Every finding on record at King David Center for Nursing And Rehabilitation

Based on observation, interview, and record review the facility failed to maintain the residents' right to a safe, clean, and comfortable homelike environment. Specifically, housekeeping and maintenance services were not maintained in Units 2, 3, 4, 5, and 8. The findings include but are not limited to: The facility's undated Maintenance Policy and Procedure Manual stated that the building will be maintained in good repair and kept free of hazards. The responsibility for all maintenance and all preventive maintenance rests with the Maintenance Services Director, who reports directly to Administration. The undated Cleaning Resident and Non-Resident Area policy documented that the purpose of the policy was to improve sanitation and ensure the highest level of cleanliness throughout the facility. Frequent environmental cleaning of all frequently touched surfaces will be performed daily. 1.) During observation from 09/24/2025 to 10/01/2025, the following were observed: a. The resident's closet in room [ROOM NUMBER] had rusty metal legs, the radiator had brown spots and chipped paint, and there were holes noted in the wallpaper close to the curtain. b. The chair was ripped in room [ROOM NUMBER]. c. The bedside tables in room [ROOM NUMBER] had rusty edges. d. The radiator in room [ROOM NUMBER] had areas with missing paint. e. The chair in room [ROOM NUMBER] was ripped and the table had a crack. f. Unit 2 dining room had dusty air conditioning units, ripped wallpapers, there was a gap between the wall and the air-conditioning unit. g. The frame of the raised toilet bowl in the residents' bathroom in Unit 2 had rust. h. Unit 3 dining room had ripped wallpaper, and the air-conditioning unit were in disrepair and had stains. During an interview on 10/01/2025 at 12:02PM, the Maintenance Director stated that the leg of the raised toilet needs to be changed. During an interview on 10/01/2025 at 1:40 PM, the Director of Nursing stated they identified some of the residents' air-conditioning units needed repair. They stated that renovations were ongoing, and the goal was to complete the renovations for all rooms. 2.) The following were observed during in Unit 4 on 09/24/2025 at 10:30 AM: a. The residents' dining room had brownish, sticky substance on the corner of the floor next to the heating/cooling system, the silver paper towel holder had brownish, tarnish stains, and there were six (6) ripped window screens. b. room [ROOM NUMBER] was observed with ripped widow screens, bed with chipped wood, and the floor had debris. c. room [ROOM NUMBER] had brown stains on the window shades, the heating/cooling system had silver and black tape covering the sides and bottom, there was a white colored towel over the top, the walls were chipped, and the ceiling tiles had brown stains. d. room [ROOM NUMBER]'s heating/cooling system had brown stains. e. room [ROOM NUMBER] was observed with scuffed walls behind the resident's bed, the base board was tarnished, and the window screens were either ripped or missing a piece. f. room [ROOM NUMBER]P had brownish/black stains on the vent of the heating/cooling system. The walls have whitish patches, cracked floor tile, the window shade had brownish stains, the walls have peeling paint. The resident's television had blurry picture. The resident's bathroom had mismatched tile, cracked tiles, and some tiles were falling off the wall. There is a green colored metal base board with brownish stains, missing tile on the bathroom floor, stains in the ceiling, and the wall had paint bubble. g. room [ROOM NUMBER]'s bathroom light was not working. h. room [ROOM NUMBER]'s heating/cooling system had brown / black stains, and debris in the grooves and on the sides. On 09/25/2025 at 1:15 PM, the handheld shower in the residents' bathroom was observed with a slow water stream and the shower head that was on the bathroom wall had water spewing out from the sides of the shower head. On 09/29/2025 at 10:10 AM, an interview was conducted with the Maintenance Director, who stated that residents in 4th floor are putting food in the vents and were pushing food trays out of the windows that was why the window screens are ripped. The Director stated that there are a lot of maintenance work to do but sometimes they are short of staff. They stated that repairs in the building started in 2024, but they do not know when it will be completed. They stated that repairs/constructions on the 3rd and 4th floor have not been completed because it is difficult to get the residents out of their rooms. On 09/29/2025 at 10:43 AM, the Housekeeping Director was interviewed and stated that it is the housekeeping staff's job to clean the unit, mop, wash the beds, empty trash, and dust. On 09/30/2025 at 2:45 PM, the Administrator was interviewed and stated that they have noticed that some of the air conditioning units need cleaning and repainting. They stated they started renovation of residents' rooms in 2024, and plans to redo all the rooms. 