Every finding on record at Hope Center for HIV and Nursing Care

Based on record review, and interviews during survey, the facility did not ensure that the physician reviewed the resident's total program of care, including medications and treatments, at each visit. This was evident in one out of four residents sampled. Specifically, Resident #1 was on Warfarin (blood thinner), and Medical Doctor #1 ordered laboratory tests on 03/10/2026 and 03/18/2026 for Prothrombin Time (measures how long your blood takes to clot) and International Normalized Ratio level (used to monitor patients taking blood-thinning medications) and several other laboratory tests. Medical Doctor #1 failed to follow up on several laboratory tests they ordered. Cross Reference: F658 Services Meet Professional Standards and F684 Quality of CareThe findings include:A facility policy titled ' Anticoagulation Therapy' with a revision date of 03/2019 documented that all residents requiring anticoagulation therapy will have labs drawn as ordered by the physician to determine effectiveness of therapy and subsequent dosages. Clinical Staff will monitor residents as needed for safety of medication therapy. In addition, the nurse shall assess and document/report the following recent labs, including therapeutic dose monitoring. The physician should stop, taper, or change medications that interact with Warfarin, or monitor the Prothrombin Time/ International Normalized Ratio very closely while the individual is receiving Warfarin, to ensure that the Prothrombin Time/ International Normalized Ratio stabilizes.A facility policy titled ' Lab/Test Results- Reporting' with a revision date of 10/22/2025 documented that the facility provides resident laboratory services in an accurate, safe, and timely manner in accordance with current standards of practice and federal and state regulations. The licensed nurse will notify the Health Care provider (HCP) of any abnormal laboratory test results and will document the notification and additional orders as indicated in the clinical record.Resident #1 was admitted to the facility with diagnoses including atrial fibrillation (irregular heart rhythm), diabetes mellitus (high sugar in the blood) and heart failure (heart muscle does not pump enough blood).The Minimum Data Set (a resident assessment tool) dated 03/17/2026 documented Resident #1 had intact cognition. The assessment documented that Resident #1 was receiving an anticoagulant medication.A hospital Inpatient Discharge Summary signed 03/10/2026 documented that Resident #1 was discharged from the hospital on Warfarin 4 milligram at bedtime. The recommendation was repeating the international normalized ratio while at nursing home to ensure levels remain therapeutic as Resident #1 was previously on 5.5 milligram daily.An Order Summary Report written by Medical Doctor #1 dated 03/10/2026 documented Warfarin Sodium (blood-thinner) oral tablet 2 milligram (Warfarin Sodium) give 2 tablets by mouth in the morning for anticoagulant therapy.An Order Summary Report written by Medical Doctor #1 dated 03/10/2026 documented monitor for signs and symptoms of bleeding while receiving Warfarin. Notify Medical doctor if resident has dark/discolored urine, black tarry stools, nosebleed, vomiting and /or coughing out blood every shift. If bleeding occurs check results of last prothrombin time/ international normalized ratio as well as notify medical doctor. An Order Summary Report written by Medical Doctor #1 dated 03/10/2026 documented notify Medical Doctor of previous and current lab results, date of next Prothrombin Time/ International Normalized Ratio to be done on 04/07/2026 one time only for Warfarin. Laboratory monitoring for seven days to be scheduled on date of next Prothrombin Time/ International Normalized Ratio. Warfarin should not be administered until lab results are reviewed.An Order Summary Report written by Medical Doctor #1 dated 03/18/2026, revealed that several laboratory tests ordered were not done. Tests include Prothrombin Time/ International Normalized Ratio, Partial Thromboplastin Time, CD4 Count (a type of white blood cell), CD8 Count (type of white blood cell that directly attacks and destroys virus-infected cells, abnormal cells, and certain cancer cells), RFTs (Renal Function Tests) with electrolytes, Liver Function Tests, Hemoglobin A1c, TSH (thyroid stimulating hormone), Vitamin D (25-Hydroxy), Extended Storage, Serum, Free T4 (Thyroxine, Direct), Total T3 (Triiodothyronine), CMP14, Lipid Panel, CBC ( Complete Blood Count) with Differential, Platelet Count, RPR (Rapid Plasma [NAME], a blood test used to screen for syphilis), Urinalysis, Thyroid Panel, HCV RT-PCR Quantitative (Hepatitis C Viral Load), and Hepatitis Panel (Hepatitis A, B, Hepatitis C).There was no documented evidence that the above laboratory tests were performed. There was no documented evidence that Medical Doctor #1 and Registered Nurse Supervisor #1 were notified.A nursing note dated 04/09/2026 by Licensed Practical Nurse #1 documented notify medical doctor of previous and current lab results, date of next prothrombin time/ international normalized ratio 04/07/2026 one time only for Warfarin. Laboratory monitoring for seven days to be scheduled on date of next prothrombin time/ international normalized ratio. Warfarin should not be administered until lab results are reviewed.A review of the medical notes dated 03/18/2026 through 04/24/2026 revealed there was no documented evidence Medical Doctor #1 followed up on the laboratory tests that they ordered.An attempt was made to contact Medical Doctor #1 on 07/16/2026 at 11:50 AM but they were unavailable due to being out of state.During a telephone interview on 07/16/2026 at 12:07 PM, Medical Director stated that when Resident #1 on Warfarin medication, they monitored the prothrombin time and international normalized ratio. They stated that monitoring depends on the clinician and how often they want to see the levels. Medical Director stated that nursing should have notified the medical doctor that the lab tests were not done and the medical doctor should have followed up. Medical Director stated they oversee the care of residents in the facility and that they were not aware Resident #1's labs were not performed. 10 New York Codes, Rules, and Regulations 415.15 (b)(2)(iii)

Based on record reviews and interviews during survey, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice. This was evident for one out of four residents (Resident #1) sampled. Specifically, Resident #1 had a Physician's Order dated 03/10/2026 and 03/18/2026 for laboratory tests to be done for Prothrombin Time (measures how long your blood takes to clot) and International Normalized Ratio level (used to monitor patients taking blood-thinning medications) and several other laboratory tests. Record review revealed that laboratory tests were not performed, and a Nursing Supervisor and Medical Doctor were not notified.The findings include:A facility policy titled 'Anticoagulation Therapy' with a revision date of 03/2019 documented that all residents requiring anticoagulation therapy will have labs drawn as ordered by the physician to determine effectiveness of therapy and subsequent dosages. Clinical Staff will monitor residents as needed for safety of medication therapy. In addition, the nurse shall assess and document/report the following recent labs, including therapeutic dose monitoring. The physician should stop, taper, or change medications that interact with Warfarin, or monitor the Prothrombin Time/ International Normalized Ratio very closely while the individual is receiving Warfarin, to ensure that the Prothrombin Time/ International Normalized Ratio stabilizes.A facility policy titled 'Lab Services' with a revision date of 08/2019 documented that the facility will provide or obtain laboratory services to meet the needs of its residents. The facility will promote practices to ensure the quality and timeliness of laboratory services including routine and STAT (immediately or without delay) labs. Laboratory services may only be provided or obtained when ordered by the resident's physician. The licensed staff will make appointment and arrangements with the facility's laboratory for all of the resident's ordered laboratory tests.A facility policy titled 'Lab/Test Results- Reporting' with a revision date of 10/22/2025 documented that the facility provides resident laboratory services in an accurate, safe, and timely manner in accordance with current standards of practice and federal and state regulations. The licensed nurse will notify the Health Care provider (HCP) of any abnormal laboratory test results and will document the notification and additional orders as indicated in the clinical record.Resident #1 was admitted to the facility with diagnoses including atrial fibrillation (irregular heart rhythm), diabetes mellitus( high sugar in the blood) and heart failure (heart muscle does not pump enough blood).The Minimum Data Set (a resident assessment tool) dated 03/17/2026 documented Resident #1 had intact cognition. The assessment documented that Resident #1 was receiving an anticoagulant medication.A hospital Inpatient Discharge Summary signed 03/10/2026 documented that Resident #1 was discharged from the hospital on Warfarin 4 milligram at bedtime. The recommendation was to repeat the international normalized ratio while at nursing home to ensure levels remain therapeutic as Resident #1 was previously on 5.5 milligram daily.An Order Summary Report written by Medical Doctor #1 dated 03/10/2026 documented Warfarin Sodium (blood-thinner) oral tablet 2 milligram (Warfarin Sodium) give 2 tablets by mouth in the morning for anticoagulant therapy.An Order Summary Report written by Medical Doctor #1 dated 03/10/2026 documented monitor for signs and symptoms of bleeding while receiving Warfarin. Notify Medical doctor if resident has dark/discolored urine, black tarry stools, nosebleed, vomiting and /or coughing out blood every shift. If bleeding occurs check results of last prothrombin time/ international normalized ratio as well as notify medical doctor. An Order Summary Report written by Medical Doctor #1 dated 03/10/2026 documented notify Medical Doctor of previous and current lab results. Date of next Prothrombin Time/ International Normalized Ratio 04/07/2026 a onetime only for Warfarin. Laboratory monitoring for seven days to be scheduled on date of next Prothrombin Time/ International Normalized Ratio. Warfarin should not be administered until lab results are reviewed.An Order Summary Report written by Medical Doctor #1 dated 03/18/2026, revealed several laboratory tests were ordered and not done. Tests include Prothrombin Time/ International Normalized Ratio/Partial Thromboplastin Time, CD4 Count (a type of white blood cell), CD8 Count (type of white blood cell that directly attacks and destroys virus-infected cells, abnormal cells, and certain cancer cells), RFTs (Renal Function Tests) with electrolytes, Liver Function Tests, Hemoglobin A1c, TSH (thyroid stimulating hormone), Vitamin D (25-Hydroxy), Extended Storage, Serum, Free T4 (Thyroxine, Direct), Total T3 (Triiodothyronine), CMP14, Lipid Panel, CBC ( Complete Blood Count) with Differential, Platelet Count, RPR (Rapid Plasma [NAME], a blood test used to screen for syphilis), Urinalysis, Thyroid Panel, HCV RT-PCR Quantitative (Hepatitis C Viral Load), Hepatitis Panel (Hepatitis A, B, Hepatitis C).There was no documented evidence that the laboratory tests ordered on 03/10/2026 and 03/18/2026 were performed. There was no documented evidence that Medical Doctor #1 and Registered Nurse Supervisor #1 were notified.A review of the Medication Administration Record from 03/11/2026 through 04/24/2026, revealed that Warfarin Sodium oral tablet 2 milligram give 2 tablets by mouth in the morning for anticoagulant therapy revealed that Warfarin was being administered to Resident #1 without knowledge of Prothrombin Time/International Normalized Ratio level results. A risk for bleeding secondary to anticoagulant use care plan initiated on 03/16/2026 documented interventions to monitor for signs and symptoms of abnormal bleeding (skin bruising, bleeding gums, black stools, coffee ground like emesis, blood in urine). Monitor laboratory values and notify Medical Doctor of abnormal findings (Prothrombin Time, Partial Thromboplastin Time, International Normalized Ratio).A nursing note dated 04/09/2026 by Licensed Practical Nurse #1 documented notify medical doctor of previous and current lab results, date of next prothrombin time/ international normalized ratio 04/07/2026 one time only for Warfarin. Laboratory monitoring for seven days to be scheduled on date of next prothrombin time/ international normalized ratio. Warfarin should not be administered until lab results are reviewed. ThA review of the medical notes dated from 03/18/2026 through 04/24/2026 revealed there was no documented evidence Medical Doctor #1 followed up on the laboratory tests that they ordered for Warfarin to be done.During a telephone interview on 07/15/2026 at 10:37 AM, Resident #1 (who was the complainant) stated the facility did not perform any blood work tests on them since their admission to the facility. Resident #1 stated they kept asking when they would have blood drawn because they were on anticoagulant medication. Resident #1 stated they spoke to the nurses and multiple doctors who came, and they kept telling them they would do it. Resident #1 stated they regularly taking Warfarin and grateful they did not experience any bleeding.During a telephone interview on 07/16/2026 at 10:49 AM, Licensed Practical Nurse #1 stated they remember Resident #1 taking Warfarin and was monitored for bleeding and bruising. Licensed Practical Nurse #1 stated they did not check if the laboratory tests (for Prothrombin Time/International Normalized Ratio) were done. Licensed Practical Nurse #1 stated they do not recall documenting the notes for 04/09/2026.During a telephone interview on 07/16/2026 at 1:08 PM, Licensed Practical Nurse #2 stated the medical doctor comes to the unit, and they follow up the laboratory test results. Licensed Practical Nurse #2 stated different nurses work in the unit and if they confirmed an order for laboratory test, the phlebotomist (healthcare professional trained to collect blood) would pick up the order and would come to do the test. Licensed Practical Nurse #2 stated they work two to three days per week and were not aware the laboratory tests for Resident #1 were not performed.During an interview on 07/15/2026 at 5:36 PM, Director of Nursing stated they admitted Resident #1 on 03/10/2026 and that Medical Doctor #1 ordered laboratory test for Resident #1. The Director of Nursing stated that the phlebotomist left the facility and that is the reason the Resident #1's blood works were not done, and they did not follow up. Director of Nursing stated that Resident #1 did not want to get out of bed via mechanical lift to go to an outside lab to get blood test done. Director of Nursing stated they missed the documentation regarding the conversation between them and Resident #1. Director of Nursing stated that other residents were sent to another laboratory to get their labs done. Director of Nursing stated that the doctors check their lab results on the computer. Director of Nursing stated they were not aware Resident #1's lab work was not done and that no one notified them. Director of Nursing stated something got lost in transaction and the order was missed. During a telephone interview on 07/16/2026 at 12:07 PM, Medical Director stated that when Resident #1 on Warfarin medication, they monitored the prothrombin time and international normalized ratio. They stated that monitoring depends on the clinician and how often they want to see the levels. Medical Director stated that nursing should have notified the medical doctor that the lab tests were not done and the medical doctor should have followed up. Medical Director stated they oversee the care of residents in the facility and that they were not aware laboratory tests for Resident #1 were not performed. 10 New York Codes, Rules, and Regulations 415.12

