Every finding on record at Hebrew Home for the Aged at Riverdale

Number of residents sampled:3Number of residents cited:1 Based on observation, record review, and interviews, the facility failed to ensure each resident's right to receive written notices, including the reason for the changes, before the resident's room in the facility was changed. This was identified for one (1) of three (3) resident (Resident #368) reviewed for Choices. Specifically, on 03/18/2026 Resident #368 was relocated to a new room on the same floor without receiving a written notice before the room was changed.The findings include:The policy titled Change of Room or Roommate dated 03/2009, last revised 06/2025, documented that facility conduct room changes when considered to be necessary by the facility and/or when requested by the resident or resident representatives. The policy also documented that the notice of a change in room will be provided in writing, in a language and manner the resident and representatives understand and will include the reason(s) why the move or change is required. Resident #368 was admitted with diagnoses that included Septic shock, Heart failure, and Hypotension.The admission Minimum Data Set assessment dated [DATE] documented Resident #368 was cognitively intact and participated in the assessment and goal setting.On 03/19/2026 at 11:32 AM, Resident #368 and family members were interviewed and stated that they were notified about room change for another resident who needs to use shower room but denied receiving a written notice in advance. Resident #368 also stated that the facility did not give them an option to refuse the room change and they wanted to go back to the previous room. On 03/23/2026 at 9:37 AM, Resident #368 was interviewed and stated that they were still not satisfied with room changes, and no one had asked them if they were ok with the room change. Resident #368 also stated that facility informed them about the room change in the morning then changed the room in the afternoon on that same day.The Social Services progress note dated 03/18/2026 documented Resident #368 had a room change on 03/18/2026.The Social Services progress note dated 03/18/2026 documented they spoke to resident and family members that resident needed to change rooms for a resident with a medical necessity and family and resident receptive.There was no evidence that a written notice of room change was provided to Resident #368 or their representative. On 03/24/2026 at 11:30 AM, the Director of Social Work provided the State Surveyor with a notice titled New Room/Roommate Notification dated 03/18/2026 which was addressed to Resident #368 and stated they will be receiving a new room on 03/18/2026 and the reason for room change was medical need. On 03/24/2026 at 11:47 AM, Resident #368 was interviewed and stated that they had not received a written notice regarding the room change before the change occurred. The State Surveyor showed Resident #368 the copy of the notification which the Director of Social Work provided them and asked if Resident #368 had received it before the room change. Resident #368 stated that they had not seen that form before and repeated that they did not receive any written notification before the room was changed.On 03/24/2026 at 12:30 PM, the Director of Social Work was interviewed and stated the Social Worker involved was scheduled off and was not available for interview. The Director of Social Work stated room changes were conducted when residents requested or facility needed for medical reasons such as isolation. The Director of Social Work also stated that social workers were responsible for notifying resident and resident's representatives of the room changes. The Director of Social Work further stated that they had communication with resident and family members, informed them of necessary room changes on the same day. The Director of Social Work stated that they provided a written notice of room changes to the resident and kept one copy in the social work's office. The Director of Social Work stated that they do not request residents and/or their representatives' signatures for the receipt of notification of room changes. 10 New York Codes, Rules, and Regulations 415.5(e)(2)

Based on record review and interviews, the facility failed to ensure residents were afforded the right to formulate the advance directive of their choice. This was evident for one (1) of three (3) residents (Resident #106) reviewed for Advance Directives out of a sample of 38 residents. Specifically, the Physician Order in the electronic medical record documented Resident #106's code status as do not intubate while the Medical Orders for Life-Sustaining Treatment form did not match the physician's order and documented do not attempt resuscitation and do not intubate instead. The findings include:The policy and procedure titled Advance Directives/Medical Orders for Life-Sustaining Treatment Forms last revised in 03/2026 stated it is the facility's obligation to ensure that those residents, their Health Care Proxy and/or surrogates who have requested advance directives and whose request meet the criteria under the state law shall have these requests honored by a physician's order in the resident's medical chart. The policy also stated it is also the facility's responsibility to ensure that this order is communicated, kept current, periodically reviewed, and verified, and is carried out when available.Resident #106 had diagnoses which included Non-Alzheimer's dementia (memory loss and thinking problems), Parkinson's disease (brain loses the ability to control movement), and hypertension (high blood pressure).The Quarterly Minimum Data Set Assessment (a resident assessment tool) dated 01/30/2026, documented Resident #106 had intact cognition.The Medical Orders for Life-Sustaining Treatment form dated 05/23/2017 and last reviewed on 01/30/2026 documented options which included do not resuscitate and do not intubate.A physician's order dated 01/21/2026 documented do not intubate.A medical progress note dated 02/01/2026 (date of service 01/30/2026) documented Resident #14's advance directives for do not resuscitate and do not intubate have been signed and order initiated.A review of the physician orders, hard chart, and electronic medical record on 03/19/2026 revealed no physician orders for Resident #106 which documented Resident #106's code status as do not attempt resuscitation.On 03/24/2026 at 12:09 PM, Social Worker #1 was interviewed and stated advance directives are reviewed quarterly during care plan meetings. Social Worker #1 also stated they recently asked Resident #106 about their advance directives, and they deferred to their next of kin. Social Worker #1 further stated they called Resident #106's next of kin to discuss Resident #106's advance directives on 03/19/2026, and the next of kin confirmed Resident #106's code status as do not resuscitate.On 03/24/2026 at 12:30 PM, the [NAME] President of Social Services was interviewed and stated social workers review advance directives quarterly and they were unable to provide an explanation for why Resident #106 did not have an order for do not resuscitate among their physician orders.On 03/24/2026 at 4:45 PM, the [NAME] President of Nursing was interviewed and stated when the Medical Orders for Life-Sustaining Treatment is reviewed by the physician, the physician orders should also be reviewed to ensure they match. On 03/25/2026 at 2:40 PM, Physician #1 was interviewed and stated they are not sure why the do not resuscitate order was not in place in Resident #106's physician orders. Physician #1 also stated they did not cross check the orders on the Medical Orders for Life-Sustaining Treatment form with the physician orders in Resident #106's electronic medical record because they assumed both the Medical Orders for Life-Sustaining Treatment and physician orders matched since there were no changes made at that time. 10 New York Codes, Rules, and Regulations 415.3(e)(1)(ii)

Based on record review and interviews, the facility failed to ensure that a comprehensive person-centered care plan was developed and implemented for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs. This was evident for one (1) of six (6) residents (Resident #14) investigated for Activities of Daily Living out of 38 total sampled residents. Specifically, a care plan to address hospice care was not developed for Resident #14. The findings are:The facility policy and procedure titled Person-Centered Care Planning revised on 02/02/2026 stated the comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Resident #14 had diagnoses of diabetes mellitus (too much sugar in the blood), hypertension (high blood pressure), and peripheral vascular disease (blood vessels outside the heart and brain become narrowed and blocked).The Quarterly Minimum Data Set (a resident assessment tool) dated 03/04/2026 documented Resident #14 had severely impaired cognition.A physician's order dated 03/09/2026 documented hospice care on 03/08/2026.A Calvary Hospital Hospice Social Worker note dated 03/08/2026 documented that Resident #14 was admitted to hospice today.A review of Resident #14's comprehensive care plans had no documented evidence that a care plan to address hospice care was developed. On 03/24/2026 at 12:15 PM, Social Worker #1 was interviewed and stated the social service department is responsible for creating a care plan to address that Resident #14 is receiving hospice care. Social Worker #1 was unable to provide an explanation for why Resident #14 did not have a care plan in place for hospice care. On 03/24/2026 at 12:24 PM, the [NAME] President of Social Services was interviewed and stated there is not a specific care plan for hospice in the electronic medical record system the facility recently implemented. The [NAME] President of Social Services also stated they usually try to create a hospice care plan or update the advance directives care plan as soon as a resident is placed on hospice.10 New York Codes, Rules, and Regulations 415.11(c)(1)

