knees started to buckle. Both the CNA and RCA were with me. The RCA could not help me, and the CNA could not help me alone. Resident #394 started to go down and their knees twisted and started to bend. Then they got the nurse and even though the nurse tried to help, [the nurse] could not help either. A written statement from the Assistant Director of Nursing Services (ADNS)/Risk Manager in the 9/8/2021 A/I report documented on 9/8/2021 at 5:15 PM Resident #394 asked CNA #3 to put the resident back to bed. In preparation for getting in bed, the resident had their (Resident #394) braces (AFOs) taken off and sneakers were put on at their (Resident #394) request. On re-enactment CNA #3 stated RCA #1 was in the room, so CNA #3 asked the RCA to assist with the transfer. RCA #1 stated they (RCA #1) were in the resident's room looking for a phone charger and did not assist with the transfer. RCA #1 explained that they (RCA #1) only went over to the resident to help break the fall. The Chief Nursing Officer was interviewed on 8/18/2022 at 11:00 AM and stated both CNA #3 and RCA #1 are no longer employed at the facility. There were multiple attempts made to contact both CNA #3 and RCA #1 without success. The RN Nursing Educator was interviewed on 8/18/2022 at 2:28 PM and stated CNAs are aware of what the RCAs can do and cannot do, and RCAs are aware of what they can do. The RN Nursing Educator stated CNAs are taught specifically what an RCA can do, which is in the CNA orientation manual. The RN Nursing Educator stated CNAs get copies of the CNA job description and the RCA job description and also verbal instructions of what the RCAs can do. The 2021 CNA Inservice Record documented that CNA #3 received inservice education on 8/9/2021 for Body Mechanics/Safe Patient Handling/Accident Prevention/Transfer Technique and on 8/10/2021 for following the plan of care and the CNA tasks in the Kardex. The facility's undated document, titled CNA Position Description, documented under the direction and supervision of a licensed nurse, provides high quality care to residents, as well as assists them with activities of daily living (ADLs), to ensure the residents attain and maintain their highest practicable well-being. CNA duties include assisting residents in and out of bed, chairs, and stretchers per the resident's plan of care. The facility's undated document, titled Daily Duties for Resident Care Assistants (RCA), documented No Transfers/No Toileting. The Rehabilitation Director was interviewed on 8/19/2022 at 9:55 AM and Resident #394's transfer should have been performed with the resident wearing the bilateral AFOs because the AFOs help with the transfer by stabilizing the resident's legs. The RN Nursing Educator was re-interviewed on 8/19/2022 at 11:27 AM and stated the AFOs should be removed after the resident is in bed because the AFOs are needed to stabilize the resident's feet. The Chief Nursing Officer was interviewed on 8/19/2022 at 11:57 AM and stated the transfer should be performed according to what the Kardex documents for the resident's transfer needs. The ADNS/Risk Manager was interviewed on 8/22/2022 at 2:15 PM and stated they (ADNS/Risk Manager) completed the investigation related to the incident with Resident #394 on 9/8/2021 and concluded that the AFOs were removed prior to the transfer talking to the staff involved, re-enacting the incident, and asking questions. CNA #3 told them (ADNS/Risk Manager) that the AFOs were removed prior to transferring Resident #394. The ADNS/Risk Manager stated that Resident #394 had bilateral artificial hip and knee joints and was morbidly obese. According to the 8/26/2021 rehabilitation department progress note, the AFOs were issued to prevent knee buckling. The Medical Director was interviewed on 8/22/2022 at 3:05 PM and stated removing the AFOs prior to the transfer if they were required for out of bed activities to prevent knee buckling would be a contributing factor to the fall. 2) Resident #35 has diagnoses which include [CONDITION(S)] and Depression. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had severely impaired cognitive skills for daily decision making. The resident was totally dependent on two persons for bed mobility, transfers, and toilet use. The Physician's Order dated 12/7/2020 documented bilateral padded upper side rails while in bed every shift. The Authorization for Use of Side Rails form dated 12/7/2020 documented rationale for Resident #35's siderail use was bed boundaries due to impaired vision ([CONDITION(S)]). The Certified Nursing Assistant Task assignment last revised 12/7/2020 documented under the standard task: Safety-Side rails-Padded Up in Bed for bed boundaries due to being legally blind. The Comprehensive Care Plan (CCP) entitled: The resident has an Activities of Daily Living (ADL) self-care performance deficit related to (r/t) impaired mobility and Terminal Dementia was initiated on 10/3/2020. The CCP was updated on 12/8/2020 to include bilateral padded side rails when in bed due to restlessness, confusion, and resident does not recognize bed boundaries. The CCP entitled: The resident has impaired visual function r/t [CONDITION(S)] and being legally blind was initiated on 12/7/2020. The CCP was updated on 4/19/2021 to include bilateral padded upper side rails for safety due to being legally blind. The Physical Therapy (PT) Discharge Summary dated 12/24/2020 documented that the resident was dependent for bed mobility and transfers. The Incident Review Quality Assurance Form (Accident/Incident form) dated 6/8/2021 documented that at 3:15 AM, the resident was found lying on the floor, on the right side of the bed, on their right side. The resident was noted with a moderate amount of bleeding to a right forearm hematoma. There was a hematoma to the resident's left forehead with a laceration under the left eye measuring 2.0 centimeters (cm) by (x) 0.5 cm. There was a bump noted to the back of the right side of the resident's head. There was a right elbow skin tear measuring 2.0 cm x 2.0 cm and a right thigh skin tear measuring 1.5 cm x 0.5 cm. The Investigative Summary dated 6/15/2021 documented that on 6/3/2021 the nurse was notified that another resident needed a wide bed. Resident #35's wide bed that had the bilateral padded upper side rails was exchanged for a regular sized bed that did not have the bilateral padded upper side rails in place. The Certified Nursing Assistant (CNA), caring for Resident #35, did not put up the half side rails because the regular bed had none. The Director of Rehabilitation was interviewed on 8/17/2022 at 3:45 PM and stated that the resident's last PT assessment before