Based on record reviews and interviews during survey, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice. This was evident for one out of four residents (Resident #1) sampled. Specifically, Resident #1 had a Physician's Order dated 03/10/2026 and 03/18/2026 for laboratory tests to be done for Prothrombin Time and International Normalized Ration (used to monitor patients taking blood-thinning medications) and several other tests. Record review revealed that the laboratory tests were not performed, and a Nursing Supervisor and Medical Doctor were not notified.Cross Reference: F684 - Quality of CareThe findings include:A facility policy titled 'Anticoagulation Therapy' with a revision date of 03/2019 documented that all residents requiring anticoagulation therapy will have labs drawn as ordered by the physician to determine effectiveness of therapy and subsequent dosages. Clinical Staff will monitor residents as needed for safety of medication therapy. In addition, the nurse shall assess and document/report the following recent labs, including therapeutic dose monitoring. The physician should stop, taper, or change medications that interact with Warfarin, or monitor the Prothrombin Time/ International Normalized Ratio very closely while the individual is receiving Warfarin, to ensure that the Prothrombin Time/ International Normalized Ratio stabilizes.A facility policy titled 'Lab Services' with a revision date of 08/2019 documented that the facility will provide or obtain laboratory services to meet the needs of its residents. The facility will promote practices to ensure the quality and timeliness of laboratory services including routine and STAT (immediately or without delay) labs. Laboratory services may only be provided or obtained when ordered by the resident's physician. The licensed staff will make appointment and arrangements with the facility's laboratory for all of the resident's ordered laboratory tests.A facility policy titled 'Lab/Test Results- Reporting' with a revision date of 10/22/2025 documented that the facility provides resident laboratory services in an accurate, safe, and timely manner in accordance with current standards of practice and federal and state regulations. The licensed nurse will notify the Health Care provider (HCP) of any abnormal laboratory test results and will document the notification and additional orders as indicated in the clinical record.Resident #1 was admitted to the facility with diagnoses including atrial fibrillation (irregular heart rhythm), diabetes mellitus( high sugar in the blood) and heart failure (heart muscle does not pump enough blood).The Minimum Data Set (a resident assessment tool) dated 03/17/2026 documented Resident #1 had intact cognition. The assessment documented that Resident #1 was receiving an anticoagulant medication.A hospital Inpatient Discharge Summary signed 03/10/2026 documented that Resident #1 was discharged from the hospital on Warfarin 4 milligram at bedtime. The recommendation was to repeat the international normalized ratio while at nursing home to ensure levels remain therapeutic as Resident #1 was previously on 5.5 milligram daily.An Order Summary Report written by Medical Doctor #1 dated 03/10/2026 documented Warfarin Sodium (blood-thinner) oral tablet 2 milligram (Warfarin Sodium) give 2 tablets by mouth in the morning for anticoagulant therapy.An Order Summary Report written by Medical Doctor #1 dated 03/10/2026 documented monitor for signs and symptoms of bleeding while receiving Warfarin. Notify Medical doctor if resident has dark/discolored urine, black tarry stools, nosebleed, vomiting and /or coughing out blood every shift. If bleeding occurs check results of last prothrombin time/ international normalized ratio as well as notify medical doctor. An Order Summary Report written by Medical Doctor #1 dated 03/10/2026 documented notify Medical Doctor of previous and current lab results. Date of next Prothrombin Time/ International Normalized Ratio 04/07/2026 a onetime only for Warfarin. Laboratory monitoring for seven days to be scheduled on date of next Prothrombin Time/ International Normalized Ratio. Warfarin should not be administered until lab results are reviewed.An Order Summary Report written by Medical Doctor #1 dated 03/18/2026, revealed several laboratory tests were ordered and not done. Tests include Prothrombin Time/ International Normalized Ratio/Partial Thromboplastin Time, CD4 Count (a type of white blood cell), CD8 Count (type of white blood cell that directly attacks and destroys virus-infected cells, abnormal cells, and certain cancer cells), RFTs (Renal Function Tests) with electrolytes, Liver Function Tests, Hemoglobin A1c, TSH (thyroid stimulating hormone), Vitamin D (25-Hydroxy), Extended Storage, Serum, Free T4 (Thyroxine, Direct), Total T3 (Triiodothyronine), CMP14, Lipid Panel, CBC ( Complete Blood Count) with Differential, Platelet Count, RPR (Rapid Plasma [NAME], a blood test used to screen for syphilis), Urinalysis, Thyroid Panel, HCV RT-PCR Quantitative (Hepatitis C Viral Load), Hepatitis Panel (Hepatitis A, B, Hepatitis C).There was no documented evidence that the laboratory tests ordered on 03/10/2026 and 03/18/2026 were performed. There was no documented evidence that Medical Doctor #1 and Registered Nurse Supervisor #1 were notified.A review of the Medication Administration Record from 03/11/2026 through 04/24/2026, revealed that Warfarin Sodium oral tablet 2 milligram give 2 tablets by mouth in the morning for anticoagulant therapy revealed that Warfarin was being administered to Resident #1 without knowledge of Prothrombin Time/International Normalized Ratio level results. A risk for bleeding secondary to anticoagulant use care plan initiated on 03/16/2026 documented interventions to monitor for signs and symptoms of abnormal bleeding (skin bruising, bleeding gums, black stools, coffee ground like emesis, blood in urine). Monitor laboratory values and notify Medical Doctor of abnormal findings (Prothrombin Time, Partial Thromboplastin Time, International Normalized Ratio).A nursing note dated 04/09/2026 by Licensed Practical Nurse #1 documented notify medical doctor of previous and current lab results, date of next prothrombin time/ international normalized ratio 04/07/2026 one time only for Warfarin. Laboratory monitoring for seven days to be scheduled on date of next prothrombin time/ international normalized ratio. Warfarin should not be administered until lab results are reviewed. ThA review of the medical notes dated from 03/18/2026 through 04/24/2026 revealed there was no documented evidence Medical Doctor #1 followed up on the laboratory tests that they ordered for Warfarin to be done.During a telephone interview on 07/15/2026 at 10:37 AM, Resident #1 (who was the complainant) stated the facility did not performed any blood work tests on them since their admission to the facility. Resident #1 stated they kept asking when they would have blood drawn because they were on anticoagulant medication. Resident #1 stated they spoke to the nurses and multiple doctors who came, and they kept telling them they would do it. Resident #1 stated they regularly taking Warfarin and grateful they did not experience any bleeding.During a telephone interview on 07/16/2026 at 10:49 AM, Licensed Practical Nurse #1 stated they remember Resident #1 taking Warfarin and was monitored for bleeding and bruising. Licensed Practical Nurse #1 stated they did not check if the laboratory tests (for Prothrombin Time/International Normalized Ratio) were done. Licensed Practical Nurse #1 stated they do not recall documenting the notes for 04/09/2026.During a telephone interview on 07/16/2026 at 1:08 PM, Licensed Practical Nurse #2 stated the medical doctor comes to the unit and they follow up the laboratory test results. Licensed Practical Nurse #2 stated different nurses work in the unit and if they confirmed an order for laboratory test, the phlebotomist (healthcare professional trained to collect blood) would pick up the order and would come to do the test. Licensed Practical Nurse #2 stated they work two to three days per week and were not aware the laboratory tests for Resident #1 were not performed.During an interview on 07/15/2026 at 5:36 PM, Director of Nursing stated they admitted Resident #1 on 03/10/2026 and that Medical Doctor #1 ordered laboratory test for Resident #1. The Director of Nursing stated that the phlebotomist left the facility and that is the reason the Resident #1's blood works were not done, and they did not follow up. Director of Nursing stated that Resident #1 did not want to get out of bed via mechanical lift to go to an outside lab to get blood test done. Director of Nursing stated they missed the documentation regarding the conversation between them and Resident #1. Director of Nursing stated that other residents were sent to another laboratory to get their labs done. Director of Nursing stated that the doctors check their lab results on the computer. Director of Nursing stated they were not aware Resident #1's lab work was not done and that no one notified them. Director of Nursing stated something got lost in transaction and the order was missed. During a telephone interview on 07/16/2026 at 12:07 PM, Medical Director stated that when Resident #1 on Warfarin medication, they monitored the prothrombin time and international normalized ratio. They stated that monitoring depends on the clinician and how often they want to see the levels. Medical Director stated that nursing should have notified the medical doctor that the lab tests were not done and the medical doctor should have followed up. Medical Director stated they oversee the care of residents in the facility and that they were not aware laboratory tests for Resident #1 were not performed. 10 New York Codes, Rules, and Regulations 415.11(c)(3)(i)