Based on observation, record review, and interviews, the facility failed to ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident for one (1) of five (5) nurses observed during medication administration. Specifically, Registered Nurse #5 failed to sanitize the blood pressure cuff in between residents.The findings include:The facility's policy titled Medline Vital Signs Monitoring Device dated 07/2021, last reviewed date of 03/2025 stated Nurse and Certified Nursing Assistant cleans the machine with germicidal alcohol wipes and washes hands before resident's care. The policy further stated in procedure #12 (page 3 of 4), Nurse and Certified Nursing Assistant will wipe the blood pressure cuff after each use. On 03/24/2026 at 9:17 AM, during medication administration observation on the 6th Floor Registered Nurse #5 observed taking Resident #325's blood pressure without sanitizing the blood pressure cuff before and after using.On 03/24/2026 at 9:27 AM, Registered Nurse #5 was observed applying the same blood pressure cuff to Resident #148. Registered Nurse #5 failed to sanitize the blood pressure cuff before and between each resident. On 03/24/2026 at 10:55 AM Registered Nurse #5 was interviewed and stated that they were supposed to clean and sanitize the blood pressure cuff with sanitizing wipes between each resident to prevent infection but stated that they were nervous and forgot to do it. On 03/24/2026 at 11:02 AM, Registered Nurse Supervisor #1 was interviewed and stated that they were responsible for supervising Registered Nurse #5 to ensure that they properly sanitize the reusable equipment. Registered Nurse Supervisor #1 also stated that the blood pressure cuff must be cleaned in between residents, and the staff should use the purple top sanitizing wipes. Registered Nurse Supervisor #1 further stated that they provided in-services and competency to ensure staff are sanitizing the reusable equipment properly.On 03/24/2026 at 3:42 PM, the Nursing Compliance Manager #1 was interviewed and stated that blood pressure cuff must be sanitized with purple top wipes before and after using it, between resident to resident. 10 New York Codes, Rules, and Regulations 415.19(a)(1-3)