the fall from bed on 6/8/2021 documented that they (Resident #35) were dependent on two staff members for bed mobility and transferred with a mechanical lift. The Maintenance Mechanic who exchanged the two beds on 6/3/2021 was interviewed on 8/19/2022 at 10:25 AM and stated that moving beds was common and happens weekly. The Maintenance Mechanic stated that a Nurse will tell them (Maintenance Mechanic) where to find the bed needed and switch it with another bed. The Maintenance Mechanic stated that the resident is taken out of the bed, both beds are cleaned by Housekeeping, and then they (Maintenance Mechanic) do the actual move. The Maintenance Mechanic stated that the Nurses tells them (Maintenance Mechanic) if a bed needs side rails because most beds do not have side rails. The Maintenance Mechanic stated that they (Maintenance Mechanic) do not add or take off the side rails unless they are told to by Nursing. The Maintenance Mechanic stated that they (Maintenance Mechanic) do not look if the beds have side rails or not when they (Maintenance Mechanic) move them. The Maintenance Mechanic stated that they (Maintenance Mechanic) tell the Nurse after the move is complete. The Director of Nursing Services (DNS) was interviewed on 8/19/2022 at 1:45 PM and stated that during the facility's investigation it was found that the resident's plan of care was not followed because the regular sized bed that the resident received did not have side rails. The DNS further stated that the side rails could have prevented the resident's fall. 415.12(h)(1)

Based on observation, record review, and staff interviews during the Post Survey Revisit (PSR) conducted on 10/21/2022, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents reviewed for tracheostomy care. Specifically, during observation of tracheostomy care for Resident #1, who was on Contact and Droplet precautions due to Carbapenem-resistant Enterobacterales (CRE) in sputum and Extended Spectrum Beta-Lactamase (ESBL) infection in the urine, Respiratory Therapist (RT) # 1 did not utilize appropriate Personal Protective Equipment (PPE); did not follow infection control protocols while changing the tracheostomy inner cannula; and did not wash their (RT #1) hands during the procedure. The finding is: The Tracheostomy Care and Documentation Policy dated 8/96 and last revised on 9/2022 documented procedures that included but were not limited to: wash hands, don (put on) gloves and any other PPE that may be appropriate, mask and goggles if risk of splashing. Remove disposable inner cannula and discard. Insert sterile disposable inner cannula make sure it snaps into place. The Handwashing/Hand Hygiene Technique Policy dated March 2013 documented handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections. The indications for antiseptic Handwashing included but were not limited to when providing resident care which involved bloody or body fluids, bodily excretion, and secretions. The Transmission Based Precaution Policy dated 7/15/2022 documented for residents on Contact Precautions the healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. For residents on Droplet Precautions if there is a risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield) should be worn. The Personal Protective Equipment Policy dated 8/2021 documented to perform hand hygiene before donning gloves and after glove removal. The policy further documented that glove are not substitute for hand hygiene. The policy included gowns are to be worn to protect arms, exposed body areas and clothing from contamination with blood, body fluids, and other potentially infectious material. Indication/consideration for PPE use of gloves included but were not limited to: perform hand hygiene before donning gloves and after removal; gloves are not a substitute for hand hygiene; and change gloves and preform hand hygiene between clean and dirty tasks. Resident #1 was readmitted with diagnoses of Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease with Acute Lower Respiratory infection, and Quadriplegia. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderately impaired cognition. The MDS documented that the resident was ventilator dependent, required oxygen therapy, suctioning and tracheostomy care. The Physician's orders dated 10/17/2022 documented the resident was on Contact/Droplet precautions secondary to CRE in the sputum and ESBL in the urine. Change disposable tracheostomy inner cannula every shift and as needed for hygiene. The Comprehensive Care Plan (CCP) for Multi Drug Resistant Organisms (MDRO) colonization, Pseudomonas aeruginosa, (Carbapenem Resistant) CRE in the sputum, and ESBL in the urine dated 8/31/2021 and last revised on 7/29/2022 documented Resident #1 was on standard and contact precautions effective 8/31/2021. Resident #1's care equipment be appropriately cleaned, disinfected, or sterilized according to facility protocol. The CCP for tracheostomy for Impaired breathing mechanics, respiratory failure, vent dependence dated 5/06/2022 documented to provide tracheostomy care daily and as needed. Resident #1, who was ventilator dependent, was observed for tracheostomy care on 10/21/2022 at 10:40 AM. There was signage outside the resident's room with instructions Stop see the nurse for appropriate PPE use. RT #1 was wearing a face mask and eye protection; however, was not wearing a gown. RT #1 was observed donning a pair of disposable gloves without washing their hands before donning the gloves. RT #1 pulled Resident #1's privacy curtain around the resident's bed to provide privacy. RT #1 removed water cups, napkins, and pieces of gauze from the over-the-bed table then proceeded to clean Resident's #1 chest area. RT #1 set up the sterile field on the over-the-bed table to replace the resident's tracheostomy inner cannula wearing the same gloves. RT #1 then opened a sterile glove packet while wearing the same disposable gloves. While wearing the same disposable gloves RT #1 was observed inserting their right-hand pointer, middle and ring fingers into the sterile glove as a second layer. RT #1 did not remove their soiled gloves and did not wash their hands before they opened and utilized the sterile glove. RT #1 was observed removing the tracheostomy inner cannula with the right hand three fingers and then replaced the sterile inner cannula with their right hand while stabilizing the surrounding area with the left hand. RT #1 was interviewed on 10/21/2022 at 10:50 AM and stated that they do not remove their soiled gloves before they apply sterile gloves for any procedure. RT #1 stated they will not remove their used gloves and wash their hands