Based on observation, record review, and interviews during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility failed to maintain each resident's right to a safe, clean, comfortable, and homelike environment. This was evident in 1 (Units 2) of 3 units observed. Specifically, floors in residents' rooms were sticky and not waxed, there was a leak in the bathroom shower, the bedside tables had dirt and dust, and there was a missing window treatment. The findings include but are not limited to: The undated facility's policy titled Equipment Cleaning Procedure documented that the purpose of the policy is to provide a safe sanitary and comfortable environment for the resident. The undated facility's procedure on Resident Room Cleaning included weekly deep cleaning that includes dusting furniture, cleaning windows, and mopping the living space. The procedure also documented a 3-step floor care that included stripping, waxing, and buffing. The following were observed in Unit 2 during multiple observations from 05/12/2025 to 05/16/2025: 1. Resident #25's room had no window blinds. Resident #25 stated that there had been no blinds for the past 3 months, and that the light comes in that makes it difficult to use the phone. 2. Resident #25's bedside table was dusty and dirty. 3. The floors in Residents #25, #213, and #19's room were sticky and had brown stains. 4. Resident #19's bed side table was dusty and had spills. The walls have scuffed marks. 5. The shower head had a leak in Unit 2 bathroom. 6. On 05/12/2025 at 7:03 AM, room [ROOM NUMBER] had a strong urine odor. There were dirty diapers in a plastic bag on the floor next to the B bed. 7. Resident #213's bedside table was dusty and caked with dirt. Resident #213 was observed using an extension cord next to their bed. The resident stated the outlet in their room was plugged and they have no electric outlet to use. On 05/12/2025 at 12:59 PM, Housekeeper #1 was interviewed and stated the rooms need to be cleaned but they do not have the equipment to wax the floor. They stated Resident #25's window blinds were removed a week ago and that the Maintenance Department had to replace them. On 05/15/2025 at 5:21 PM, the Housekeeping Director was interviewed and stated that heavy cleaning on the units is scheduled every Tuesdays and Thursdays, and it include cleaning the bedside tables. The Housekeeping Director stated it is the housekeeper's responsibility to clean, strip, and buff the floors; and that they were not able to do any of those because they have been waiting for 3 months for the machines to be fixed. The Housekeeping Director stated they were notified today of the missing window blinds and that it needs to be replaced by the Maintenance Department. 10 NYCRR 415.5(h)(2)

Based on observation, record review, and interview during the Recertification Survey conducted from 05/12/2025 to 05/19/2025, the facility did not ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was evident in 3 (Residents #6 and #213) of 7 residents reviewed for respiratory care out of 19 total sampled residents. Specifically, 1.) Resident #6 received oxygen at a flow rate inconsistent with the physician's order. 2.) Residents #41 and 213's physician's order for the use of incentive spirometer 3 times daily was not implemented. The findings include: 1.) The facility policy titled Oxygen Therapy with a last revised date of 09/2022 stated that administering supplemental oxygen is an essential element of appropriate management for various clinical conditions. However, oxygen should be regarded as a drug and, therefore, requires prescribing in all but emergencies. Failure to administer oxygen appropriately can result in serious harm to the patient. Oxygen is delivered according to the physician's order. Resident #6 was admitted to the facility with diagnoses that included Heart Failure, Chronic Obstructive Pulmonary Diseases, and Respiratory Failure. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #6 had intact cognition. A physician's order dated 03/05/2025 documented oxygen 2 liters per minute via nasal cannula. On 05/12/2025 at 7:39 AM, 05/13/2025 at 9:20 AM, and 05/14/2025 at 9:32 AM, Resident #6 was observed receiving oxygen from an oxygen concentrator via nasal cannula. The oxygen flow meter was set at 3 liters per minute. On 05/12/2025 at 7:39 AM, Resident #6 was interviewed and stated their oxygen is set at 3 liters per minute and it has always been that way. On 05/15/2025 at 1:04 PM, Licensed Practical Nurse #2 was interviewed and stated that Resident #6 has an order to receive oxygen at 2 liters per minute. On 05/16/2025 at 12:28 PM, Registered Nurse #1, who was the nursing supervisor, was interviewed and stated that Resident #6 is supposed to receive oxygen at 2 liters per minute, but they regulate it to 3 liters per minute because the resident stated 2 liters per minute is not enough. On 05/15/2025 at 3:36 PM, the Primary Care Physician was interviewed and stated that Resident #6's oxygen order is continuous at 2 liters per minute. And that they are not aware that Resident #6 was getting 3 liters per minute instead. They stated they will evaluate the resident. On 05/16/2025 at 1:19 PM, the Director of Nursing was interviewed and stated that oxygen is administered according to the doctor's order. They stated it is the nurse's responsibility to ensure that Resident #6 receives 2 liters of oxygen as ordered. 2.) Resident #213 was admitted to the facility with diagnoses that included Pulmonary Mycobacterial Infection and Pneumocystosis. The admission MDS dated [DATE] documented Resident #213's cognition as intact, no impairments, independent with bed mobility, transfers, set up for toilet use, and always continent of bowel and bladder. The physician's order dated 05/01/2025 documented Incentive Spirometry (3) times per day for 10 breaths (resting in-between breaths as needed) every shift for potential/actual deficiency in lung capacity. A review of Resident #213's Treatment Administration Record from 05/01/2025 to 05/15/2025 had no documented evidence that incentive spirometry was performed as ordered on 22 occasions. Resident #213's medication administration notes dated 05/01/2025 at 8:38 PM, 05/02/2025 at 7:12 AM, 05/02/2025 at 7:01 PM, 05/07/2025 at 4:54 AM, 05/08/2025 at 5:12 AM, 05/09/2025 at 6:39 PM, 05/10/2025 at 1:53 PM, 05/10/2025 at 3:32 PM, 05/11/2025 at 9:42 AM, 05/11/2025 at 7:55 PM, 05/14/2025 at 10:48 PM, and 05/15/2025 at 5:17 AM documented that incentive spirometer was not available. On 05/15/2025 at 4:28 PM, Registered Nurse #1, who was the Registered Nurse Supervisor, was interviewed and stated they are aware that there is no incentive spirometer available for resident's use and that they told the Administrator's secretary to order them. On 05/15/2025 at 4:47 PM, the Administrative Assistant was interviewed and stated they are responsible for ordering nursing supplies and was made aware of the need for the incentive spirometers. The Administrative Assistant stated they ordered the incentive spirometer on 05/14/2025. On 05/16/2025 at 3:07 PM, the Primary Care Physician was interviewed and stated they were not aware that Resident #213 need an incentive spirometer. They stated that Resident #213 does not need the incentive spirometer initially and that they do not know why it was even ordered. On 05/15/2025 at 4:53 PM, the Director of Nursing was interviewed and stated that the attending physician must be notified if they do not have the equipment such as incentive spirometer. The Director of Nursing stated they have since ordered the incentive spirometer. 3.) Resident #41 was admitted to the facility with diagnoses that included Asthma and Acute Pulmonary edema. The physician's order dated 01/29/2025 documented Incentive Spirometry (3) times per day for 10 breaths, resting in-between breaths as needed, every shift to prevent respiratory complications. Resident #41's medication administration notes dated 05/08/2025 at 7:41 AM, 05/07/2025 at 9:54 PM, 05/07/2025 at 5:41 AM documented that incentive spirometer was not available. A physician progress note dated 05/16/2025 documented that Resident #41 was seen because they needed an incentive spirometer and a spirometer kit was ordered. A review of the interdisciplinary progress notes showed no documented evidence that the attending physician was notified prior to 05/16/2025 that there was no incentive spirometer available and that incentive spirometry had not been performed for Resident #41. On 05/15/2025 at 4:53 PM, the Director of Nursing was interviewed and stated that the attending physician must be notified if they do not have the equipment such as incentive spirometer. The Director of Nursing stated they have since ordered the incentive spirometer. 10 NYCRR 415.12(k)(6)

Based on observation, record review, and interviews during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility did not ensure that food were stored and prepared in accordance with professional standards for food service safety. This was evident during the kitchen task. Specifically, 1.) Outdated food items were stored in the refrigerator. 2.) Pureed food were not maintained at safe temperature. The findings are: 1.) The facility's policy titled Food Service with a last revision date of 01/2023 documented that dietary and nursing staff will be responsible to ensure that food items stored in pantry, refrigerators, and freezers are not expired or past perish dates. During observations conducted on 05/13/2025 at 10:10 AM, the unit refrigerator on the 3rd floor was observed with a container of sour cream dated 04/23/2025 and a soup container labelled with a resident's name and dated 04/25/2025. The unit refrigerator on the 4th floor had a container of low-fat milk dated 04/20/2025 and a container of sour cream dated 12/02/2024. On 05/13/2025 at 11:19 AM, Registered Nurse #1 was interviewed and stated that it is the housekeepers' responsibility to clean the refrigerators and remove any outdated food. On 05/13/2025 at 12:24 AM, the Housekeeper was interviewed and stated that the unit refrigerators are cleaned every day and that they check the dates on the food. They stated milk is sometimes kept for a few days past its expiration date. They stated that residents who keep food in the refrigerator are reminded to consume them within 2 days or the food will be discarded. 2.) The facility's policy titled Food Temperature with a last reviewed date of 03/2023 stated that all employees are responsible to notify their supervisor of any food item that does not meet the regulated safe acceptable ranges (at or below 41 degrees Fahrenheit or above 135 degrees Fahrenheit). On 05/13/2025 at 11:44 AM, tray line food temperatures were measured and revealed the following: pureed meat had a temperature of 130 degrees Fahrenheit, pureed vegetables had a temperature of 120 degrees Fahrenheit, and pureed soup was measured at 123 degrees Fahrenheit. On 05/15/2025 at 12:42 PM, the Food Services Director was interviewed and stated that the cook typically takes the food off the stove and then purees it, causing it to lose heat prior to serving. On 15/15/2025 at 12:52 PM, the Corporate Dietary Director was interviewed and stated it was possible that the temperature of pureed food were lower than regulatory parameters because they were recorded using an infrared thermometer. 10 NYCRR 415.14(h)