Number of residents sampled: 2Number of residents cited: 2 Based on observation, record review and staff interviews, the facility failed to ensure that the residents and their representatives were provided with a summary of the baseline care plan. This was evident for two (2) of two (2) residents (Residents #102 and #368) reviewed for Care Planning out of 38 sampled residents. Specifically, there was no documented evidence that Resident #102 and Resident #368 or their representatives had received a written summary of their baseline care plan.The findings include: The facility policy titled Baseline Care Plan dated 05/05/2017, last revised 02/02/2026 stated that the baseline care plan will be developed within 48 hours of a resident's admission. The policy also stated that a Social Worker is responsible for providing the written summary of the baseline care plan to the residents and representatives. 1.Resident #102 was admitted on [DATE] with diagnoses of right knee arthroplasty (joint replacement surgery), Morbid obesity, and Anxiety.The admission Minimum Data Set assessment (a resident assessment tool) dated 02/08/2026 documented resident was cognitively intact, required Substantial/ Maximal assistance of staff for most Activities of Daily Living. The admission Minimum Data Set assessment also documented Resident#102 and family participated in the assessment and goal setting.On 03/19/2026 at 12:07 PM, Resident #102 was interviewed and stated that they had not been given a written summary of the initial baseline care plan.Review of Resident #102's electronic medical record revealed a baseline care plan, created 02/02/2026, with a lock date of 02/09/2026 which was signed by the facility interdisciplinary team members but was not signed by the resident or their representative.There was no documented evidence that a copy of the baseline care plan was provided to Resident #102 or their Representative.2. Resident #368 was admitted on [DATE] with diagnoses of Septic shock, Heart failure, and Hyperthyroidism.The admission Minimum Data Set assessment dated [DATE] documented Resident #368 was cognitively intact and participated in the assessment and goal setting.On 03/19/2026 at 11:32 AM, Resident #368 was interviewed and stated that they had not been given a written summary of their baseline care plan.Review of Resident #368's electronic medical record revealed a baseline care plan, created 03/10/2026, with a lock date of 03/12/2026, which was signed by the facility interdisciplinary team members but was not signed by the resident or their representative.There was no documented evidence that a copy of the baseline care plan was provided to Resident #368 or their Representative.On 03/24/2026 at 11:55 AM, Registered Nurse Supervisor #3 was interviewed and stated that Nursing and Social Worker completed the baseline care plan in the electronic medical record within 48 hours of admission. Registered Nurse Supervisor #3 also stated that after completion of Baseline care plan, they reviewed it to see if there were any missing items. Registered Nurse Supervisor #3 further stated that nursing staff do not provide a copy of baseline care plan to the residents or their representatives.On 03/24/2026 at 12:30 PM, the Director of Social Work was interviewed and stated that the baseline care plan is completed by nursing and the social worker within 48 hours of admission. The Director of Social Work also stated the social work department was responsible for reviewing and providing the baseline care plan to the residents or their representatives within five (5) days of admission and kept one copy in the social work office. The Director of Social Work further stated they do not document in the progress notes after providing a copy of baseline care plan to the residents or their representatives, and they do not request residents and/or their representatives' sign when they receive a copy of the baseline care plan. 10 New York Codes, Rules and Regulations 415.11(c)(1)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY 00336157, NY 00331163, and NY 00308371), the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment were reported in a timely manner to local law enforcement, and to the New York State Department of Health in accordance with federal and state regulations. This was evident in three out of three residents sampled for abuse (Resident #1, Resident #2, and Resident #3). Specifically, on 01/01/24, between 1:00 pm and 2:00 pm, Resident #1's adult child reported to the facility that Resident #1 complained on 12/31/23, in the evening, Certified Nurse Assistant #1 pulled their hair and broke the fingernail on their left thumb. The facility did not report the incident to the New York State Department of Health or to local law enforcement. Specifically, on 03/08/24 at 11:15 am, Resident #2 complained that on 03/05/24, while in the rehabilitation gym, Physical Therapist #1's private body part was close to their right hand. The facility did not report the incident to the New York State Department of Health or local law enforcement. Specifically, on 01/08/23 at approximately 2:00 pm, a family member alleged that on 01/06/23 at 7:00 pm, Certified Nursing Assistant #2 slapped Resident #3 because they did not go to bed. On 01/09/23 at 1:48 pm, The facility reported Resident #3's allegation of physical abuse to the New York State Department of Health and did not report the alleged abuse to the law enforcement. The findings are: The Facility's Policy and Procedure entitled Investigation and Reporting of Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents, revision date 02/24. It is a facility's policy that staff immediately report all events involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property, any reasonable suspicion of a crime against a resident of the facility, all incidents of unknown source, alleged or suspected quality of care issues, physical environment incidents, and death not due to natural causes. This document stated that all allegations/occurrences of all types of staff-to-resident abuse must be reported to the administrator and to other officials, including the New York State Department of Health and Adult Protective Services. The time frames for reporting to the New York State Department of Health and Local Law Enforcement (if applicable) are: Serious Bodily Injury 2 Hour Limit. If the events that cause the reasonable suspicion of a crime against a result in serious bodily injury to the resident, the report must be made immediately to the New York State Department of Health and local law enforcement, but not later than 2 hours after forming the suspicion. All others are within 24 Hours, if the events that cause the reasonable suspicion of a crime do not result in serious bodily injury to a resident, the report must be filed with the New York State Department of Health. The Facility's Policy and Procedure entitled Prohibition and Prevention of Resident Abuse, Neglect, Exploitation, Misappropriation of Resident Property, revised date 02/24, documented, all staff are required to report all incidents to the Director of Nursing. Staff are also required to report reasonable suspicion of a crime to the New York State Department of Health and to Local Law Enforcement. Resident #1 was admitted to the facility with diagnoses including Major Depressive Disorder, Aphasia (unable to speak), and anxiety disorder. The Minimum Data Set (assessment tool) dated 12/20/23, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) and scored 3 out of 15, indicating severely impaired cognition. A Grievance Complaint dated 01/02/24, documented on 01/01/24 (no time was documented), Resident #1's adult child complained to Registered Nurse #1 that Resident #1 told them on 12/31/23 in the evening, Certified Nursing Assistant #1 pulled their hair and caused fingernail on their left thumb to break. Resident #1 was assessed, and it was noted that the left thumbnail was a little broken off. No complaints of pain or bleeding was noted. No skin bruises or breaks were noted. Resident #1 has aphasia and was not consistent with the story. Certified Nursing Assistant #1, who worked double shifts on 12/31/23 (3-11 and 11-7), denied pulling Resident #1's hair or breaking their nail. There were no witnesses from staff or other residents. The facility concluded that there was no evidence of abuse, neglect, or mistreatment. During an interview on 05/28/24 at 1:35 pm, the Director of Nursing stated that on 01/01/24 between 1:00 pm and 2:00 pm, Resident #1 and their family reported to Registered Nurse #1 that Certified Nursing Assistant #1 pulled their hair and broke their nail on 12/31/23, during the evening shift. The Director of Nursing stated Registered Nurse #1 reported to the Nurse Manager #1. The Director of Nursing stated Nurse Manager #1 did not report to them until 01/02/24. The Director of Nursing stated Nurse Manager #1 should have informed them or their designee about the allegation immediately. The Director of Nursing stated that they and the Administrator or designee are responsible for reporting incidents of abuse to the New York Department of Health and to local law enforcement within two hours if there is suspicion of crime. The Director of Nursing stated they did not report the incident to the New York Department of Health and local law enforcement because there was nothing to report, because they immediately decided that abuse did not occur. During an interview on 05/28/24 at 3:04 pm, the Administrator stated that the Director of Nursing is the abuse coordinator and primary contact of abuse allegations and oversees the investigation. The Director of Nursing is responsible for reporting abuse allegations. The Administrator stated they were informed about Resident #1's allegation by the Director of Nursing on 01/02/24 (don't recall the time). The Administrator stated they discussed the case, investigation status, and reporting status. The Administrator stated the incident was not reported to the Department of Health and the police because they did not feel it was reportable because there was no evidence of abuse. The Administrator stated that allegations of abuse should be reported within two hours to the Department of Health. The Administrator stated Police should be notified when there is reasonable suspicion of a crime. Resident #2 was admitted to the facility with diagnoses including Malignant Neoplasm of the Brain (Brain Cancer), Difficulty Walking, and Pain. The Minimum Data Set, dated dated dated [DATE], documented Resident #2 had a Brief Interview of Mental Status and scored 14 out of 15, indicating intact cognition. A review of the facility's Internal Investigation dated 03/08/24, documented that Resident #2 told Transporter #1 on 03/07/24 they were not comfortable around Physical Therapist #1. Transporter #1 then informed the Director of Nursing on 03/08/24 at around 11:15 am. Resident #2 was interviewed and claimed that last Tuesday (03/05/24), while they were in the rehabilitation gym, Physical Therapist #1, had their penis close to Resident #2's right hand. The facility investigated the incident and concluded that there was no evidence of abuse, neglect, or mistreatment had occurred. During an interview on 5/24/24 at 12:46 pm, Registered Nurse #1 stated they got a call from the Assistant [NAME] President of Resident Engagement on 03/08/24 due to Transporter #1 reported that Resident #2 told them they were uncomfortable with Physical Therapist #1. Registered Nurse #1 stated they and the Assistant Director of Nursing interviewed Resident #2, who said that they were in rehabilitation unit on 03/05/24, their right hand was holding onto something, and the Physical Therapist #1 was standing at the front of them with their penis close to their right hand and was rubbing to their right hand. Registered Nurse #1 stated Resident #2 said Physical Therapist #1 was not exposed. Registered Nurse #1 stated they reported to the Director of Nursing, but did not call the police. During an interview on 05/28/24 a 1:35 pm, the Director of Nursing stated they were informed about the allegation in the rehabilitation unit on 03/08/24 between 11:30 and 12:00 pm and reported to the Administrator. The Director of Nursing stated they did not report the incident to the New York Department of Health because there was no violation. The Director of Nursing stated the incident did not happen, they investigated immediately, and there were a lot of witnesses in the rehabilitation unit that said Physical Therapist #1 did not sexually abuse Resident #2. The Director of Nursing stated police were not called because there was no reasonable suspicion of a crime, it was ruled out immediately. Resident #3 was admitted to the facility with diagnoses including Anxiety, Depression, Behavioral and Psychiatric Disturbances. The Minimum Data Set, dated dated dated [DATE], documented that Resident #3 had a Brief Interview for Mental Status and scored 11 out of 15, indicating moderate cognitive impairment. The facility's Investigation Summary dated 01/08/23, documented on 01/07/23 at 7:00 pm, Family Member reported that Certified Nursing Assistant #3 clapped Resident #3 when they did not go to bed. The family member stated that Resident #3 called them on 01/07/23 at 7:00 pm. Registered Nurse Supervisor #1 interviewed Resident #3, who stated that it was not 7:00 pm when they were slapped in the face but at 11:30 pm that night when they were going back to bed. The investigation also documented Resident #3 was immediately assessed by Registered Nurse Supervisor #1, and there was no redness, no swelling, and no skin break was noted on Resident #3's face. The investigation concluded that the allegation was unfounded, Resident #3 was assisted by two staff members and neither witnessed the incident. The form Submission from Nursing Home Facility Incident Report documented that the Nursing Home Facility Incident Report was submitted on 01/09/2023 at 1:48 pm. During an interview on 05/29/24 at 9:19 am, Registered Nurse Supervisor #1 stated they reported the allegation to the Assistant Director of Nursing Services and Director of Nursing on 01/08/2023 via telephone. Registered Nurse Supervisor #1 stated all abuse must be reported to the New York State Department of Health within 2 hours with injury or no injury. During an interview on 05/24/2024 at 4:07 pm, the Assistant Director of Nursing Services stated the facility must report all abuse if there is injury within two hours and if there is no injury within twenty-four hours to the New York State Department of Health. The Assistant Director of Nursing Services stated they reported the allegation to the New York State Department of Health within twenty-four hours and did not report it to law enforcement. During an interview on 05/24/2024 at 3:48 pm, the Administrator stated they became aware of the allegation by the Director of Nursing on 01/09/23. The Administrator stated the alleged incident was reported to the New York State Department of Health by the Assistant Director of Nursing Services on 01/09/23, which was within the two-hour window. The Administrator stated the facility reports abuse to the New York State Department of Health within two hours if there are injuries, and if no injuries within twenty-four hours. 10 NYCRR 415.4(b)(2)