before they open a sterile glove packet to apply the sterile gloves, since this was their routine practice. RT #1 stated there was no reason to remove the soiled gloves and wash their hands and that touching surfaces will not make the gloves soiled. RT #1 stated they did not use a disposable gown because Resident #1 did not have any infection control concerns. RT #1 stated they did not notice the stop see the nurse for appropriate PPE use sign that was posted outside the resident's room. RT #1 stated they were educated on the importance of washing their hands and using the correct technique to apply the sterile gloves; however, could not recall when they received the training. RT#1 stated that if we do not use the appropriate glove technique, the resident can get an infection because of germs on the gloves. RT #2 was interviewed on 10/21/2022 at 11:10 AM and stated that they overheard RT #1's sterile glove usage technique while they (RT#2) were outside Resident #1's room. RT #2 stated RT #1 was supposed to remove their soiled gloves and wash their hands before they applied the sterile gloves to change Resident #1's inner cannula. The Director of Respiratory Therapy was interviewed on 10/21/2022 on 2:00 PM and stated that RT #1 should have taken their soiled gloves off and washed their hands before applying the sterile gloves to complete the inner cannula change task. The Director of Respiratory Therapy stated that RT #1 put Resident #1 at risk of contracting bacteria, since RT #1 had not used proper technique for changing the inner cannula. The Infection Control Nurse, who is also the Director of Nursing Services (DNS), was interviewed on 10/21/2022 at 2:30 PM and stated that they educated RT #1 upon hire and periodically regarding hand washing and proper use of gloves. The DNS stated RT #1 failed to remove their soiled gloves prior to wearing sterile gloves. The DNS stated Resident#1 had an infection in the sputum and RT #1 put the resident at risk for further infection. RT#1's sterile glove technique was not acceptable. The DNS further stated that RT#1 should have worn a disposable gown while providing care to Resident #1 since the resident was on contact and droplet precautions. 415.19 (a)(1-3); 415.19(b)(4)

Based on record review and staff interviews during the Recertification survey and Abbreviated Survey (NY 250) initiated on 8/15/2022 and completed on 8/22/2022, the facility did not ensure that each resident is treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. This was identified for one (Resident #489) of two residents reviewed for dignity. Specifically, on 11/9/2021 Resident #489 refused a scheduled shower. Resident #489's right to refuse the shower was not honored; and the staff administered the shower even though the resident refused to be showered. The finding is: The facility's policy for Resident Rights dated 11/2016 documented the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The policy documented the facility must ensure that the resident can exercise his/her rights without interference, coercion, discrimination, or reprisal from the facility. The policy also documented the resident has the right to refuse and/or discontinue medications and treatments and have the right to be treated with dignity and respect. Resident #489 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 12 which indicated moderate cognitive impairment. The resident required extensive assistance of one staff for bathing and did not reject care. A Comprehensive Care Plan (CCP) dated 12/13/2020 documented the resident had Activities of Daily Living (ADL) selfcare performance deficit related to a Stroke and Dementia. Interventions included bathing/showering as per the Certified Nursing Assistant (CNA) task. The CCP did not include shower days and the nursing shift that the resident was to be showered. The Certified Nursing Assistant (CNA) accountability record dated 11/2021 documented the resident required extensive assist of one staff member for bathing and receives showers on the 7:00-3:00 shift. An Active Incident report dated 11/9/2021 documented that on 11/9/2021 at approximately 10:30 AM Certified Nursing Assistant (CNA) #6 and CNA #7(student) informed Resident #489 that a shower would be provided. CNA #6 told the resident that they (Resident #489) refused the previous showers and today they (Resident #489) really needed to take a shower. The resident started to yell and then screamed rape rape while they (Resident #489) were fully dressed and in the hallway. When the resident was taken to a shower room, CNA#6 began undressing the resident and identified that there was no hot water. CNA #6 then wrapped Resident #489 in a sheet and with CNA #7 (student) transported the resident to another shower room. While being transported to another shower room Resident #489 again began yelling and screaming rape; however, stopped yelling when the shower began with warm water. The untitled Incident report summary dated 11/12/2021, written by Assistant Director of Nursing Services (ADNS), documented Resident #489 was interviewed by the ADNS and stated, I did not want a shower, it was rough. when questioned what that meant, Resident #489 repeated I did not want a shower. The resident stated no one raped them. CNA #6, who was assigned to Resident #489 on 11/9/2021, was interviewed on 8/18/2022 at 2:42 PM. CNA #6 stated Resident #489 was scheduled for a shower on 11/9/2021. When CNA #6 took the resident to the shower room with another CNA (CNA #7), the water in the shower room was not hot and CNA #6 took Resident #489 to a different shower room. During transport to the other shower room Resident #489 began yelling rape, leave me alone I don't want a shower, rape rape. CNA #6 stated when the resident stated they (Resident #489) did not want a shower, they (CNA #6) were supposed to stop and not give the shower; however, CNA #6 continued to provide the shower to the resident because a student was with them (CNA #6). CNA #6 stated they had to teach the student CNA #7 what to do. CNA #6 stated Resident #489 refused the previous three showers, and they (CNA #6) did not want to get blamed for not providing a shower to the resident. CNA #7 (student) was interviewed on 8/18/2022 at 3:20 PM and stated they were assigned to shadow CNA #6 and was assisting with performing care. CNA #7 (student) stated when they (CNA #6 and CNA #7/student) got to Resident #489 CNA #6 explained to the resident it was their (Resident #489's) shower day and that they (Resident #489) were getting a shower. CNA #7 (student) stated that the resident adamantly refused to be showered. CNA #7 (student) stated that CNA #6 