Based on record review and interviews conducted during the Recertification Survey from 05/12/2025 to 05/16/2025, the facility did not ensure that a drug regimen review performed by the Consultant Pharmacist was reviewed and acted upon by the attending physician or medical director in a timely manner. This was evident in 3 (Resident #2, #41, and #55) of 5 residents reviewed for Unnecessary Medications out of 19 total sampled residents. Specifically, there was no documented evidence that the attending physician addressed the consultant pharmacist's recommendations for Residents #2, #41, and #55 in a timely manner. The findings are: The facility's policy titled Pharmacy Consultant Medication Review with a last revised date of March 2020 documented that the pharmacy consultant shall review the medication regimen review (MRR) of each resident at least monthly and more frequently as needed. The Pharmacy Consultant should report irregularities to the attending physician, medical director, and the Director of Nursing with the resident's medication regimen. The Pharmacy Consultant will document their findings and recommendations on the monthly drug/regimen review report. The Director of Nursing will provide the Unit Manager or Designee with a copy of the unit's monthly pharmacy report and ensure that all recommendations are communicated to the resident physicians. The Director of Nursing will also remind the resident's physician to sign the resident's consultant report, which is filed in the resident's chart. The Director of Nursing will notify the facility's medical director if the resident's physician does not follow through on the consultant's recommendations. 1. Resident #2 was admitted to the facility with diagnoses that included Arterial Fibrillation, Diabetes Mellitus, Anxiety Disorder, and Depression. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #2's cognition as intact. The resident received antianxiety, antidepressants, and opioids. The pharmacy consultant notes dated 12/28/2024 documented an evaluation of the need for the use of Robitussin. There was no documented evidence of when the Physician and Medical Director responded to the recommendation. The medication regimen report dated 04/25/2025 recommended increasing the dose of Metformin to 875 milligrams from 500 milligrams. There was no documented evidence of when the Physician and Medical Director responded to the recommendation. On 05/15/2025 at 3:23 PM, the Primary Care Physician was interviewed and stated they do not know they had to put the date on the response. They stated they typically respond within 7 business days, but do not include the date of the response. 3.) Resident #55 was admitted to the facility with diagnoses that includes Anxiety Disorder and Lung Disease. The Quarterly Minimum Data Set, dated [DATE] documented Resident #55's cognition as intact, feeling down, depressed, or hopeless, occurring 2-6 days takes an antianxiety, an antidepressant, and had no gradual dose reduction done. The physician's order dated 05/13/2025 documented Trazodone Hydrochloride Oral Tablet 50 milligram, one tablet by mouth at bedtime for Depression. The Pharmacy Consultant Medication Regimen Review note dated 03/30/2025 documented to see report: page 19. The Pharmacy Consultant Note dated 04/24/2025 documented see report: Psych 3/12, Trazadone dose 50 milligram from 25. The facility was not able to provide a copy of the report and had no documented evidence that the findings were reviewed and addressed by the Physician and/or the Medical Director. On 05/15/2025 at 3:32 PM, the Pharmacy Consultant was interviewed and stated that the monthly medication regimen review is done remotely, and that the medication regimen review form or report is submitted to the Director of Nursing. They stated that if the recommendations were not corrected, they would follow up and would write the same recommendations. On 05/16/2025 at 3:15 PM, the Primary Care Physician was interviewed and stated they are not aware when the Pharmacy Consultant completes the medication regimen review. They stated the Administrator sends them the medication regimen review report and addresses them as they are sent. On 05/16/2025 at 3:23 PM, the Director of Nursing was interviewed and stated the Pharmacy Consultant emails the medication regimen review report to the Director of Nursing and the Administrator. Once the report is received, it is reviewed by the medical provider and the response must be made within 7 days. The Director of Nursing stated the Medical Director is given a copy of the report, they review and discuss the report with the primay care physician if there is an issue. On 05/16/2025 at 4:19 PM, the Medical Director was interviewed and stated that the recommendations on the medication regimen review are to be responded within the week or 2, and if they agree, the primary physician will make the changes based on the recommendations. They stated that medication regimen review is reviewed when the pharmacist sends the report. The report should be signed and dated when the recommendations are made. 10 NYCRR 415.18(c)(2) 2.) Resident #41 had diagnoses of Bipolar and Schizoaffective Disorders. The Comprehensive Minimum Data Set assessment dated [DATE] documented Resident #41 had received mood stabilizing medications since admission into the facility. A Physician Order Report documented on 03/10/2025 a medication order for Lamotrigine (Lamictal) 25 milligrams, 1 tablet to be administered by oral route 2 times a day. A Pharmacy Consultant Medication Regimen Review progress note dated 03/30/2025 and 04/25/2025 documented Resident #41 was currently receiving Lamictal since 03/10/2025 and recommended an updated Lamictal level be drawn. An undated Medication Regimen Review Response documented the Primary Care Physician's response to the Consultant Pharmacist's recommendation for Resident #41 as follows -Ordered. There was no documented evidence that a Lamictal level was ordered or a blood sample collected. On 05/16/2025 at 12:37 PM, the Primary Care Physician was interviewed and stated that the medication regimen review performed by the pharmacy consultant is a way to check if unnecessary medications are given. The consultant reviews the record monthly and the primary care physician is supposed to look at the recommendations, respond, and write the dateof the response every 30 days. The Primary Care Physician also stated they have not been receiving the medication regimen review reports unless the Administrator provides them. They stated the April recommendations were not provided to them until 05/13/2025. The Primary Care Physician also stated that they are not dating their response to the recommendations as they were instructed not to. The Primary Care Physician further stated that the Lamictal level has not been drawn as there are delays in blood draws though the phlebotomist works in the facility.

Based on observation, record review, and interviews during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility did not ensure that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This was evident in 1 (4th Floor) of 3 units observed during the medication storage task. Specifically, the facility failed to keep an accurate count and record of disposition for Dronabinol, a controlled medication. In addition, there were missing licensed nurses' signature in the Dronabinol narcotic sheet to verify accurate count. The findings include: The facility policy titled Medication - Narcotic Management with a last revision date of 04/2019 documented that all narcotics and Scheduled II medications will be maintained in the medication cart in a locked drawer. Narcotics and Scheduled II medications will be counted with two (2) professional nurses at the beginning and end of each shift. Documentation that a count was completed and accurate will be completed at the beginning and end of each shift. Narcotics and Scheduled II medications will be logged into a bound book once received from the pharmacy as well as for individual countdown records. If a medication is discontinued, all applicable sections of the discontinued medication section of the individual page will be completed. Any discrepancy in a shift-to-shift count must be immediately communicated to the Director of Nursing. The facility policy titled Pharmacy Consultant Medication Review with a last revised date of 03/2020 documented that the Pharmacy Consultant provides consultation of all aspects of the provisions of pharmacy services in the facility, establishes a system of records of receipt and disposition of all controlled drugs maintained and periodically reconciled, and monitors the storage of medications to ensure they are in locked compartments under proper temperature controls. On 05/14/2025 at 2:08 PM, an observation of the 4th Floor Medication Storage room was performed with Registered Nurse #5. The medication refrigerator was not locked. There were sixteen (16) 5 milligram capsules of Dronabinol, prescribed for Resident #264, found inside the unlocked refrigerator, on a shelf that is outside the affixed double locked box. A review of individual narcotic record for Resident #264 documented Dronabinol 5 milligrams, dated 04/08/2025, 30 capsules, 1 capsule once daily. The narcotic record documented that the last administration date was on 04/20/2025 at 9:00 AM and that there were 20 capsules remaining. This quantity was different from the actual number of Dronabinol observed in the medication refrigerator. A review of the shift count for Dronabinol from 03/06/2025 through 05/13/2025 showed 24 shifts with missing licensed nurses' signatures validating the correct narcotic count. There was no documented evidence that pharmacy consultation services are performed to determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. On 05/14/2025 immediately after the medication storage observation, Registered Nurse #5 was interviewed and stated that there were only 16 Dronabinol capsules in the refrigerator but the narcotic count documented there were 20 remaining. They stated they were not sure why the count was inaccurate because they did not count the controlled medications this morning at the beginning of their shift. They also stated that they do not know why the Dronabinol capsules are not locked inside the affixed refrigerator medication box. On 05/14/2025 at 2:45 PM, Registered Nurse #2, who was the nursing supervisor, was interviewed and stated that Dronabinol is a controlled medication and must be stored in a double locked box. Registered Nurse #2 stated that the discrepancy in Dronabinol count might be because Resident #264 has been administered 4 Dronabinol capsules and were not documented in the narcotic book. Registered Nurse #2 further stated that the nursing supervisors and the pharmacy consultant have the responsibility to audit the medication carts and the narcotic book for medication reconciliation and medication errors. On 05/15/2025 at 12:58 PM, the Assistant Administrator was interviewed and stated that the pharmacy consultant provides their services remotely. On 05/15/2025 at 10:50 AM, the Director of Nursing was interviewed and stated that 2 licensed nurses must count and reconcile all narcotics at the change of each shift and that both nurses must sign the narcotic book. The Director of Nursing stated there were missing signatures in the narcotic sheets because some nurses worked double shift and there is no other nurse to count with them. The Director of Nursing stated that the discrepancy in the Dronabinol count was because the nurses did not start a new narcotic count sheet when Resident #264 returned from the hospital. They stated the nurses are administering the medication but are not documenting it in the narcotic sheet. 10 NYCRR 415.18 (a)