Based on interviews and record review conducted during the Recertification survey, the facility did not ensure residents' right to communicate with individuals and entities external to the facility. This was evident for 10 of 10 attendees of the Resident Council meeting. Specifically, the facility did not have a system in place for residents to receive and send mail on Saturdays. The findings are: The facility's policy titled Resident Mail revised 04/2022 documented the resident has the right to send and receive mail outside of the facility. On 04/27/2022 at 11:02 AM, a Resident Council meeting was held with 10 residents of the facility. All ten residents present at the meeting stated that they were not able to receive or send out mail on Saturdays. On 05/03/2022 at 09:06 AM, the Director of Social Services (DSS) was interviewed and stated mail has not been delivered to the facility or picked up in the facility by the United States Postal Service (USPS) since the COVID-19 pandemic began in 2020. A security officer from the facility was assigned to go to the local post office twice a day during the week to drop off and pick up mail. Mail brought to the facility by the security officer is sorted by the nursing department unit clerk and distributed to the residents. The facility did not have a staff member assigned to pick up or drop off resident mail on Saturdays because USPS shortened their hours of operation and staff prioritized other departmental duties. On 05/03/2022 at 10:34 AM, the Director of Nursing (DON) was interviewed and stated the facility has had issues with USPS that precede the COVID-19 pandemic in 2020. The USPS does not deliver mail to the facility or pick up mail in the local letterbox located just outside the facility's main gate. The Chief Operating Officer (COO) was interviewed on 05/03/2022 at 11:29 AM and stated the USPS was concerned about spreading COVID-19 in 2020 and made the decision to stop mail services to the facility. The facility has not communicated with the USPS and addressed the issue internally. The COO was not aware residents have the right to send and receive mail on Saturdays. 483.10(g)(7)

Based on observation, record review and interviews conducted during the Recertification survey, the facility did not ensure that food was stored in accordance with professional standards for food safety. This was evident during the Kitchen observation. Specifically, multiple food items were observed without a use-by date and were moldy. The findings are: The facility policy titled Storage Policy revised 1/16/22 documented all food products are correctly labeled with the receive date to ensure First-In First-Out (FIFO) rotation is used. Stock foods are stored in original containers that include source identification tags or labels. Refrigerated and stored foods that expire 30 days from open date: salad dressings, mayonnaise, and tartar sauce. Foods that expire 60 days from open date: ketchup, mustard, and horseradish. On 4/26/22 at 09:20 AM, the Pareve Refrigerator in the Kitchen was observed with mustard, ranch dressing, Italian dressing, and lemon juice opened and undated. The Kitchen freezer contained an open undated package of golden patties. The Produce Refrigerator contained a box of moldy cucumbers, and undated unlabeled bags of fresh herbs and green peppers. A Kitchen cart was observed with an undated bottle of garlic powder and vinegar bottle. The Pantry contained two undated and unlabeled plastic bins of sugar and flour. On 4/29/22 at 11:03 AM, a unopened undated case of non-fat dry milk was observed in the emergency food storage area. On 05/02/22 at 12:08 PM, Food Services Worker (FSW) #3 was interviewed and stated they are responsible for receiving shipments and storing food items. FIFO method is followed and FSW #3 ensures food is dated with expiration dates and rotated daily. If food items are opened and undated or spoiled, FSW #3 will discard them. The Food Service Director (FSD) was interviewed on 5/2/2022 at 02:00 PM and stated delivered boxes contain a sticker from the vendor with the delivery date. Items taken out of the delivery boxes have the delivery date and discard dated written on them. All open food and pantry items must be labeled with a discard date. 415.14(h)

Based on record review and interviews, conducted during the Recertification and Abbreviated Complaint survey (NY 885), the facility did not ensure all alleged violations involving abuse, including injuries of unknown origin, were reported to the State Survey agency (New York State Department of Health (NYSDOH) within 2 hours of the allegation being made. This was evident in 1 out of a sample of 35 residents (Resident #670). Specifically, the facility did not report Resident #670's right femur fracture of unknown origin to the NYSDOH within 2 hours of the occurrence. The findings are: The facility policy titled Accident/Incident (A/I) Report revised 10/2021 documented the facility is responsible for determining if the resident's accident was avoidable or unavoidable. Resident #670 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #670 was severely cognitively impaired and required extensive or total assistance with activities of daily living (ADL). A Summary of Investigation (SOI) dated 09/26/2021 documented a statement from Certified Nursing Assistant (CNA) #2 they found Resident #670 with a twisted/fractured bone on the swollen right thigh area and informed Licensed Practical Nurse (LPN)# 1. Medical Doctor (MD) note dated 09/26/2021 documented Resident #670 was assessed for deformity of right femur that was highly suspicious for fracture. There were no signs of trauma, and the right femur fracture was likely due to minimal force. X-ray of Resident #670's right thigh was ordered. Nurse Practitioner (NP) note dated 09/27/2021 documented Resident #670 was assessed following x-ray report that documented acute completely displaced and severely angulated fracture involving the mid femoral diaphysis. Resident #670 was sent to the hospital emergency room due to right fracture femur bone that is puncturing the skin. There was no documented evidence the facility reported Resident #670's right femur fracture of unknown origin to the NYSDOH within 2 hours. On 05/03/2022 at 11:20AM, the MD was interviewed and stated Resident #670 was fragile with osteopenia and the right femur fracture may have been pathological. On 05/03/2022 at 02:00 PM, the Director of Nursing (DNS) was interviewed and stated the facility did not report Resident #670's right femur fracture to the NYSDOH within 2 hours of because the facility did a root cause analysis and the resident had osteopenia and [CONDITION(S)]. The x-ray report received the day after the investigation was initiated did reveal Resident #670 did have a right femur fracture. 415.4(b)(2)