explained to the resident that they had refused several showers prior and that they (Resident #489) had to take the shower. CNA #7 (student) stated that the resident began cursing at CNA #6 and stated they (Resident #489) did not want a shower. CNA #7 (student) stated CNA #6 explained to them (CNA #7) that the resident had to take the shower because they (Resident #489) had not taken a shower in days. The Licensed Practical Nurse (LPN) #2, who was the LPN for Resident #489 on the 7:00 AM - 3:00 PM shift on 11/9/2021, was interviewed on 8/19/2022 at 4:15 PM. LPN #2 stated that Resident #489 has refused showers on multiple occasions and the CNAs know not to force the resident to take a shower. LPN #2 stated that CNA #6 did not report to them (LPN #2) that Resident #489 refused their shower on 11/9/2021. LPN #2 further stated that they did not hear the resident screaming and yelling during transport to the shower room. The Chief Nursing Officer was interviewed on 8/22/2022 at 2:06 PM and stated they were not directly involved with the investigation of this incident; however, if a resident is refusing to be showered and is visibly upset the expectation is that the CNA should stop and report to the nurse that the resident refused to be showered. ADNS #1 was interviewed on 8/22/2022 at 2:40 PM. ADNS #1 stated that due to allegation of rape, police were involved. Resident #489 reported to the Police Officer that they (Resident #489) were not raped and that they (Resident #489) just did not want to take a shower. ADNS #1 stated if the resident did not want to take the shower that the staff should have re-approached the resident. Additionally, ADNS #1 stated that the expectation is that CNA #6 should not have continued to give the resident a shower when the resident refused and should have stopped and re-approached the resident. 415.3(c)(1)(i)

Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY 250) initiated on 8/15/2022 and completed on 8/22/2022, the facility did not ensure that each resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. This was identified for one (Resident #489) of one resident reviewed for choices. Specifically, on 11/9/2021 Resident #489 refused a scheduled shower and the staff administered the shower even though the resident refused to be showered. The finding is: The facility Bathing/Personal Care Policy dated 10/2008 documented if the resident refuses the bath/shower, the nurse is to be notified. This is to be noted by the nurse in a quick note in the electronic medical record (EMR). Resident #489 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score as 12 which indicated moderate cognitive impairment. The MDS indicated Resident # 489 required extensive assistance of one staff member for bathing and did not reject care. A Comprehensive Care Plan (CCP) dated 12/13/2020 documented the resident had Activities of Daily Living (ADL) selfcare performance deficit related to a Stroke and Dementia. Interventions included bathing/showering as per the Certified Nursing Assistant (CNA) task. The CCP did not include shower days and what nursing shift the resident was to be showered. The CNA accountability record dated 11/2021 documented the resident required extensive assist of one staff member for bathing and receives showers on the 7:00-3:00 shift. An Active Incident report dated 11/9/2021 documented that on 11/9/2021 at approximately 10:30 AM Certified Nursing Assistant (CNA) #6 and CNA #7(student) informed Resident #489 that a shower would be provided. CNA #6 told the resident that they (Resident #489) refused the previous showers and today they (Resident #489) really needed to take a shower. The resident started to yell and then screamed rape rape while they (Resident #489) were fully dressed and in the hallway. When the resident was taken to a shower room, CNA #6 began undressing the resident and identified that there was no hot water. CNA #6 then wrapped Resident #489 in a sheet and with CNA #7 (student) transported the resident to another shower room. While being transported to another shower room Resident #489 again began yelling and screaming rape; however, stopped yelling when the shower began with warm water. The untitled Incident report summary dated 11/12/2021, written by Assistant Director of Nursing Services (ADNS), documented Resident #489 was interviewed by the ADNS and stated, I did not want a shower, it was rough. when questioned what that meant, Resident #489 repeated I did not want a shower. The resident stated no one raped them. CNA #6, who was assigned to Resident #489 on 11/9/2021, was interviewed on 8/18/2022 at 2:42 PM. CNA #6 stated Resident #489 was scheduled for a shower on 11/9/2021. When CNA #6 took the resident to the shower room with another CNA (CNA #7), the water in the shower room was not hot and CNA #6 took Resident #489 to a different shower room. During transport to the other shower room Resident #489 began yelling rape, leave me alone I don't want a shower, rape rape. CNA #6 stated when the resident stated they (Resident #489) did not want a shower, they (CNA #6) were supposed to stop and not give the shower; however, CNA #6 continued to provide the shower to the resident because a student was with them (CNA #6). CNA #6 stated they had to teach the student (CNA #7) what to do. CNA #6 stated Resident #489 refused the previous three showers, and they (CNA #6) did not want to get blamed for not providing a shower to the resident. CNA #7 (student) was interviewed on 8/18/2022 at 3:20 PM and stated they were assigned to shadow CNA #6 and was assisting with performing care. CNA #7 (student) stated when they (CNA #6 and CNA #7/student) got to Resident #489 CNA #6 explained to the resident it was their (Resident #489's) shower day and that they (Resident #489) were getting a shower. CNA #7 (student) stated that the resident adamantly refused to be showered. CNA #7 (student) stated that CNA #6 explained to the resident that they had refused several showers prior and that they (Resident #489) had to take the shower. CNA #7 (student) stated that the resident began cursing at CNA #6 and stated they (Resident #489) did not want a shower. CNA #7 (student) stated CNA #6 explained to them (CNA #7) that the resident had to take the shower because they (Resident #489) had not taken a shower in days. The Licensed Practical Nurse (LPN) #2, who was the LPN for Resident #489 on the 7:00 AM - 3:00 PM shift on 11/9/2021, was interviewed on 8/19/2022 at 4:15 PM. LPN #2 stated that Resident #489 has refused showers on multiple occasions and the CNAs know not to force the resident to take a shower. LPN #2 stated that CNA #6 did not report