Based on observation, record review, and interview during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for each resident. This was evident during the Sufficient and Competent Nurse Staffing Task. Specifically, interviews with residents, members of the Resident Council, and staff members; as well as review of minutes of the Resident Council meeting reflected ongoing concern about staffing levels at the facility. The findings include but are not limited to: The facility's policy titled Staffing hours dated 10/2015 with a last revised date of 03/2019 documented that the facility has developed and assigned duty hours for the Nursing Services department and that departmental work schedules may be revised by the Director of Nursing Services when deemed necessary and appropriate to ensure that each resident's needs are met. The Facility assessment dated [DATE] documented the staffing ratio as follows: Day Shift - 1 Registered Nurse, 2 Licensed Practical Nurses, and 3 Certfiied Nursing Assistants Evening Shift - 1 Registered Nurse, 2 Licensed Practical Nurses, and 2 Certfiied Nursing Assistants Night Shift - 1 Registered Nurse, 1 Licensed Practical Nurses, and 2 Certfiied Nursing Assistants The facility assessment documented the facility acuity status as follows: 35 residents with reduced physical functions 13 residents required assistance of 1-2 staff for dressing, 3 residents were totally dependent 20 residents required assistance of 1-2 staff for bathing, 5 residents were totally dependent 12 residents required assistance of 1-2 staff for transfers, 3 residents were totally dependent 8 residents required assistance of 1-2 staff for eating, and 1 resident was totally dependent 8 residents required assistance of 1-2 staff for toileting, and 5 residents were totally dependent 14 residents required assistive devices to ambulate, amd 13 residents were in chair most of the time On 05/12/2025 at 6:00 AM, the staffing pattern revealed 2 Licensed Practical Nurses, no Registered Nurses on duty, and 2 Certified Nursing Assistants. On 05/13/2025 at 10:02 AM, the staffing pattern revealed 1 Licensed Practical Nurse in Unit 2; 2 Certified Nursing Assistants and 1 Home Health Aide were assigned for Units 2,3, and 4. A review of the minutes of the Resident Council meeting held on 11/19/2024 documented that the residents' concerns included medications administered hours late on weekends and call bells were not answered for a very long time. The facility's documented response was there was a delay in some residents receving medication because of the staffing shortage and that the facility is working on having more staffing to ensure residents's needs are met. A review of the minutes of the Resident Council meeting held on 12/27/2024 documented that the residents' concerns included the Certified Nursing Assistants not responding timely to calls made by residents. The facility's documented response was that the nursing department begun interviewing for Certified Nursing Assistants to work and help with residents' needs. A review of the minutes of the Resident Council meeting dated 01/28/2025 documented that the residents' concerns included nurses were not available on the unit when needed by the residents; that a lot of residents need help with personal hygiene. The facility's documented response was that the facility started hiring for more staff. A review of the minutes of the Resident Council meeting held on 03/25/2025 documented that the residents' concerns included the residents missing their outside medical appointments because of staffing problems. The facility's documented response was that extra workers were hired during middle of April 2025. On 05/13/2025 at 11:34 AM, during the Resident Council Meeting 11:34 AM, Residents #17, 18, 51, 264, and #46 stated the major issue they experience is with staffing and that there is only one Certified Nursing Assistant that works from 12:00 MN to 8:00 AM. They added that there are no nurses to administer medications. On 05/16/2025 at 2:06 PM, Certified Nursing Assistant #1 was interviewed and stated they work from 8:00 AM to 4:00 PM and that the staffing is not good on the weekends with only 1 Certified Nursing Assistant and a home health aide to attend to the residents. They stated that call bell will ring on the other units and the staff from other units have to leave and answer the bell. On 05/15/2025 at 5:44 PM, Certified Nursing Assistant #3 was interviewed and stated they work from 4:00 PM to 12:00 MN. They stated they would be assigned in 1 floor and will have some of the residents in other floors as well. They stated they currently have 3 residents that need to be fed, about 8 residents on the 2nd floor and some on the 3rd floor that needs assistance with evening care. They stated they are usally short with aides on the weekend and will tell the residents to wait when they call for help. On 05/12/2025 at 6:58 AM, Licensed Practical Nurse#2 was interviewed and stated they worked on 05/12/2025 from 12:00 MN - 8:00 AM and that there was no Registered Nurse on duty that night. On 05/15/2025 at 12:10 PM, Registered Nurse #4 was interviewed and stated they cover 2 resident units when they are short staffed and there are lot of times when there was only a home health aide who works on all units. Registered Nurse #4 stated there was only 1 Certified Nursing Assistant and a Registered Nurse on duty for all units on 05/10/2025 from 8:00 AM to 1:00 PM. They stated that when this happens, the medications are administered late and residents does not get the care they need. On 05/15/2025 at 1:17 PM, Registered Nurse #2 was interviewed and stated that they are usually working 2 consecutive shifts and that staffing and scheduling is challenging. They stated they and the Director of Nursing sometimes fills in to cover shifts with no nurses. They stated they sometimes do not have enough nurses and there is no one else to call. On 05/15/2025 at 4:28 PM, Registered Nurse #1 was interviewed and stated Certified Nursing Assistants have to share the units and some of the residents complain, especially on the weekend, that the Certified Nursing Assistants take too long to attend to their needs. Registered Nurse #1 stated that they are aware that sometimes the residents miss their appointments if they are short staffed and does not have any extra staff to send with the residents. On 05/15/2025 at 4:57 PM, the Director of Nursing was interviewed and stated staffing is an issue because they have a problem with staff retention. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, record review, and interview during the Recertification Survey conducted from 05/12/2025 to 05/19/2025, the facility did not ensure that each resident received treatment and care in accordance with goals for care and professional standards of practice. This was evident in 2 (Resident #213 and Resident #41) of 3 residents reviewed for respiratory care. Specifically, Resident #213 and Resident #41 had a physician's order for incentive spirometry that was not implemented because there was no available incentive spirometer in the facility. Cross Reference: F-tag 695 Respiratory/Tracheostomy care and Suctioning The findings include: 1.) Resident #213 was admitted to the facility with diagnoses that included Pulmonary Mycobacterial Infection and Pneumocystosis. The admission Minimum Data Set assessment dated [DATE] documented Resident #213's cognition as intact, independent with bed mobility, transfers, set up for toilet use, and always continent of bowel and bladder. The physician's order dated 05/01/2025 documented Incentive Spirometry (3) times per day for 10 breaths, resting in-between breaths as needed, every shift for potential/actual deficiency in lung capacity. A review of Resident #213's Treatment Administration Record from 05/01/2025 to 05/15/2025 had no documented evidence that incentive spirometry was performed as ordered on 22 occasions. Resident #213's medication administration notes dated 05/01/2025 at 8:38 PM, 05/02/2025 at 7:12 AM, 05/02/2025 at 7:01 PM, 05/07/2025 at 4:54 AM, 05/08/2025 at 5:12 AM, 05/09/2025 at 6:39 PM, 05/10/2025 at 1:53 PM, 05/10/2025 at 3:32 PM, 05/11/2025 at 9:42 AM, 05/11/2025 at 7:55 PM, 05/14/2025 at 10:48 PM, and 05/15/2025 at 5:17 AM documented that incentive spirometer was not available. A review of the interdisciplinary progress notes showed no documented evidence that the attending physician was notified that there was no incentive spirometer available and that incentive spirometry has not been performed for Resident #213. On 05/15/2025 at 4:28 PM, Registered Nurse #1, who was the Registered Nurse Supervisor, was interviewed and stated they are aware that there is no incentive spirometer available for resident's use and that they told the Administrator's secretary to order them. On 05/16/2025 at 3:07 PM, the Primary Care Physician was interviewed and stated they were not aware that Resident #213 need an incentive spirometer. They stated that Resident #213 does not need the incentive spirometer initially and that they do not know why it was even ordered. 2.) Resident #41 was admitted to the facility with diagnoses that included Asthma and Acute Pulmonary edema. The physician's order dated 01/29/2025 documented Incentive Spirometry (3) times per day for 10 breaths, resting in-between breaths as needed, every shift to prevent respiratory complications. Resident #41's medication administration notes dated 05/08/2025 at 7:41 AM, 05/07/2025 at 9:54 PM, 05/07/2025 at 5:41 AM documented that incentive spirometer was not available. A physician progress note dated 05/16/2025 documented that Resident #41 was seen because they needed an incentive spirometer and a spirometer kit was ordered. A review of the interdisciplinary progress notes showed no documented evidence that the attending physician was notified prior to 05/16/2025 that there was no incentive spirometer available and that incentive spirometry had not been performed for Resident #41. On 05/15/2025 at 4:47 PM, the Administrative Assistant was interviewed and stated they are responsible for ordering nursing supplies and was made aware of the need for the incentive spirometers. The Administrative Assistant stated they ordered the incentive spirometer on 05/14/2025. On 05/15/2025 at 4:53 PM, the Director of Nursing was interviewed and stated that the attending physician must be notified if they do not have the equipment such as incentive spirometer. The Director of Nursing stated they have since ordered the incentive spirometer. 10 NYCRR 415.12

Based on record review and interview during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility failed to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical nursing, mental and psychosocial needs. This was evident in 2 (Residents #1 and #213) of 19 total sampled residents. Specifically, 1.) Resident #1 who had an active diagnosis of Chronic Obstructive Pulmonary Disease had no care plan developed to address their respiratory status. 2.) Resident #213 who had diagnoses of Pulmonary Mycobacterial Infection and Pneumocytosis had no car eplan developed to address their respiratory status. The findings are: The facility's policy titled Care Plans with a last reviewed date of 10/2019 states that a comprehensive, person- centered care plan will incorporate identified problem areas and their causes and interventions that are targeted and meaningful to the resident. Resident #1 was admitted to the facility with diagnoses that included Chronic Obstructive Pulmonary Disease, Nicotine Dependence, and Unspecified Asthma. The Minimum Data Set assessment dated [DATE] documented that Resident #1 was cognitively intact. A physician's order for Resident #1 dated 02/24/2025 included Symbicort 160-4.6 micrograms, 2 puffs twice a day for COPD. A physician's order dated 05/12/2025 included Tiotropium 2.5 micrograms, 2 puffs once a day for Chronic Obstructive Pulmonary Disease. There was no documented evidence that a care plan to address Resident #1's respiratory status related to diagnosis of Chronic Obstructive Pulmonary Disease was developed. Resident #213 was admitted to the facility with diagnoses that included Pulmonary Mycobacterial Infection and Pneumocystosis. The admission MDS dated [DATE] documented Resident #213's cognition as intact, no impairments, independent with bed mobility, transfers, set up for toilet use, and always continent of bowel and bladder. The physician's order dated 05/01/2025 documented Incentive Spirometry (3) times per day for 10 breaths (resting in-between breaths as needed) every shift for potential/actual deficiency in lung capacity. There was no documented evidence that a care plan to address Resident #213's respiratory status related to diagnoses of Pulmonary Mycobacterial Infection and Pneumocystosis was developed. On 05/15/2025 at 9:39 AM, Licensed Practical Nurse #1 was interviewed and stated it is the Registered Nurse Supervisors responsibility to initiate resident care plans. On 05/15/2025 at 10:36 AM, Registered Nurse #1, a Registered Nurse Supervisor, stated the care plan on respiratory status should have been initiated on admission and that they do not know why it was not done. On 05/15/2025 at 11:02 AM, Registered Nurse #2, a Registered Nurse Supervisor, was interviewed and stated Registered Nurse Supervisors are responsible for reviewing each resident's care plans after they were initiated by the admitting nurse. Registered Nurse #2 stated that nurse supervisors are busy assisting the unit nurses because of insufficient staffing in the facility that they have no time to review care plans. On 05/16/2025 at 1:45 PM, the Director of Nursing was interviewed and stated that Registered Nurses are responsible for implementing and updating the care plans. They stated they are aware that the residents' care plans have not been updated because Registered Nurses sometimes have to work on the floor when someone calls out or when they are short. The Director of Nursing stated when Registered Nurses cover the floor, they cannot perform their work, and that include updating care plans. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and interviews during the Recertification Survey conducted from 05/12/2025 to 05/15/2025, the facility did not ensure that a resident with limited range of motion received treatment and services to maintain and/or to prevent further decrease in range of motion. This was evident in 1 (Resident #29) of 1 resident reviewed for Limited Range of Motion out of 19 total sampled residents. Specifically, Resident #29 was not provided with a left resting hand splint and a left elbow extension splint per the physician's order. The findings include: The facility policy and procedure titled Appliance Splints, Braces, Splint with the last revised date of April 2019 documented that to protect the safety and well-being of residents and to promote quality of care this facility uses appropriate techniques and devices for appliances, splint, brace, and sling to assure all splint, brace and sling etc., are used appropriately and cared for properly and upper and lower extremity maintained in the functional position. Resident #29 was admitted with diagnoses of Hemiplegia/Hemiparesis, Heart Failure, and Depression. The quarterly Minimum Data Set assessment dated [DATE] documented Resident #29's cognition as intact. The resident had impairment on one side of the upper and lower extremities and required substantial assistance with activities of daily living. A physician's order dated 11/07/2024 documented Resident #25 to wear a left resting hand splint and a left elbow extension splint during the day and take them off during the night. The splint should be removed during hygiene, skin check, and range of motion exercises. On 05/13/2025 at 11:35 AM, Resident #29 was observed out of bed in a wheelchair in the lobby. The resident had a left arm contracture, and no splint device was in place. On 05/13/2025 at 11:36 AM, Resident #29 was interviewed and stated the staff does not apply the splint to their left arm. On 05/14/2025 at 10:43 AM, Resident #29 was observed out of bed in a wheelchair in front of the medication room on Unit 3. The resident had no splint device in place. On 05/15/2025 at 9:15 AM, Resident #29 was observed in a wheelchair at the lobby, with left arm contracture, and had no splint device. A Rehabilitation Note dated 10/11/2024 at 8:23 AM documented Resident #29 continued to complain of left-sided weakness. The resident has contracture on the left hand, wrist, and elbow, and a flexor synergy pattern due to hypertonicity. Resident #29 stated they were using a resting hand splint and elbow extension splint; however, someone had to reach over to the previous facility to bring it over. The Certified Nursing Assistant Kardex had no documented instruction to apply a left elbow splint to Resident #25's left upper extremity. On 05/15/2025 at 11:52 AM, Certified Nursing Assistant #1 was interviewed and stated they do not know if Resident #25 had a left arm splint, and they had not seen the resident wear one. On 05/16/2025 at 9:15 AM, the Occupational Therapist was interviewed and stated that Resident #25 was admitted from a different nursing home with a left side contracture and had a long history of stroke. The therapist stated they placed an order for a left hand splint for the resident and that they contacted the previous nursing home to send the resident's splint over to the facility. They stated they were not sure if the splint was received. On 05/16/2025 at 1:27 PM, the Director of Nursing was interviewed and stated that Resident #29 has a contracture when they were admitted . They stated there was an order for a hand splint on 11/07/2024 but they do not remember if they received the splint. 10 NYCRR 415.12(e)(2)