Based on record review and interviews, conducted during the Recertification and Abbreviated Complaint survey (NY 885), the facility did not ensure results of an investigation involving an injury of unknown origin were reported to the State Survey Agency (NYSDOH) within 5 working days of the incident. This was evident for 1 out of sample of 35 residents reviewed (Resident #670). Specifically, the outcome of an investigation into Resident #670's right femur fracture of unknown origin was not reported to the NYSDOH. The findings are: The facility policy titled Accident/Incident (A/I) Report revised 10/2021 documented the facility is responsible for determining if the resident's accident was avoidable or unavoidable. Resident #670 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #670 was severely cognitively impaired and required extensive or total assistance with activities of daily living (ADL). A Summary of Investigation (SOI) dated 09/26/2021 documented a statement from Certified Nursing Assistant (CNA) #2 they found Resident #670 with a twisted/fractured bone on the swollen right thigh area and informed Licensed Practical Nurse (LPN)# 1. The SOI conclusion documented Resident #670 sustained a spontaneous femur fracture in danger of skin rupture. Ecchymosis was observed by staff on Resident #670's left shin on 9/27/2021. Resident #670 had fragile bones and there was no evidence of abuse. Medical Doctor (MD) note dated 09/26/2021 documented Resident #670 was assessed for deformity of right femur that was highly suspicious for fracture. There were no signs of trauma, and the right femur fracture was likely due to minimal force. X-ray of Resident #670's right thigh was ordered. Nurse Practitioner (NP) note dated 09/27/2021 documented Resident #670 was assessed following x-ray report that documented acute completely displaced and severely angulated fracture involving the mid femoral diaphysis. Resident #670 was sent to the hospital emergency room due to right fracture femur bone that is puncturing the skin. There was no documented evidence the facility reported the outcome of the investigation into Resident #670's right femur fracture of unknown origin to the NYSDOH within 5 days. On 05/02/2022 at 3:10 PM the Registered Nurse/Charge Nurse Manager (RNCNM) was interviewed and stated they were responsible for investigating Resident #670's right femur fracture of unknown origin. The RNCNM gathered statements from the previous shifts but did not interview the last person to see Resident #670 before the injury was reported. The investigation concluded on 9/27/2021 that Resident #670's right femur fracture was not related to abuse. On 05/03/2022 at 02:00 PM, the Director of Nursing (DNS) was interviewed and stated the facility did not report Resident #670's right femur fracture to the NYSDOH because the facility did a root cause analysis and the resident had osteopenia and [CONDITION(S)]. The x-ray report received the day after the investigation was initiated did reveal Resident #670 did have a right femur fracture.

Based on record review and interviews conducted during the Recertification and Complaint survey (NY 949), the facility did not ensure a resident and/or resident representative (RR) was involved in comprehensive care planning (CCP) with the interdisciplinary team (IDT). This was evident for 1 of 35 residents reviewed (Resident #425). Specifically, Resident #425 was not invited to scheduled CCP meetings with the IDT. The findings are: The facility policy titled Person-Centered Planning revised 5/2017 documented the Social Worker (SW) invites residents and RRs schedule CCP meetings in advance; and all attendees will sign the CCP Attendance Sheet which will be maintained as part of the medical record. Resident #425 was diagnosed with [CONDITION(S)] and diabetes mellitus. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #425 had intact cognition. On 04/27/2022 at 1:41 PM, Resident #425 was interviewed and stated they had not been invited to attend quarterly CCP meetings with the IDT. CCP Meeting Attendance documented CCP meetings with the IDT were held on 2/23/2021, 3/18/2021, and 12/28/2021. Resident #425's signature was not documented. There was no documented evidence Resident #425 was invited to or attended scheduled CCP meetings with the IDT. On 05/02/22 at 11:22 AM, the SW was interviewed and stated residents and the RR are invited to initial, annual, and significant change CPMs. The SW does not invite the resident or RR to quarterly CPMs. On 05/03/22 at 10:00 AM, the SW Director (SWD) was interviewed and stated residents and families are invited to initial, annual, and significant change CPMs. A progress note is written when a resident and/or RR are invited to CPMs, and an attendance sheet documents the signatures of who attends the CPMs. Residents and RRs were not invited to quarterly CPMs. 415.11(c)(2)(i-iii)

Based on observation, record reviews and interviews conducted during the COVID-19 Focused Infection Control Survey completed on 12/29/2020, the facility did not establish and maintain an Infection Control Program to ensure residents' health and safety and to prevent the transmission of COVID-19 infection. Specifically, the facility failed to ensure infection control measures were maintained during a medication pass, proper hand hygiene was performed, and that staff donned (applied) and doffed (removed) Personal Protective Equipment (PPE) prior to entering and exiting resident rooms. This was evident for 3 of 14 units observed. (Units JR 2, JR 4 and GB 4). The findings are: The U.S. Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated November 4, 2020 provides: HCP (Healthcare Provider) who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH (National Institute for Occupational Safety and Health)-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. CDC guidance titled Hand Hygiene Recommendations dated 5/17/20, documented clinical indications for hand hygiene as: immediately before touching a patient, when hands are visibly soiled, after touching a patient or the patient's immediate environment, and immediately after glove removal. The New York State Department of Health (NYSDOH) Revised Health Advisory entitled COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 3/13/20 and updated 7/10/2020, documented that if there are confirmed cases of COVID-19 in a Nursing Home, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. HCP and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e. do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed, and hand hygiene must be performed. The facility's policy and procedure entitled Hand Washing, revised 05/01/2020, documents, Procedure- Responsibility- Staff- 1) Will wash hands. a) Before preparing or handling medications. c) Before and after having direct contact with a resident. l) Before donning and after removing gloves. The facility's policy and procedure titled, Protocol-Personal Protective Equipment revised 5/2020 documents: 1) Gloves- Perform hand hygiene, then put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. Remove discard gloves when leaving the patient room or care area and immediately perform hand hygiene. Gowns- Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use. Key Points about PPE- Don before contact with the patient, generally before entering the room. Remove and discard carefully, either at the doorway or immediately outside patient room. Immediately perform hand hygiene. On 12/29/2020 at 10:35 AM, RN #1 was observed on Unit JR 4. RN #1 was observed exiting room [ROOM NUMBER] wearing a gown without doffing the gown or performing hand hygiene then entered room [ROOM NUMBER]. RN #1 then exited room [ROOM NUMBER] and went to the medication cart without doffing the gown or performing hand hygiene. On 12/29/2020 at 10:36 AM, CNA #1 was observed on Unit GB4 which was located in a COVID-only building. CNA #1 was observed exiting a resident's room wearing a gown and gloves did not doff her gown or gloves and entered another residents room. On 12/29/2020 at 10:39 AM, CNA #1 was interviewed. CNA #1 stated she was not aware that she was being watched. CNA #1 also stated she should have removed PPE outside the resident's room once she exited. On 12/29/2020 at 10:50 AM, LPN #1 was observed administering medication on Unit JR 2. LPN #1 was observed dispensing medications from a blister pack into his bare hand before placing them into a medication cup. LPN #1 then administered the medication to a resident. The LPN was not observed performing hand hygiene prior to or after administering the resident's medication. On 12/29/2020 at 10:50AM, LPN #1 was interviewed. LPN #1 stated medical equipment is disinfected with wipes. LPN #1 pointed to the area on the medication cart where wipes are stored, there were no disinfecting wipes available on the medication cart. On 12/29/2020 at 12:45 PM, an interview was conducted with the Infection Control Preventionist (ICP). The ICP stated that the facility has two Nurse Educators who review protocols and provide orientation to new employees. Nurse Managers make rounds at least weekly on all units to review protocols as well. The facility policy is that every staff should behave as though every floor is a quarantine floor. On 12/29/2020 at 1:30 PM, the Director of Nursing (DON) was interviewed. The DON stated that Nurse Managers are expected to make rounds on their units at least once per shift to monitor the staff for adherence to infection control protocols. Additionally, a Consultant Pharmacist monitors medication pass on all units to make sure medications are being given according to infection control protocols. The facility holds weekly in-services and takes corrective action when needed. The DON further stated she was aware that it would be impossible to supervise staff members 24/7 and that due to the holiday season many staff members are off, putting some strain on the staff who are available. 415.19(a)(1),(b)(4); 400.2