to them (LPN #2) that Resident #489 refused their shower on 11/9/2021. LPN #2 further stated that they did not hear the resident screaming and yelling during transport to the shower room. The Chief Nursing Officer was interviewed on 8/22/2022 at 2:06 PM and stated they were not directly involved with the investigation of this incident; however, if a resident is refusing to be showered and is visibly upset the expectation is that the CNA should stop and report to the nurse that the resident refused to be showered. ADNS #1 was interviewed on 8/22/2022 at 2:40 PM. ADNS #1 stated that due to allegation of rape, police were involved. Resident #489 reported to the Police Officer that they (Resident #489) were not raped and that they (Resident #489) just did not want to take a shower. ADNS #1 stated if the resident did not want to take the shower that the staff should have re-approached the resident. Additionally, ADNS #1 stated that the expectation is that CNA #6 should not have continued to give the resident a shower when the resident refused and should have stopped and re-approached the resident. 415.5(b)(1-3)

Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 891) initiated on 8/15/2022 and completed on 8/22/2022, the facility did not report an alleged violation related to an injury that resulted from not following the resident's plan of care to the New York State Department of Health (NYSDOH) within the required 24 hours. This was identified for one (Resident #35) of six residents reviewed for Accidents. Specifically, Resident #35 fell from their bed on 6/8/2021 which resulted in an injury, however the facility did not report the injury to the NYSDOH until 6/15/2021. The finding is: The facility's policy and procedure entitled Free From Abuse and Neglect dated 9/2017 documented: One element is needed for an incident of neglect to be reported to DOH: a) Failure to follow care plan with injury, (even just once, remember pain is an injury); or b) Repeated failure to follow care pan, with or without injury; or c) Failure to provide timely, consistent, safe, adequate and appropriate services. Resident #35 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had severely impaired cognitive skills for daily decision making. The resident was totally dependent on two persons for bed mobility, transfers. and toilet use and totally dependent on one person for locomotion on the unit, dressing, eating, personal hygiene, and bathing. The Authorization For Use of Side Rails from dated 12/7/2020 documented that the resident's son agreed for the use of side rails for Resident #35 for bed boundaries due to impaired vision ([CONDITION(S)]). The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Comprehensive Care Plan (CCP) entitled: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) impaired mobility and Terminal Dementia was initiated on 10/3/2020. An intervention initiated on this CCP on 12/8/2020 documented bilateral padded side rails when in bed due to restlessness, confusion, and resident does not recognize bed boundaries. The CCP entitled: The resident has impaired visual function r/t [CONDITION(S)] and being legally blind was initiated on 12/7/2020. An intervention initiated on this CCP on 4/19/2021 documented bilateral padded upper side rails for safety due to being legally blind. The Incident Review Quality Assurance Form dated 6/8/2021 documented that at 3:15 AM, the resident was found lying on the floor, on the right side of the bed, on their right side. The resident was noted with a moderate amount of bleeding to a right forearm hematoma. There was a hematoma to the resident's left forehead with a laceration under the left eye measuring 2.0 cm (centimeters) x (by) 0.5 cm. There was a bump noted to the back of the right side of the resident's head. There was a right elbow skin tear measuring 2.0 cm x 2.0 cm and a right thigh skin tear measuring 1.5 cm x 0.5 cm. The Investigative Summary dated 6/15/2021 documented that on 6/3/2021 the Nurse was notified that a peer needed a wide bed. Resident #35's wide bed was exchanged for a regular sized bed so the peer could be in an appropriate bed, however Resident #35's wide bed had half side rails and the regular bed it was exchanged for, did not. The Certified Nursing Assistant (CNA) (caring for Resident #35) did not put up the half side rails because the regular bed had none. The Director of Nursing Services (DNS) was interviewed on 8/19/2022 at 1:45 PM and stated that during the facility's investigation it was found that the resident's plan of care was not followed because the regular sized bed that the resident received did not have side rails. The DNS stated that if the plan of care is not followed, the incident should be called into the NYSDOH within 24 hours. 415.4(b)(2)

Based on observation, record review, and interviews conducted during the Recertification survey, initiated on 8/15/2022 and completed on 8/22/2022, the facility did not ensure residents who need respiratory care, including [CONDITION(S)] care, are provided such care consistent with professional standards of practice and the Comprehensive Person-Centered Care Plan. This was evident for one (Resident #88) of five residents reviewed for respiratory care. Specifically, Resident #88 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of the [CONDITION(S)] care on 8/17/2022, Resident #88 was observed without a disposable inner cannula in place. The finding is: The facility Policy and Procedure dated 8/1996, and last updated on 8/17/2022 for [CONDITION(S)] care documented: Purpose for the care of the inner cannula is to maintain resident's airway and to keep the area around the [CONDITION(S)] tube clean. The procedure for the inner cannula care includes to replace the inner cannula daily by the day shift. The inner cannula should be assessed every shift. Resident # 88 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident receives [CONDITION(S)] care and is on a respiratory ventilator. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] # 8 disposable inner cannula one time a day for hygiene. During a [CONDITION(S)] care observation on 8/17/2022 at 2:43 PM, Respiratory Therapist (RT) # 3 provided the treatment to Resident # 88. Resident # 88 was observed without a disposable inner cannula. RT #3 inserted a new [MEDICATION(S)] # 8 disposable inner cannula. The RT #3 could not explain why the resident did not have a disposable inner cannula in place at the time of the treatment. RT #3 further stated the resident should always have an inner cannula in place. The current Comprehensive Care Plan (CCP) dated 6/7/2022 documented Resident #88 had a [CONDITION(S)] related to Impaired breathing mechanics. Interventions included to provide [CONDITION(S)] care daily and as needed (PRN). Monitor [CONDITION(S)] site for any abnormalities. The Treatment Administration Record documented that RT # 2 provided [CONDITION(S)] care including changing the disposable inner cannula on 8/17/2022 during the day shift. RT #1 provided [CONDITION(S)] care and changed the disposable inner cannula on 8/16/2022. RT # 2 was interviewed on 8/17/2022 at 3:15 PM and stated that they (RT #2) did not change the disposable inner cannula on 8/17/2022 earlier in the day and did not know why they (RT #2) signed the TAR indicating that they (RT #2) changed the resident's disposable inner cannula. RT #2 further stated they (RT #2) only cleaned around the [CONDITION(S)] tube. RT # 1 was interviewed on 8/22/2022 at 1 PM and stated that they (RT #1) performed [CONDITION(S)] care on August 16, 2022 and stated they (RT #1) inserted the new disposable inner cannula after removing the old disposable inner cannula. RT #1 stated they (RT #1) would never leave a resident without a disposable inner cannula. The Registered Nurse (RN) Educator was interviewed on 8/17/2022 at 3:30 PM and stated disposable inner cannula should be in place for hygienic purposes. If the disposable inner cannula is not present, it can compromise the [CONDITION(S)] tube. The disposable inner cannula can be pulled out when a [MEDICATION(S)] plug develops or when there are thick secretions. The Director of Respiratory Therapy was interviewed on 8/17/2022 at 4:45 PM and stated Resident # 88 has a [CONDITION(S)] tube that should always have an inner cannula. The [CONDITION(S)] tube is replaced once every 56 days as per the facility policy. If the inner cannula is not in place, the [CONDITION(S)] tube may have to be replaced more frequently than 56 days. The inner cannula may have a buildup of secretions and/or [MEDICATION(S)] plugs. The inner cannula should be changed on a daily basis or as needed and should always be in place. 415.12(k)(6)

Based on observation, record review, and staff interviews during the Post Survey Revisit (PSR) conducted on 10/21/2022, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents reviewed for tracheostomy care. Specifically, during observation of tracheostomy care for Resident #1, who was on Contact and Droplet precautions due to Carbapenem-resistant Enterobacterales (CRE) in sputum and Extended Spectrum Beta-Lactamase (ESBL) infection in the urine, Respiratory Therapist (RT) # 1 did not utilize appropriate Personal Protective Equipment (PPE); did not follow infection control protocols while changing the tracheostomy inner cannula; and did not wash their (RT #1) hands during the procedure. The finding is: The Tracheostomy Care and Documentation Policy dated 8/96 and last revised on 9/2022 documented procedures that included but were not limited to: wash hands, don (put on) gloves and any other PPE that may be appropriate, mask and goggles if risk of splashing. Remove disposable inner cannula and discard. Insert sterile disposable inner cannula make sure it snaps into place. The Handwashing/Hand Hygiene Technique Policy dated March 2013 documented handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections. The indications for antiseptic Handwashing included but were not limited to when providing resident care which involved bloody or body fluids, bodily excretion, and secretions. The Transmission Based Precaution Policy dated 7/15/2022 documented for residents on Contact Precautions the healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. For residents on Droplet Precautions if there is a risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield) should be worn. The Personal Protective Equipment Policy dated 8/2021 documented to perform hand hygiene before donning gloves and after glove removal. The policy further documented that glove are not substitute for hand hygiene. The policy included gowns are to be worn to protect arms, exposed body areas and clothing from contamination with blood, body fluids, and other potentially infectious material. Indication/consideration for PPE use of gloves included but were not limited to: perform hand hygiene before donning gloves and after removal; gloves are not a substitute for hand hygiene; and change gloves and preform hand hygiene between clean and dirty tasks. Resident #1 was readmitted with diagnoses of Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease with Acute Lower Respiratory infection, and Quadriplegia. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderately impaired cognition. The MDS documented that the resident was ventilator dependent, required oxygen therapy, suctioning and tracheostomy care. The Physician's orders dated 10/17/2022 documented the resident was on Contact/Droplet precautions secondary to CRE in the sputum and ESBL in the urine. Change disposable tracheostomy inner cannula every shift and as needed for hygiene. The Comprehensive Care Plan (CCP) for Multi Drug Resistant Organisms (MDRO) colonization, Pseudomonas aeruginosa, (Carbapenem Resistant) CRE in the sputum, and ESBL in the urine dated 8/31/2021 and last revised on 7/29/2022 documented Resident #1 was on standard and contact precautions effective 8/31/2021. Resident #1's care equipment be appropriately cleaned, disinfected, or sterilized according to facility protocol. The CCP for tracheostomy for Impaired breathing mechanics, respiratory failure, vent dependence dated 5/06/2022 documented to provide tracheostomy care daily and as needed. Resident #1, who was ventilator dependent, was observed for tracheostomy care on 10/21/2022 at 10:40 AM. There was signage outside the resident's room with instructions Stop see the nurse for appropriate PPE use. RT #1 was wearing a face mask and eye protection; however, was not wearing a gown. RT #1 was observed donning a pair of disposable gloves without washing their hands before donning the gloves. RT #1 pulled Resident #1's privacy curtain around the resident's bed to provide privacy. RT #1 removed water cups, napkins, and pieces of gauze from the over-the-bed table then proceeded to clean Resident's #1 chest area. RT #1 set up the sterile field on the over-the-bed table to replace the resident's tracheostomy inner cannula wearing the same gloves. RT #1 then opened a sterile glove packet while wearing the same disposable gloves. While wearing the same disposable gloves RT #1 was observed inserting their right-hand pointer, middle and ring fingers into the sterile glove as a second layer. RT #1 did not remove their soiled gloves and did not wash their hands before they opened