Based on observation, record review, and interviews during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility did not ensure that drugs and biologicals were stored in accordance with professional standards. This was evident in 2 (3rd and 4th Floor) of 3 units observed for medication storage. Specifically, 1.) The 4th floor medication storage room refrigerator was unlocked and contained controlled medications that were not stored in the affixed lock box. 2.) The 3rd Floor medication storage room contained food, and multiple prescribed medications were stored in unlocked cabinets. 3.) A previously administered 50 milliliter bag of intravenous solution was stored inside the 3rd Floor medication cart. The findings include: The facility policy titled Medication - Narcotic Management with a last revision date of 04/2019 documented that all narcotics and scheduled II medications will be maintained in the medication cart in a locked drawer. The facility policy titled Medication Storage with last revision date of 01/2019 documented that to provide guidelines for proper storage of medications within the facility, the center will have medications stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with Department of Health guidelines. With the exception of emergency drug kits, all medications will be stored in a locked cabinet. Expired, discontinued and or contaminated medications will be removed from the medication storage area and disposed of in accordance with facility policy. Employee or resident food may not be stored in the medication refrigerator. On 05/14/2025 at 2:08 PM, an observation of the 4th Floor Medication Storage room was performed with Registered Nurse #5. The medication refrigerator was not locked. There were sixteen (16) 5 milligram capsules of Dronabinol, prescribed for Resident #264, found inside the unlocked refrigerator, on a shelf that is outside the affixed double locked box. On 05/14/2025 immediately after the medication storage observation, Registered Nurse #5 was interviewed and stated that controlled medications including refrigerated medications should be kept in a double locked storage. Registered Nurse #5 stated they are unsure why the Dronabinol capsules were not locked inside the affixed refrigerator medication box because they did not perform the controlled medication count this morning at the change of shift. On 05/14/2025 at 2:45 PM, Registered Nurse #2, who was the nursing supervisor, was interviewed and stated that controlled medications, even when refrigerated, should be stored in the affixed double locked box. On 05/14/2025 at 3:15PM, an observation of the 3rd Floor Medication Storage room was performed with Registered Nurse #3. A bag of fruits and 2 fully packed food storage containers were observed inside the medication storage room. Multiple bottles of prescribed medications in plastic bags were stored in unlocked cabinets. A 50 milliliter bag of used intravenous solution was stored inside the medication cart. On 05/14/2025 at 3:25 PM, Registered Nurse #3 was interviewed and stated that the bag of intravenous solution found in the medication cart was previously administered to a resident and was placed in the medication cart after changing the bag. They stated that prescribed medications were kept in unlocked cabinets because there is not enough room to store them in the medication cart. On 05/14/2025 at 3:35 PM, Registered Nurse #2, who was the nursing supervisor, was interviewed and stated that the prescribed medications should be stored in locked medication carts. The food stored in the medication storage room and the used intravenous bag inside the medication cart violate the infection control standards and can cause contamination. On 05/15/2025 at 10:50 AM, the Director of Nursing was interviewed and stated that nurses should not keep food in the medication storage room, nor should they have a used intravenous solution bag brought back into the medication room because of infection control standards. The Director of Nursing stated that prescribed medications should be stored in a locked medication cart. 10 NYCRR 415.18(e)(1-4)

Based on observation, record review, and interview during the Recertification Survey conducted from [DATE] to [DATE], the facility did not ensure that infection control practices and procedures were maintained. This was evident in 1 (3rd Floor) of 3 units observed for medication storage. Specifically, a bag of previously administered antibiotic intravenous solution was observed inside the medication cart. The findings are: The facility policy titled Medication Storage with a last revision date of 01/2019 documented that with the exception of emergency drug kits, expired, discontinued, and or contaminated medications will be removed from the medication storage area and disposed of in accordance with facility policy. The facility policy and procedure titled Infection Prevention and Control with a last revision date of [DATE] documented that the facility adheres to 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. The facility policy and procedure titled Medication Administration with a last revision date of 12/2019 documented that staff shall follow established facility infection control procedures when these apply to the administration of medications. On [DATE] at 3:15 PM, an observation of the 3rd floor Medication Storage Room was performed with Registered Nurse #3. Located on the medication administration cart was a previously used bag of 50 milliliter intravenous solution labeled with the following: 1 gram Meropenem / Sodium Chloride 1 gram/50millilters in intravenous solution, administer over 30 minutes for 8 hours for Resident #315. Meropenem is a broad spectrum antibiotic used to treat a variety of bacterial infections. A review of Resident #315's physician's order revealed an order for Meropenem-Sodium Chloride Intravenous Solution Reconstituted 1 gram/50 milliliters, administer every 8 hours for sepsis due to Extended-spectrum beta-lactamases (enzymes that make bacteria resistant to common antibiotics) Escherichia Coli (a group of bacteria) urinary tract infection. On [DATE] at 3:25 PM, Registered Nurse #3 was interviewed and stated that the previously used bag of intravenous solution was brought back into the medication storage room after changing the intravenous bag in the resident's room. Registered Nurse #3 stated this practice should not have been done and they do not have anything to say except they should not have brought it in the medication storage room. On [DATE] at 3:35 PM, Registered Nurse #2, who was the nursing supervisor, was interviewed and stated that bringing the previously used intravenous bag in the storage room and putting it on the medication cart violates infection control standards and can cause contamination. On [DATE] at 10:50 AM, the Director of Nursing was interviewed and stated that the used and contaminated intravenous solution bag should have not been brought back into the medication storage room because of infection control standards, it will contaminate the surfaces. On [DATE] at 9:26 AM, the Infection Control Preventionist / Staff Educator was interviewed and stated that the nurse should follow the standards of practice as it relates to infection control such as the use of a biohazard bag to dispose the used intravenous solution and supplies. They stated there is no competency or observation performed for medication administration and storage as it relates to infection control. 10 NYCRR 415.19 (a) (1-3)

Based on record review and interviews during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility did not ensure that the interdisciplinary team reviewed and revised a resident's comprehensive care plan after each assessment. This was evident in 1 (Resident #2) out of 19 sampled residents reviewed for unnecessary medication and advance directives. Specifically, Resident #2's Comprehensive Care Plan for Advance Directives, Diabetes Mellitus, Skin Integrity, Anticoagulant medication use, and Psychoactive medication use was not reviewed or revised after each assessment. The Findings include: The facility policy and procedure titled Care Plan-Comprehensive with a last revised date of 08/02/2024 stated that a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical and functional needs is developed and implemented for each resident. The Interdisciplinary Team reviews and updates the care plan when the resident is readmitted to the facility from a hospital stay and at least quarterly, with the scheduled quarterly minimum data set. Resident #2 was admitted to the facility with diagnoses that included Arterial Fibrillation, Diabetes Mellitus, Anxiety Disorder, and Depression. The Annual and Quarterly Minimum Data Set assessments dated 07/12/2024, 01/02/2025, and 03/18/2025 documented that Resident #2 had intact cognition. A comprehensive care plan related to the use of psychoactive medication was initiated for Resident #2 on 11/04/2024. There was no documented evidence that the care plan was reviewed and revised after the annual and quarterly assessments on 01/02/2025 and 03/18/2025. A comprehensive care plan for advance directive was initiated for Resident #2 on 04/23/2024. There was no documented evidence that the care plan was reviewed and revised after the quarterly and annual assessments on 07/12/2024, 01/02/2025, and 03/18/2025. A comprehensive care plan for the risk for bleeding secondary to anticoagulant use was initiated for Resident #2 on 02/21/2024 and was last revised on 4/23/2024. There was no documented evidence that the care plan was reviewed and revised after the quarterly and annual assessments dated 07/12/2024, 01/02/2025, and 03/18/2025. A comprehensive care plan related to skin integrity was initiated for Resident #2 on 02/01/2024. There was no documented evidence that the care plan was reviewed and revised after the quarterly and annual assessments dated 07/12/2024, 01/02/2025, and 03/18/2025. A comprehensive care plan related to Diabetes Mellitus was initiated for Resident #2 on 02/21/2024 and was last revised on 4/23/2024. There was no documented evidence that the care plan was reviewed and revised after the quarterly and annual assessments dated 07/12/2024, 01/02/2025, and 03/18/2025. On 05/16/2025 at 12:33 PM, Registered Nurse # 1, who was the Nursing Supervisor, was interviewed and stated that the care plans should be updated quarterly. They stated care plans were not updated because of staffing issues. Registered Nurse #1 stated the facility is short of staff and they had to work on the floor as a unit nurse. Therefore, they were unable to update the residents' care plans. On 05/16/2025 at 1:45 PM, the Director of Nursing was interviewed and stated that Registered Nurses are responsible for implementing and updating the care plans. They stated they are aware that the residents' care plans have not been updated because Registered Nurses sometimes have to work on the floor when someone calls out or when they are short. The Director of Nursing stated when Registered Nurses cover the floor, they cannot perform their work, and that include updating care plans. 10 NYCRR 415.11(c)(2) (i-iii)