Based on interview and record review during the COVID-19 Focused Infection Control Survey (Complaint # NY 546) completed on 5/13/20, the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, for 3 of 3 covid units, the facility did not ensure that there was contact/droplet precaution signage present at the entrance to the units or on individual resident rooms. Additionally, the facility did not ensure that visitors (DOH surveyors) were adequately screened for communicable disease prior to entering the facility. This is evidenced by: Finding #1: The Goldfine Pavilion (GP)-Main Floor, GP-1st Floor unit, and GP-3rd Floor units were inspected on 05/10/2020 at 4:15 PM through 5:30 PM. Signage was not posted at the entrance to these units or on individual resident room doors instructing persons that infection control practices are required when on the units or while in resident rooms. The Vice President of Nursing stated in an interview on 05/10/2020 at 5:50 PM that the GP-Main Floor, GP-1st Floor, and GP-3rd Floor units are dedicated coronavirus-positive (COVID-positive) units, signs are not posted at the unit entrances or anywhere on the units indicating the coronavirus status of these units, and staff understand both that COVID-positive residents have been cohorted on these units and upon entering to don personal protective equipment (PPE). Finding #2: A Health Advisory dated March 20, 2019, documented to carefully screen visitors for fever or respiratory symptoms. A facility policy titled Coronavirus Surveillance issued March 2020 and last revised May 2020, documented that it would implement heightened surveillance activities for coronavirus illness during periods of transmission in the community and/or during declared public health emergency for the illness. The following screening is done for visitors and staff: - Is there signs and symptoms of respiratory illness such as fever, cough, shortness of breath, or sore throat. - In the last 14 days has the person had contact with someone with a confirmed or [DIAGNOSES REDACTED]. - traveled within the last 14 days to geographic areas with sustained community transmission, - or resides in a community where community-based spread of COVID-19 is occurring. The following observations were made: - 5/10/20, at 2:15 pm, the screener at the gate did not 2 of 2 surveyors if they had been exposed to someone with confirmed or suspected COVID. - 5/11/20 at 7:30 am, the screener did not ask 2 of 2 surveyors if they had been exposed to someone with confirmed or suspected COVID and did not ask if the surveyors felt ill. - 5/11/20 at 8:00 AM, staff screeners at the front gate took the surveyor's temperature but did not ask any screening questions. During an interview on 5/10/20 at 2:45 AM, the Vice President (VP) of Nursing stated they check temperatures but do not document it unless it is 100 or over. As part of the screening process she would not expect screeners to ask if the person being screened had an exposure with a person confirmed or suspected of COVID-19; early on they would but not anymore. During an interview on 5/12/19 approximately 2:00 PM, the Infection Control Preventionist stated the visitor/staff screening process, was continually being improved. They used to have Certified Nursing Assistants performing the screening but when they needed them for resident care, they trained the security staff on the proper procedure. She was not aware that it was being done improperly and have retrained staff. 10 NYCRR 415.19 (b)(1)

Based on interview and record review during the COVID-19 Focused Infection Control Survey (Complaint # NY 546) the facility did not ensure compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility did not comply with New York State Executive Order (EO) 202.18 to ensure that all residents and/or their next of kin were notified of either a single confirmed infection of COVID19 or COVID19 death within 24 hours from the date of occurrence between [DATE] to [DATE]. The EO 202.18 as amended by EO 202.19 documented Any skilled nursing facility, nursing home, or adult care facility licensed and regulated by the Commissioner of Health shall notify family members or next of kin if any resident tests positive for COVID-19, or if any resident suffers a COVID-19 related death, within 24 hours of such positive test result or death. The facility's policy titled COVID-19 Communication to Residents, their representatives, and staff issued [DATE], and revised [DATE], documented notification to residents' families and staff would occur daily for COVID-19 residents who expired. The facility's resident death records dated from [DATE] - [DATE], documented 3 confirmed COVID-19 in-facility deaths and 5 confirmed COVID-19 deaths in the hospital. In-facility deaths were documented 1 death on [DATE] and 2 deaths on [DATE], Additionally, it documented deaths that occurred in the hospital as; 1 death on [DATE], [DATE], [DATE] and [DATE]. The facility's Email COVID-19 notifications from [DATE] - [DATE], did not include notifications of these deaths. A family email dated [DATE] documented that one resident who tested positive in the hospital had died . During an interview on [DATE] the Social Services Director stated there was a daily email blast by the Vice President (VP) of Communications updating families of the number of: new COVID [DIAGNOSES REDACTED]. During an interview on [DATE] at approximately 9:45 AM, the VP of nursing stated that when a resident expired, a call was placed to that individual's family members, but this information was not put into the daily email blasts to family. They did not start sending email notifications to families regarding COVID-19 deaths until [DATE]. 10NYCRR 400.2

Based on observations and interviews conducted during the recertification survey, the facility did not ensure that garbage and refuse were disposed of properly. Specifically, garbage bins located in the kitchen were observed to be uncovered and overflowing with garbage. This was observed during the Kitchen Observation Task. The findings are: The facility Policy and Procedure titled Kitchen Waste dated 5/21/19 documented that kitchen staff returns to the kitchen, covers the Black Bins and brings the waste filled Black Bins to the compactor. On 08/08/19 at 12:16 PM, a large uncovered garbage bin was observed in the facility kitchen. The garbage bin was overflowing with boxes and clear plastic garbage bags. The State Agent (SA) observed as a dietary worker wheeled the overflowing garbage bin from the kitchen, through double doors, and into the hallway. The bin was then wheeled across a hallway, through another set of double doors and brought to the outside trash compactor area. The uncovered bin was then wheeled across the parking lot to the trash compactor. On 08/08/19 at 12:21 PM, a second large uncovered garbage bin approximately 1/4 full of discarded food from breakfast and other garbage bags was wheeled out of the kitchen by another dietary worker. The uncovered garbage bin was taken on the same same path as the previous dietary worker, through the hallway and then through the parking lot to the trash compactor. On 8/08/19 at 12:19 PM, an interview was conducted with the Dietary Worker that wheeled the first large garbage bin to the trash compactor. The Dietary Worker stated that he does not usually take the garbage out to the compactor but was asked to do so by his supervisor. The Dietary Worker stated that sometimes the boxes that are thrown in the garbage bins makes it difficult to put a cover on the bin before it is wheeled out of the kitchen. On 08/09/19 at 01:14 PM, an interview was conducted with the Food Service Director (FSD). The FSD stated that the garbage bins are supposed to be covered when transporting garbage from the kitchen to the trash compactor. The FSD also stated that he met with the his kitchen supervisors following the SA's observation and re-inserviced that garbage bins are to be covered. The FSD further stated that there are covers for the bins but some cooks will overfill the bins and then remove the covers. There is no set schedule for garbage removal, and bins are removed as needed. Dietary Workers should know that the garbage bin should be covered. 415.14(h)