and utilized the sterile glove. RT #1 was observed removing the tracheostomy inner cannula with the right hand three fingers and then replaced the sterile inner cannula with their right hand while stabilizing the surrounding area with the left hand. RT #1 was interviewed on 10/21/2022 at 10:50 AM and stated that they do not remove their soiled gloves before they apply sterile gloves for any procedure. RT #1 stated they will not remove their used gloves and wash their hands before they open a sterile glove packet to apply the sterile gloves, since this was their routine practice. RT #1 stated there was no reason to remove the soiled gloves and wash their hands and that touching surfaces will not make the gloves soiled. RT #1 stated they did not use a disposable gown because Resident #1 did not have any infection control concerns. RT #1 stated they did not notice the stop see the nurse for appropriate PPE use sign that was posted outside the resident's room. RT #1 stated they were educated on the importance of washing their hands and using the correct technique to apply the sterile gloves; however, could not recall when they received the training. RT#1 stated that if we do not use the appropriate glove technique, the resident can get an infection because of germs on the gloves. RT #2 was interviewed on 10/21/2022 at 11:10 AM and stated that they overheard RT #1's sterile glove usage technique while they (RT#2) were outside Resident #1's room. RT #2 stated RT #1 was supposed to remove their soiled gloves and wash their hands before they applied the sterile gloves to change Resident #1's inner cannula. The Director of Respiratory Therapy was interviewed on 10/21/2022 on 2:00 PM and stated that RT #1 should have taken their soiled gloves off and washed their hands before applying the sterile gloves to complete the inner cannula change task. The Director of Respiratory Therapy stated that RT #1 put Resident #1 at risk of contracting bacteria, since RT #1 had not used proper technique for changing the inner cannula. The Infection Control Nurse, who is also the Director of Nursing Services (DNS), was interviewed on 10/21/2022 at 2:30 PM and stated that they educated RT #1 upon hire and periodically regarding hand washing and proper use of gloves. The DNS stated RT #1 failed to remove their soiled gloves prior to wearing sterile gloves. The DNS stated Resident#1 had an infection in the sputum and RT #1 put the resident at risk for further infection. RT#1's sterile glove technique was not acceptable. The DNS further stated that RT#1 should have worn a disposable gown while providing care to Resident #1 since the resident was on contact and droplet precautions. 415.19 (a)(1-3); 415.19(b)(4)

Based on record review and interviews during a COVID-19 Focused Infection Control Survey conducted on 2/24/2021, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of COVID-19. Specifically, the facility did not follow the New York State Governor's Executive Order (EO) 202.88 regarding staff COVID-19 testing requirements, insofar as a per-diem Certified Nursing Assistant (CNA #1) was not tested at least weekly as directed by the EO and related Department of Health directives. The finding is: Executive Order (202.88) dated 01/04/2021, Continuing Temporary Suspension and Modification of Laws Relating to the Disaster Emergency documented: The directive contained in Executive Order 202.73 which modified Executive Orders 202.30, and 202.40, requiring testing of nursing home staff as directed by the Commissioner of Health is hereby modified to authorize the Commissioner of Health to set forth testing of all personnel at such facility in any area of the state irrespective of location in a micro-cluster zone as provided in 202.68. The New York State Department of Health (NYSDOH) Dear Administrator Letter, NH-21-01, titled Nursing Home Staff Testing Requirements, dated 1/7/21, documented: Operators and administrators of all nursing homes are required to test or arrange for the testing of all personnel, including all employees, contract staff, medical staff, operators and administrators, for COVID-19 twice per week in all nursing homes. NYSDOH guidance Executive Order 202.30 - Nursing Home and Adult Care Facility Staff Testing Requirement FAQ Update - June 24, 2020, provided that staff who work at a facility three days per week or less only need to be tested on ce a week. The facility's policy dated February 2021, titled [MEDICAL CONDITION] Testing of Residents/Employees for [DIAGNOSES REDACTED]-CoV-2 with an Outbreak, documented to continue repeat [MEDICAL CONDITION] testing of all previously negative Health Care Personnel, generally between every 3-7 days, until the testing identifies no new cases of [DIAGNOSES REDACTED]-CoV-2 infection among residents or health care personnel for a period of at least 14 days since the most recent positive result. The facility's COVID-19 resident roster for 2/12/21 revealed that there were 16 COVID-19 positive residents in the facility. CNA #1's Time and Attendance payroll record revealed that CNA #1 worked on 2/5/2021 from 9:17 AM-12:26 PM and on 2/12/2021 from 8:29 AM-10:30 AM. CNA #1 had a polymerase chain reaction (PCR) COVID-19 test collected on 2/5/2021, which returned negative on 2/6/2021. There was no documented evidence that CNA #1 had a weekly COVID-19 test when she worked on 2/12/2021. CNA #1 had a PCR COVID-19 test collected on 2/16/2021 that resulted positive on 2/17/2021. The Chief Nursing Officer was interviewed on 2/24/2021 at 1:30 PM. She stated the testing schedule for the facility's staff is from Wednesday to Tuesday and staff are told they have to get tested within that schedule. She stated that for the week of 2/3/2021 (Wednesday)-2/9/2021 (Tuesday), CNA #1 worked 2/5/2021 (Friday) and was tested that day. She stated that CNA #1 next worked on 2/12/2021 (Friday), but did not get tested until the following Tuesday, 2/16/2021, because that was still within the facility's Wednesday (2/10/2021)-Tuesday (2/16/2021) staff testing schedule. The Assistant Human Resources Director was interviewed on 2/24/2021 at 2:00 PM. She stated that CNA #1 did not work on 2/16/2021, she just came into the facility to get tested . The Chief Operating Officer was interviewed on 2/24/2021 at 3:20 PM. He stated the best practice would have been for CNA #1 to be tested on [DATE] when she came into the facility. He stated that the facility does not know when per diem and part-time employees are going to work next and it would be truly burdensome to require all staff to get tested on ce a week and not know if they are going to work again. CNA #1 was interviewed on 2/24/2021 at 4:20 PM. She stated that she came into the facility on [DATE] to transport a resident and went to unit 3 North. She stated when she arrived on unit 3 North the nurse told her that the resident's appointment was cancelled, so she left the facility. 415.19(a)(1); 400.2