Based on record review and interview during the Recertification Survey conducted from 05/12/2025 to 05/16/2025, the facility did not ensure that the Infection Preventionist participated on quality assessment and assurance committee. Specifically, the Infection Preventionist had not participated in any of the Quality Assurance and Performance Improvement meetings held from June 2024 through April 2025. The findings are: The facility's Infection Preventionist job description stated that the Infection Preventionist attends and reports monthly at the quality assurance meeting. The facility's Quality Assurance & Performance Improvement Plan - 2025 did not include the Infection Preventionist in the list of committee members. A review of the Quality Assurance and Performance Improvement attendance sheets dated June 2024 through April 2025 had no documented evidence that the Infection Preventionist attended the meetings. On 05/16/2025 at 8:45 AM, the Infection Preventionist was interviewed and stated they do not attend the quality assurance meeting and does not know they are supposed to be a member of the committee. On 05/16/2025 at 1:25 PM, the Director of Nursing was interviewed and stated that the quality assurance committee comprises the department heads and the nursing educator. They stated they do not know why the Infection Preventionist is not listed as a committee member. 05/16/2025 5:11 PM, the Administrator was interviewed and stated, they are not sure why the Infection Preventionist was not included in the quality assurance committee. 10 NYCRR 415.27 (a-c)

Based on observations, record review, and interviews conducted during an abbreviated survey (NY00332540), the facility did not ensure that a resident was able to exercise their rights as a resident in the facility and as a citizen or resident of the United States. This was evident in one out of four residents sampled (Resident #1). Specially, on 01/25/2024 at 11:00 AM, Recreational Aide #1 reported to Recreational Supervisor #1 that Resident #1 refused to have their hair cut and become agitated and combative. The Director of Social Work instructed License Practical Nurse #1, and Home Health Aide #1 to hold Resident #1's arms and legs against Resident #1's will and cut Resident #1's hair. The findings are: The facility's Policy titled Resident Rights dated 05/28/2024, documented Healthcare Personnel shall treat all residents with kindness, respect, and dignity. The policy further documented resident has the right to exercise his or her rights as a resident of the facility and as a resident or citizen of the United States and be supported by the facility in exercising his or her rights. The facility's Policy titled Abuse and Neglect dated 12/2022, documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends, and residents of the facility. The facility prohibits any exploitation of the mentally and physically disabled resident in the facility. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and or misappropriation of property. Resident # 1 was admitted to the facility on [DATE], with diagnoses of Antiviral Disease, Major Depressive Disorder and Dementia. The Minimum Data Set (an assessment tool), dated 11/25/2023, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of six associated with severe impaired cognition. The Facility's Investigative Form dated 01/29/2024, documented on 01/25/2024 at 11:00 AM, Recreational Aide #1 reported to their supervisor, the Recreational Supervisor, Resident #1 was refusing their hair cut and become agitated and combative and staff held Resident #1 and continued with the haircut. Staff then stop the haircut with the intention of return and to continue Resident #1's hair cut later. License Practical Nurse #1 informed the Director of Social Service that Resident #1 was refusing the haircut and the Director of Social Service responded by going to the unit to see how they could assist. Resident #1 was moved to their room where the environment was less stimulating to continue with the haircut. Resident #1 once again become agitated, kicking, shouting, and screaming. The staff tried to console Resident #1 and held their hands, shoulders, and legs to complete the haircut. The hair cut was completed without any physical harm to the resident. The Facility's conclusion documented that after conducting a thorough investigation, it was concluded that Resident #1 although not harmed in the process was provided a haircut against their will. During an interview on 10/17/2024 at 3:02 PM, Home Health Aide #1 stated they were asked by Social Worker Director to assist them in getting Resident #1's hair cut by Barber #1. Home Health Aide #1 stated that Resident #1 was removed from Barber #1's chair, and was taken to their room by Licensed Practical Nurse #1 because other residents were making a lot of noise. Home Health Aide #1 stated that Barber #1 came to Resident #1's room to complete cutting Resident #1's hair. Home Health Aide #1 stated that while Resident #1 was sitting in their wheelchair Resident #1 started swing to their right hand and they held on to Resident #1's right hand and was stroking and talking to Resident #1 to calm Resident #1 down. Home Health Aide #1 stated Social Worker Director was present and they placed their hands on Resident #1 thigh and Licensed Practical Nurse #1 was holding Resident #1's shoulder so that Resident #1 can get their haircut. During an interview on 10/17/2024 3:29 PM, Licensed Practical Nurse #1 stated Social Worker Director asked them to assist them in getting Resident #1's haircut done. Licensed Practical Nurse #1 stated they were informed by Social Worker Director that Resident #1's Guardian was coming to visit and Resident #1's hair was too long and unkept. Licensed Practical Nurse #1 stated Resident was removed from the barber in their wheelchair and taken to their room. Licensed Practical Nurse #1 stated that Barber #1, Social Worker Director, and Home Health Aide #1 was present in the room with Resident #1. Licensed Practical Nurse #1 stated that they placed their hands gently holding Resident #1's shoulder to keep Resident #1 steady because Resident #1 was combative, and they were concerns for Resident # 1's safety. Licensed Practical Nurse #1 stated that Home Health Aide #1 held on to Resident #1's right hand to keep Resident #1 calm while Social Worker Director placed their hands on Resident #1's thighs. During an interview on 10/17/2024 at 3:45 PM, Registered Nursing Supervisor #1 stated that they never receive any calls from the staffs on the second floor informing them that Resident #1 was refusing their haircut. Registered Nursing Supervisor #1 stated that they become aware of the incident when they were doing staffing the following day. During an interview on 10/17/2024 at 3:45 PM, Director of Nursing stated that they become aware of the alleged incident on 01/25/2024 at approximately 11:00 AM by the Recreational Supervisor. Director of Nursing stated that they were informed that Resident #1 was schedule for a haircut and while doing the procedure, Resident #1 become combative and did not want the haircut anymore. Director of Nursing stated that Resident #1's hair was not completely shaved but could visually see that Resident #1's hair and bread was trimmed. Director of Nursing stated that Barber #1 is a contractor and was informed by recreational staff if resident become combative during cutting their hair, they should stop. The Director of Nursing stated that recreational staff was present, and reported the alleged incident to their supervisor and their supervisor reported it to them. Director of Nursing stated that the Social Worker Director informed Licensed Practical Nurse #1 if Resident #1's refused the haircut they should call them. The Director of Nursing stated that the staffs held down Resident #1 and cut Resident #1's hair against Resident #1's will. During a phone interview on 10/18/2024 at 4:13 PM, Barber #1 stated that they are a Licensed Barber and has been scheduled to cut Resident #1' s hair in the facility. Barber #1 stated that Resident #1 had given their consent for the haircut. Barber #1 stated after they started cutting Resident #1's hair, Resident #1 become combative and was removed from the barber 's chair. Barber #1 stated that Social Worker Director was notified and arrived on the unit and informed them that Resident #1 hair must cut because Resident #1 is looking unkept. Barber #1 stated that Resident #1 was [NAME] to their room and a second attempt was made to perform the haircut. Barber #1 stated three other staff members was holding Resident #1 to prevent Resident #1 from harming themself in the process. Barber #1 stated it was three people trying to assist in helping to get Resident #1 haircut but Resident #1 was still combative, cursing and kicking; therefore, they did not complete the haircut. A statement dated 01/26/2024 (no time), written by Social Worker Director documented License Practical Nurse #1 informed the Social Worker Director that Resident #1 was getting a haircut and Resident #1 was kicking, cursing, and using profanities at staff. Social Worker Director went to the unit to assist staff with Resident #1. Social Worker Director documented at first Resident #1 was observed calm and relaxed and was not in distress. Social Worker Director informed Resident #1 that they were going to get a haircut, as Resident #1 was observed to be unkept, with their hair going into their mouth. Resident #1 agreed and said, yes. Social Worker Director took Resident #1 to their room where there was less stimulation because there were loud music playing and many other residents were gathered for a haircut. Social Worker Director, Licensed Practical #1 and Home Health Aide were present. The hair cut was performed by Barber #1 where Resident #1 was still calm, after a little while Resident #1 continued using profanity and stated they wanted a cigarette. Barber #1 kept shaving Resident #1's hair, and moustache. Social Worker Director, Licensed Practical Nurse #1 and Home Health Aide #1 was providing emotional support and Barber #1 cut Resident #1 hair without incident or any accident. During an interview on 10/22/2024 at 2:04 PM, Recreational Staff #1 stated that on 01/25/2024 at approximately 11:00 AM Resident #1 give their consent to get their hair cut. Recreational Staff #1 stated that while Resident #1 was on the 2nd floor getting their hair cut, in the middle of the hair cut Resident #1 tell Barber #1 to stop. Recreational Staff #1 stated Resident #1 was kicking, cursing, and waving their hands. Recreational Staff #1 stated they informed Barber #1 to stop, and Resident #1 was taken away from Barber #1 by Licensed Practical Nurse #1. Recreational Staff #1 stated when to inform their supervisor and when they returned to the unit, they heard Resident #1 yelling in their room, and they went to see what was happening. Recreational Staff #1 stated that they observed Social Worker Director crossed Resident #1 leg to prevent Resident #1 from kicking and Licensed Practical Nurse #1 and Home Health Aide #1 was each standing on one side of Resident #1 holding down Resident #1 to get their hair cut. 10 NYCRR 483.10 (a)(1)