Based on observations and staff interviews conducted during the recertification survey, the facility did not ensure that infection control practices were maintained. Specifically, (1). 2 residents receiving oxygen therapy through a nasal cannula were observed to have their oxygen tubing laying on the floor (Resident #135 and #137), (2). multiple rooms on 1 of 13 units were found to have oxygen cannulas, nebulizers and other devices stored without being covered. (Jacob Reingold Pavilion, Unit 2) and (3). a nurse was observed not performing hand hygiene appropriately during wound care observations (Resident #13). The findings are: 1.) The facility Policy and Procedure Oxygen Therapy dated 8/20/2015 documented that when nasal cannula is being used, the staff nurse secures the tubing properly. On 08/06/19 at 10:59 AM, Resident #135 was observed to be lying in bed. The resident had a nasal cannula inserted into her nose. The tubing connecting the nasal cannula to the flow meter on the wall behind the resident's bed was hanging down the side of the bed and laying on the floor. The tubing was labeled with a handwritten date of 8/5/19. After multiple observations of the oxygen tubing being on the floor, the State Agent (SA) observed a Certified Nursing Assistant (CNA) enter the resident's room at 12:07 PM to address a beeping tube feeding monitor attached to Resident #135. The CNA left the room without addressing the oxygen tubing on the floor. The Licensed Practical Nurse (LPN) #1 then entered the room at 12:11 PM to flush the resident's feeding tube. The feeding tube pole and LPN #1 were stationed directly next to the oxygen tubing that was on the floor. LPN #1 then left the room without addressing the oxygen tubing on the floor. During a follow-up visit to the resident's room on 08/06/19 at 02:38 PM, the SA observed that oxygen tubing with the date of 8/5/19 was still on the floor and attached to the nasal cannula for Resident #135. On 08/06/19 at 12:39 PM, an interview was conducted with LPN #1. The SA brought LPN #1 to the room of Resident #135 to observe the oxygen tubing on the floor. LPN #1 stated that the oxygen the tubing is too long. LPN #1 stated that she does not want to wrap it around the bed frame because it can be pulled on and damaged if the CNAs are providing care to the resident. LPN #1 stated that the oxygen tubing should be kept off the floor and may benefit from being draped across the bedside table. Even though the tubing gets coiled up and placed on the table, it still sometimes hits the floor. LPN #1 then proceeded to take the oxygen tubing off of the floor and place it on the table without donning gloves. The oxygen tubing was not replaced. 2) On 08/06/19 at 11:13 AM, Resident #137 was observed to be lying in bed. The resident had a nasal cannula attached to his nose and was connected to the flow meter on the wall behind his bed by oxygen tubing. The oxygen tubing was observed to be hanging onto the floor by the resident's bedside. The tubing was labeled with the date of 8/5/19. On 08/06/19 at 12:02 PM, the SA observed that the resident continued to have a nasal cannula in his nose and also had a nebulizer mask placed over the nasal cannula. LPN #2 was observed coming into the resident's room to remove the nebulizer mask. LPN #2 did not address the oxygen tubing on the floor. On 08/06/19 at 12:02 PM, an interview was conducted with LPN #2. LPN #2 stated that she is a floater. She stated that the oxygen tubing for this resident is longer and harder to keep off of the floor because the resident is toileted in the bathroom in his room while still wearing it. LPN #2 stated that the length of the tubing makes it difficult to control and to keep off of the floor. The SA then observed as LPN #2 proceeded to pick up the oxygen tubing off of the floor and wrap it around the nebulizer machine at the resident's bedside in order to keep it off of the floor. LPN #2 did not change the tubing after picking it up off of the floor. An interview was conducted on 08/09/19 at 10:19 AM with the Infection Preventionist (IP). The IP stated that she conducts in-services on all shifts for nursing staff, meets with the staff one-on-one if they have any issues, and makes rounds to ensure that all staff are following the infection control policies. The IP also stated she gives competency evaluations to nursing staff on all shifts and if there is an issue she will re-inservice the staff member and make sure they understand the process. IP stated infection control is important and an ongoing process because she wants the infection control practices to be second nature to staff. 3) On 08/06/2019 at 10:00 AM, during the initial pool observations conducted on Unit 2 of the(NAME)Reingold Pavilion, the following rooms were observed with either an oxygen tank or oxygen concentrator with an attached nebulizer that was not covered: 205 W, 220 S, 234 S, 238 S, 2-241 S, 222 B-1, and 222 A. An interview was conducted immediately with the RN Unit Manager #4 who stated that nasal cannulas, nebulizers and other devices should be covered at all times when not in use. 4) Resident # 13 is an [AGE] year-old male admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident with moderately impaired cognition and totally dependent on staff for Activities of Daily Living (ADL's). Physician order [REDACTED]. On 08/09/2019 at 10:10 AM, during a wound care observation, Resident #13 was observed in bed positioned on his left side. Certified Nursing Assistants (CNA's) # 4 and #5 and Registered Nurse (RN) # 7 introduced themselves and checked the residents ID Band. All staff proceeded to wash hands and donned gloves. RN #7 cleansed working table with Clorox sanitizing wipes, removed gloves, washed hands, donned gloves and prepared supplies. No breaks in infection control were observed. Resident #13 was repositioned onto his right lateral side and the diaper was opened. A dressing was observed on the left hip. RN #7 removed the dressing which contained moderate exudate. The wound site was observed with necrotic tissue and redness to the periwound area. RN #7 removed her gloves, washed her hands with soap and water and donned clean gloves. She proceeded to cleanse the wound site with 4 x 4 gauze moistened with NSS several times. RN #7 then applied Santyl ointment to the wound and covered the wound with a foam dressing fastened with tape. RN #7 did not perform hand hygiene after cleansing the wound bed site and before applying treatment to the wound. RN#7 discarded the soiled field, washed her hands, donned clean gloves and prepared supplies for the second site. Resident #13 was re-positioned onto his left side. A dressing was observed on the right hip. The RN washed her hands, donned gloves, removed the soiled dressing. Moderate exudate was observed on the soiled dressing and wound was observed to have necrotic tissue, and redness to the periwound area. RN #7 removed her gloves, washed her hands and donned clean gloves. The wound site was cleansed with 4 x 4 gauze moistened with NS 3 times. RN #7 then applied Santyl ointment to the wound and covered the wound with a foam dressing. RN #7 did not perform hand hygiene after cleansing the wound bed site and before applying treatment to the wound. The facility Dressing Technique Audit dated 1/30/09 documented that after cleansing the wound, the area should be dried and treatment applied. The audit tool does not not reflect that after cleansing a wound, the nurse should wash hands and don new gloves before applying the treatment and clean dressing. 415.19(a)(1-3)

Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure a comprehensive care plan was developed to address a resident's contractures. This was evident for 1 of 2 residents reviewed for Limited Range of Motion out of a total sample of 38 residents (Resident #143). The finding is: Resident #143 was admitted to the facility on [DATE]. The resident's active [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had severely impaired cognition. The MDS further documented that the resident had range of motion (ROM) impairment on both sides of the lower and upper extremities. On 08/06/19 at 9:55 AM and 08/07/19 at 10:00 AM, the resident was observed with a contracture to bilateral (b/l) hands with no splint devices in place. On 08/08/19 at 12:46 PM, the resident was observed in the day room, sitting in the geri chair with both hands contracted. No splint devices were in place. The physician's orders [REDACTED]. Bilateral functional hand splints for daytime use. Remove 2 times to check for hand hygiene and provide ROM. Bilateral resting hands splints to be worn in/out of bed, check every 3 hours for skin irritation and for hand hygiene. There was no documented evidence in the medical record that a Comprehensive Care Plan regarding care for the resident's contractures and hand splints was developed. On 08/08/19 at 02:50 PM, the Registered Nurse Manager (RN #9) was interviewed. She stated that she is responsible for the care plan, and for whatever reason she did not include a care plan for contracture. She stated that it was an oversight. She stated that the care plans are updated periodically and during quarterly assessments. She could not explain why it was missed. 415.11(c)(1)

Based on observations, record review and staff interviews, the facility did not ensure that residents are assessed using the standardized Quarterly Review assessment tool no less than once every three months between comprehensive assessments. Specifically, a resident's Quarterly Minimum Data Set 3.0 (MDS) assessment was not completed within 3 months of the previous quarterly assessment. This was evident for 1 of 3 residents reviewed for Resident Assessment (Resident #2). The finding is: Resident #2 was admitted to the facility on [DATE]. A Quarterly MDS dated [DATE] was completed for the resident. A Quarterly MDS dated [DATE] was initiated in the medical record, but the assessment was incomplete. There was no documented evidence that a quarterly MDS was completed for the resident within 3 months of the last assessment. A quarterly MDS should have been done by 6/29/19. On 08/12/2019 at 12:45 PM and 1:52 PM, an interview was conducted with the Associate Director of MDS (RN #2). She stated that all Medicaid residents are required to have a quarterly assessment every 3 months, and Medicare residents should have an assessment within 5, 14, 30, 60, and 90 days of admission and annually. There are seven MDS Coordinators in the facility, two of which are assigned to the short-term units. Once the MDS assessments are completed, they are submitted to her for review and final submission. The Associate Director stated that she was aware that the resident's assessment was overdue. The MDS assessments were being tracked manually (paper system). She stated the facility is in the process of converting to a new electronic system. On 8/12/2019 at 12:56 PM, an interview was conducted with the MDS Coordinator (RN #2) assigned to the resident's unit. She stated that the MDS schedule is done by the MDS Associate Director or by another staff member in the MDS office. She stated that follows the schedule for completion dates and submits her work to the Associate Director for final review and submission. RN #2 stated that she was aware that the resident's assessment was overdue. Once she became aware, she initiated the assessment dated [DATE]. RN #2 further stated that she was assigned a lot of MDS assessments to complete during this time period, and the resident's assessment was not completed. 415.11(a)(4)

Based on observation, record review and staff interview during the recertification survey, the facility did not ensure that a resident had the right to and the facility promoted and facilitated resident self-determination through support of resident choice. Specifically, a resident who preferred to have her shower/bath in the morning instead of the evening was scheduled for evening showers. This was evident for 1 of 1 resident reviewed for Choices (Resident #669). The finding is: The facility policy on Patient Centered Activities of Daily Living (ADLs) revised on 04/30/2019 documented: The Hebrew Home at Riverdale will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. This includes the resident's ability to bathe, dress and groom. The procedure includes encouraging and incorporating resident preferences related to ADL care and encouraging independence to the highest capability of the resident. Resident #669 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition (with a brief interview of mental status score of 11 out of 15). The resident required the assist of one person to provide physical help in part of bathing. The assessment further documented that on interview for daily preferences the resident responded it was very important to choose between a bath or shower. During an initial visit and interview with the resident on 08/06/2019 at 12:18 PM, the resident stated that they have not had a shower since admission. The resident further stated,who gets a shower in the night? On 08/08/2019 at 12:00 PM, resident was visited again in her room and stated, I still did not have a shower since I came here. The Comprehensive Care Plan documented for ADLs dated 7/13/19 documented the resident prefers to be bathed in the morning on any day from Monday to Sunday. Review of the certified nursing assistant activity record (CNAAR) documented that the plan of care includes a shower twice (2) per week scheduled during the evening shift. Review of the CNAAR report reveals no shower was rendered from 07/13/2019 to 07/29/2019. The report indicated there was no shower scheduled. Further review of the CNAAR documented the resident received a shower in the evening on 8/1. The resident refused showers in the evening on 8/3, 8/5, and 8/10. On 8/8 the record indicated not documented. The resident received a shower during the day shift on 8/11 at 11:43 AM. The Registered Nurse Unit manager (RN #4) was interviewed on 08/12/2019 at 12:00 PM. She stated the record shows the resident has been offered a shower, but she refused. The surveyor pointed out that the resident was offered showers in the evening. The RN stated that no one informed her that the resident prefers to have showers in the morning. Any charge nurse can make changes to the schedule anytime. 415.5(b)(1-3)

Based on observation, interviews, and record reviews conducted during the recertification survey, the facility did not ensure that a resident's dignity was maintained. Specifically, a resident with a urinary catheter was observed on multiple occasions to have no dignity bag covering the attached urine bag. This was evident for 1 of 1 resident reviewed for Dignity (Resident #13). The findings are: Resident #13 is a resident admitted [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had moderately impaired cognition with short-term memory loss and a [DIAGNOSES REDACTED]. The resident is also documented as having urinary incontinence requiring the use of a catheter. On 08/06/19 at 11:18 AM, Resident #13 was observed in bed. The resident's urinary catheter tubing and drainage bag (approximately 1/4 filled with urine) was attached to the resident's hospital bed and was visible from the hallway when passing the resident's room. There was no dignity bag to cover the drainage bag. The State Agent (SA) made multiple subsequent observations of the drainage bag without a dignity bag cover on 8/7/19 at 12:03 PM and 8/8/19 at 9:50 AM. physician's orders [REDACTED]. On 08/08/19 at 09:52 AM, an interview was conducted with Certified Nursing Assistant (CNA #3), the CNA assigned to Resident #13. CNA #3 stated that she is a floater that works intermittently with the resident, and the resident is not on her regular assignment. CNA #3 stated that she will usually change the drainage bag and clean the area around the catheter tube. CNA #3 stated that she does not believe that the facility provides dignity bags to residents who have urinary catheters. She has not seen them in use with other residents, and she could not recall using dignity bags when assisting other residents with urinary catheters. CNA #3 stated that that she was inserviced on catheter care when she first had orientation, but she could not recall a. inservice providing information on how to place the drainage bag to maintain a resident's dignity while in bed or when to use a dignity bag. CNA #3 stated that when a resident is taken out of bed, the CNA ensures that the drainage bag is covered with a sheet or held under the pants with a leg bag. On 08/08/19 at 02:35 PM, an interview was held with Registered Nurse (RN #8), the nurse manager for the unit. RN #8 is also the Inservice Coordinator. RN #8 stated that when a resident with a urinary catheter is in bed, the drainage bag should be covered. RN #8 further stated that the dignity bag that Resident #13 had previously used was damaged few days ago. That dignity bag was discarded and a new one was ordered. RN #8 stated that as of now, the dignity bags were not in stock. An interim makeshift dignity bag has now been placed over the drainage bag until the order is delivered. RN #8 stated that the CNAs are required to complete competency and inservice regarding catheter care every 6 months. 415.3(c)(1)(i)