Based on record review and staff interview during the recertification survey the facility did not ensure that a Comprehensive Care Plan (CCP) was reviewed and revised to reflect resident specific goals and interventions. This was identified for one (Resident # 83) of five residents reviewed for Unnecessary medications. Specifically, Resident #83 had a [DIAGNOSES REDACTED]. The finding is: Resident #83 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had long and short term memory loss and severely impaired cognition. The MDS documented a [DIAGNOSES REDACTED]. A Physician order [REDACTED]. Medication Administration Records (MAR) dated 10/2019, 11/2019 and 12/2019 documented the resident received [MEDICATION NAME] 3 milligrams one time a day at bedtime for a [DIAGNOSES REDACTED]. A CCP dated 2/10/15 through 12/9/19 documented the resident was at risk for bruising and bleeding due to the use of an anticoagulant. The CCP documented a goal that the resident will not experience bruising and bleeding over the next 90 days. The CCP documented interventions to monitor for bruising and bleeding and to inform the nurse, monitor the resident's skin for skin tears. There was no documented evidence the CCP was reviewed and revised to reflect resident specific goals and interventions for monitoring for adverse effects related to the [DIAGNOSES REDACTED]. An interview was held with the Director of Nursing Services (DNS) on 12/9/19 at 10:30 AM. The DNS reviewed the CCP and stated there was no documented evidence the CCP was updated to reflect the resident's [DIAGNOSES REDACTED]. The DNS stated the CCP should have been updated. 415.11(c)(2)(i-iii)

Based on record review and staff interviews conducted during the abbreviated survey (Complaint # NY 510) the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. This was evident for one of two residents reviewed for abuse, neglect, and misappropriation of property. (Resident #1) Specifically, the facility did not ensure that a chair pad alarm, care planned as a safety measure to prevent injury related to falls was in place which resulted in the resident falling and sustaining a fractured clavicle (collar bone). This was isolated and resulted in actual harm that is not immediate jeopardy. Complaint # NY 510 The finding is: Resident#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per facility assessment dated [DATE] the resident's BIMS (Brief Interview of Mental Status) score was documented as 6, indicating that the resident has significant cognitive impairment. Review of the resident's medical record reveals that Resident #1 is assessed to be a fall risk and has been care planned for over six months to have a chair pad alarm placed on his chair at all times while seated to alert staff of his attempts to get up independently so that they can respond quickly to assist the resident, in an attempt to avert resident injury related to falls. Review of an incident report completed for Resident #1 and dated 03/05/2015 documents that at 12:45 pm the resident stood up from his wheelchair while seated in the dining room for lunch, and fell . The resident was assessed by the RN (Registered Nurse) Supervisor and sent to the hospital for evaluation where it was determined that the resident fractured his left clavicle as a result of the fall. Review of the facility conducted investigation of this incident dated 03/10/2015, reveals that an Occupational Therapy student (OTS) was sent to transport the resident from his room to the Rehab gym for therapy during the morning of 03/05/2015. The OTS transferred the resident from a chair in his room to a wheelchair but did not move the chair pad alarm to the transport wheelchair as called for by the resident's plan of care. Later that morning, the resident requested to be toileted. The OTS returned the resident to his room and transferred him from the wheelchair to the toilet. He then rang the call bell for a Certified Nursing Assistant (C.N.A.) to come to assist the resident. The C.N.A. arrived, toileted Resident #1, returned him to the wheelchair and brought him to the dining room for lunch, whereupon the resident would attempt to stand at 12:45 pm, fall and sustain the fractured left clavicle. An interview with the OTS was conducted on 03/18/2015 at 1:00 pm. During the interview the OTS stated that he had never received training with regard to the requirement to transfer a resident's alarms along with the resident when transferring a resident from one chair to another chair. He stated that he is now aware that he must transfer any alarms called for by resident specific plans of care prior to transferring residents from one chair to another. During an interview on 03/18/2015 at 12:30 pm with C.N.A. #1 who responded to Resident #1's bathroom call bell ringing, she stated that the resident was not on her assignment that day, but that she understands that answering call bells is everyone's job and responded to the call bell. She stated that she transferred the resident from the toilet to the wheelchair used by the OTS, saw no alarm on the wheelchair, assumed the resident who she does not regularly care for did not require alarms and brought him to the dining room for lunch. She further stated that she had been re-educated and will always check the care plan prior to transferring any resident in the future. During an interview with the Director of Nursing (DON) on 03/18/2015 at 1:15 pm she stated that C.N.A. #1 was re-educated and that she used the incident as a training opportunity for all nursing staff in an effort to prevent recurrence. She provided documentation to support that the training she referenced had been conducted for nursing staff. The Rehab Director, who supervises Occupation Therapy students as well as all other Rehab staff, was interviewed at 1:30 pm on 03/18/2015. During this interview he stated that as most residents remain in the same chair when transported from their rooms to the Rehab gym for therapy that it had never occurred to him to train students and other resident transport staff to ensure that all alarms are transferred with the resident to protect each resident from potential injuries related to falls. He stated that the OTS had been re-educated and that education was started with regard to the transfer of resident alarms after the incident occurred for all Rehab staff to prevent recurrence. 10 NYCRR 415.12(h) (1)