Based on observations, record review, and interviews conducted during an abbreviated survey (NY00332540), the facility failed to ensure a resident was free from physical or chemical restraints imposed for purposes of discipline or convenience and are not required to treat the resident's medical symptoms. This was evident for one out of four residents sampled (Resident #1). Specifically, on 01/25/2024, Recreational Aide #1 reported to their Recreation Supervisor that Resident #1 was refusing their hair cut and become agitated and combative. The Director of Social Work instructed License Practical Nurse #1, and Home Health Aide #1 to hold Resident #1's arms and legs against Resident #1's will and cut Resident #1's hair. There was no documented evidence that restraints were medically necessary, nor that alternatives were attempted prior to holding down Resident #1's arms and legs for a haircut. Findings are: The Facility's Policy titled Use of Restraints, dated 12/2022, documented the nursing center will promote a restraint-free environment in accordance with State and Federal regulations for the resident to attain and maintain his or her highest level of practical wellbeing. Also, documented restraints shall only be use for the safety and well-being of the resident and only after alternative have been attempted unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and shall not be imposed for the purposes of discipline, staff convenience or that unnecessarily inhibits a resident's freedom of movement or activity. Resident # 1 was admitted to the facility on [DATE] with diagnoses of Antiviral Disease, Major Depressive Disorder and Dementia. The Minimum Data Set (an assessment tool), dated 11/25/2023, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of six associated with severe impaired cognition. The Facility's Initial Event Documentation dated 01/26/2024 at 12:15 PM, documented on 01/25/2024 at 11:30 AM, Resident #1 noted to be agitated, hitting, and kicking at the barber, while receiving a haircut in the presence of recreational staff. The barber stopped the process and later approached the resident who was placed in their room in a less stimulating environment to complete their haircut with three staff members present to aid in keeping resident calm. Resident was asked by the Social Worker Director if their haircut could be performed and resident gave their consent, however during the process resident started to become agitated and moving their arms in an upward manner, kicking and cursing. Staff held their hand, shoulder, and their feet to prevent resident from hurting themselves. There were no Physician's Orders or justification for the restraint use or restraint assessment. There was no documentation to show that the restraints were medically necessary, nor that alternatives were attempted prior to holding down Resident #1 for haircut. A review of the care plans for Resident #1 revealed no care plans for restraint was developed. The Facility Investigative Form dated 01/29/2024, documented on 01/25/2024 at 11:00 AM, Recreational Aide #1 reported to their supervisor, Recreation Supervisor, that Resident #1 was refusing their hair cut and become agitated and combative during the procedure and that staff held Resident #1 and continued with the haircut. Staff at that the time stopped the haircut with the intention of returning to Resident #1 later. License Pratical Nurse informed the Director of Social Service that Resident #1 was refusing the haircut and the Director of Social Service responded by going to the unit to see how they could assist. Resident #1 was moved to their room where the environment was less stimulating to continue with the haircut. Resident #1 once again become agitated, kicking, shouting, and screaming. Staff tried consoling Resident #1 and held their hands, shoulders, and legs to complete the haircut. Hair cut was completed without any physical harm to the resident. Facility's conclusion documented after a thorough investigation Resident #1 although not harmed was provided a haircut against their will. During an interview on 10/17/2024 at 3:02 pm, Home Health Aide #1 stated they were asked by Social Worker Director to assist with getting Resident #1 a haircut. Home Health Aide #1 stated that Barber #1 was cutting Resident #1's hair in the Barber's room when Resident #1 become combative and asked Barber #1 to stop cutting their hair. Home Health Aides #1 stated Resident #1 was taken to their room and Barber #1 came to Resident #1's room to complete cutting Resident #1's hair. Home Health Aide #1 stated that while Resident #1 was sitting in their wheelchair, Resident #1 started swing their right hand and they held on to Resident #1 ' s right hand and was stroking and talking to Resident #1 to calm Resident #1 down. Home Health Aide #1 stated that Social Worker Director was present, and they placed their hands on Resident #1 thigh and Licensed Practical Nurse #1 was holding Resident #1's shoulder. Home Health Aide #1 stated that Barber #1 was able to trim Resident #1's hair, However, because Resident #1 was combative Barber #1 stop cutting Resident #1's hair and Resident #1 was left in their room after they were finished. During a telephone interview on 10/18/2024 at 4:13 PM, Barber #1 stated that they are a licensed Barber and has been scheduled to cut resident ' s hair in the facility. Barber #1 stated that Resident #1 had given their consent for the haircut. Barber #1 stated after they started cutting Resident #1's hair, Resident #1 become combative and was removed from the barber 's chair. Barber #1 stated that Social Worker Director was notified and arrived on the unit and informed them that Resident #1 hair must cut because Resident #1 is looking unkept. Barber #1 stated that Resident #1 was [NAME] to their room and a second attempt was made to perform the haircut. Barber #1 stated three other staff members was holding Resident #1 to prevent Resident #1 from harming themself in the process. Barber #1 stated even though three people was trying to assist in helping to get Resident #1 haircut, Resident #1 was still combative, cursing and kicking and they were not able to complete the haircut. During an interview on 10/22/2024 at 2:04 PM, Recreational Staff #1 stated on 01/25/2024 at approximately 11:00 AM Resident #1 give their consent to get their hair cut. Recreational Staff #1 stated that while Resident #1 was on the 2nd floor getting their hair cut, in the middle of the hair cut Resident #1 tell Barber #1 to stop. Recreational Staff #1 stated Resident #1 was kicking, cursing, and waving their hands. Recreational Staff #1 stated they informed Barber #1 to stop, and Resident #1 was taken away from Barber #1 by Licensed Practical Nurse #1. Recreational Staff #1 stated they informed their Recreation Supervisor and when they returned to the unit, they heard Resident #1 yelling in their room, and they went to see what was happening. Recreational Staff #1 stated that they observed Social Worker Director crossed Resident #1 leg to prevent Resident #1 from kicking and Licensed Practical Nurse #1 and Home Health Aide #1 was each standing on one side of Resident #1 holding down Resident #1 for their hair to get cut. The Social Worker Director was not available to be interviewed. The Social Worker Director 's statement dated 01/26/2024 (no time), documented Licensed Practical Nurse #1 informed Social Worker Director that Resident #1 was getting a haircut and Resident #1 was kicking, cursing, and using profanities at staff. Documented, Social Worker Director went to the unit to assist staff and resident. Social Worker Director documented first Resident #1 was observed calm and relaxed and no distress noted or observed during the visit. Social Worker Director informed Resident #1 that they were going to get a haircut, as Resident #1 was observed and noted to be very unkept, with their hair going into their mouth and very disheveled and required activities of daily living care. Resident #1 was agreeable. Social Worker Director took Resident #1 to their room where there was less stimulation because there were loud music playing and many other residents were gathered for a haircut. Social Worker Director, Licensed Practical #1 and Home Health Aide #1 were present. The haircut was performed by Barber #1 where Resident #1 was still calm, after a little while Resident #1 continued using profanity and stated they wanted cigarette. Social Worker Director, Licensed Practical Nurse #1 and Home Health Aide #1 was providing emotional support and Barber #1 cut Resident #1 hair without incident or any accident. During an interview on 10/17/2024 at 3:45 PM, Director of Nursing stated they become aware of the alleged incident on 01/25/2024 at approximately 11:00 AM by Recreational Supervisor. Director of Nursing stated that they were informed that Resident #1 was schedule for a haircut and while doing the procedure, Resident #1 become combative and did not want the haircut anymore. Director of Nursing stated Resident #1's hair was not completely shave, but you could visually see that Resident #1's hair and bread was trimmed. Director of Nursing stated that Barber #1 is a contractor and was informed by Recreational staff #1 if Resident #1 become combative during cutting their hair, they should stop. Director of Nursing stated that the Social Worker Director informed Licensed Practical Nurse #1 if Resident #1's refused the haircut they should call them. Director of Nursing stated that the staff held Resident #1 and cut Resident #1's hair against Resident #1's will. 10 NYCRR 415.4(a) (2-7)

Based on observations, record review, and interviews conducted during the recertification survey from 12/18/2023 to 12/22/2023, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This was evident during observation of the kitchen. Specifically, 1) the dish washing machine did not maintain appropriate temperatures for washing and rinsing dishes, and 2) Dietary Worker #1 did not follow proper sanitation procedure during the pot washing process. The findings are: The facility policy titled Dish Washing and Storage dated 5/17/2019 documented dishes, pots, and pans will be washed and dried using procedures, chemicals, and equipment that result in clean, sanitized dishes, pans, flatware, and utensils. The facility policy titled Cleaning Dishes - Manual Wash dated 1/2023 documented dishes and cookware will be cleaned and sanitized by immersion in quaternary ammonium with a strength of 200-400 Parts Per Million (PPM) at 75 degrees Fahrenheit (F) for 60 seconds of contact. On 12/18/2023 at 9:44 AM, the kitchen dish machine temperature gauge was observed with a final rinse temperature of 153 F. The instructions posted on the dish machine documented the final rinse temperature should be at a minimum of 180 F. On 12/22/2023 at 8:59 AM, the kitchen dish machine temperature gauge was observed with a wash cycle temperature of 147 F. The instructions posted on the dish machine documented the wash cycle temperature should be at a minimum of 150 F. On 12/22/2023 at 9:06 AM, the kitchen pot-washing area was observed with an empty Sink #1 labeled washing/rinsing and an empty Sink #2 labeled sanitizing. Dietary Worker #1 turned on the water in Sink #1, scrubbed food debris from soiled pots, and rinsed the pots under Sink #1's faucet. Dietary Worker #1 then took a hose from Sink #2 containing sanitizer, directly sprayed the pots, and placed the pots on a rack to air dry. Dietary Worker #1 filled a bucket with sanitizer from the hose and used a test strip check the strength of the sanitizer. The test strip read 500 PPM. On 12/22/2023 at 12:08 PM, Dietary Worker #1 was interviewed and stated they received pot-washing training from their coworker. Dietary Worker #1 scrubbed the large pots that did not fit in the dish machine, washed them in the sink, and placed them on the rack to air dry. Dietary Worker #1 did not recall receiving a formal pot-washing inservice. On 12/22/2023 at 1:04 PM, the Director of Food Services was interviewed and stated quaternary ammonium was the sanitizer used for pot-washing. The Dish Washing and Storage Policy did not reflect the facility's use of a 2-sink method and there was a discrepancy with the procedure. Repair requests were made for the dish machine upon observation of low temperatures on the wash and rinse cycles. The Director of Food Services was unable to provide documented evidence of the repair requests. 10 NYCRR 415.14(h)

Based on observations, record review, and interviews conducted during the recertification survey from 12/18/2023 to 12/22/2023, the facility did not ensure garbage and refuse were disposed of properly. This was evident during observation of the kitchen. Specifically, garbage was not properly contained outside of the facility to prevent the harborage and feeding of pests. The findings are: The facility policy titled Garbage and Rubbish Disposal dated 1/2023 documented outside dumpsters provided by the garbage pick-up service will be kept closed and free of surrounding litter. On 12/22/2023 at 8:30 AM and 9:43 AM, the outside garbage compactor was observed without a door or cover, exposing garbage contained inside of the compactor. On 12/22/2023 at 1:04 PM, the Director of Food Service was interviewed and stated the compactor did not close after being filled with garbage. On 12/22/2023 at 3:44 PM, the Director of Facilities was interviewed and stated the compactor was not equipped with a lid, door, or cover; therefore, the compactor was always left open with garbage exposed. 10 NYCRR 415.14(h)