3.) Observations made during the day tour in Unit 3 at 9:00 AM on 09/24/2025 and all throughout the Recertification Survey noted the following: a. In room [ROOM NUMBER], there was a large, dented hole in the closet door and a rusted radiator. b. In rooms [ROOM NUMBERS], there were rusted and stained radiators. c. In room [ROOM NUMBER], there were two (2) cracked tiles on the floor, cracked bottom wall on the end side with chipped and peeling paint. On 10/01/2025 at 11:47 AM, the Director of Maintenance was interviewed and stated that the rusty radiator is due to a contracting company who did not properly prime the radiator before painting it. The Director of Maintenance stated that they were aware of the rusted radiator and is currently awaiting the contractor to return and repaint it. The Director of Maintenance further stated that it takes 3 weeks for 1 room to be remodeled, and room remodeling is an ongoing project. 4.) During multiple observations from 09/24/2025 through 09/30/2025, room [ROOM NUMBER] was observed with brown stains and blackened areas on tiles in the bathroom and above Resident #23's bed. On 09/30/2025 at 12:04 PM, an observation was conducted with the Director of Maintenance and the same was observed. On 09/30/2025 at 12: 04 PM, the Director of Maintenance stated they were not aware that the tiles in room [ROOM NUMBER]P needs to be replaced. They stated that there was no log in the maintenance book for this issue. The Director of Maintenance stated that brown spots and blacked areas occurs because of condensation, and the effects of the cooling towers in the building. The Maintenance Director stated it also comes from the water pipe drip pan being clogged causing a leak. The Maintenance Director stated they make monthly rounds and had not observed this issue in room [ROOM NUMBER]P. On 10/01/2025 at 11:55 AM, the Administrator stated it is challenging to do the repairs in room [ROOM NUMBER] because the resident is not cooperating and do not want to come out of the room. They stated that residents must not be in the room during repairs. 5.) During observation from 09/24/2025 at 12:16 PM to 09/26/2025 at 2:22 PM, the top grille of the radiator in Resident #137's room was observed full of rust. On 09/29/2025 at 10:10 AM, the Maintenance Director was interviewed and stated they were sometimes short of staff and had a lot of maintenance work to do. They had no explanation on why the top grille of the radiator was full of rust. 10 NYCRR 415.5(h)(2)

Based on observation, record review, and interviews, during the Recertification and Complaint (#523045) Survey, the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the New York State Department of Health. This was evident for 3 (Residents #63, 145, and 12) of 4 residents reviewed for Accidents out of 35 total sampled residents. Specifically, 1.) On 11/25/2024, Resident #63 had an unwitnessed incident when they were observed on the floor and complained of pain to the left hip. The resident was transferred to the hospital and was found to have sustained left intertrochanteric fracture. This incident was not reported to the New York State Department of Health. 2.) On 04/06/2025, Resident #145 was found sitting on their bed with a laceration to the right side of the head. There was no witness on how Resident #145 sustained the injury, and the resident was unable to explain the occurrence. This incident was not reported to the New York State Department of Health. 3.) Resident #12 had unwitnessed fall incidents on 05/30/2025 and 06/24/2025. The resident sustained injury on both incidents and was unable to explain the occurrence. These incidents were not reported to the New York State Department of Health.The findings included: The undated facility's policy titled Reporting Abuse to State Agencies documented that all alleged / suspected violations or crimes and all substantiated incidents of abuse will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law. The policy also stated should there be reasonable cause to believe that abuse, neglect, mistreatment, or exploitation has occurred, the facility administrator, his designee or any person must report the incident to the New York State Department of Health and local enforcement agency as indicated. Reporting occurs not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or no later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. 1.) Resident #63 had diagnoses of Rheumatoid Arthritis and Non-Alzheimer's Dementia. A nurse's progress note dated 11/25/2024 documented that Resident #63 was found on the floor with altered mental status. Resident was safely transferred to bed and complained of hitting their head and left hip. A nurse's progress note dated 11/25/2024 documented that around 1:29 PM, they were told by the nursing supervisor that the Resident #63 had an unwitnessed fall. The resident was transferred to the hospital. The Accident / Incident Investigation dated 11/29/2024 documented that Resident #63 was observed on the floor in their room, complained of left hip pain and headache. The resident was sent to the hospital and was admitted . Resident had an upper acute fracture of the left intertrochanteric. The resident was treated in the hospital. There was no delay in treatment. Resident was treated with analgesic for pain. Resident #63 was last seen prior to incident at 12:50 PM and incident occurred at 1:29 PM. The facility concluded that the investigation had revealed there was no cause to believe any alleged resident abuse, mistreatment, or neglect has occurred. There was no documented evidence that the facility reported Resident #63's unwitnessed fall incident, resulting in major injury, to the New York State Department of Health. On 10/01/2025 at 2:58PM, the Director of Nursing Services was interviewed and stated they were not the Director of Nursing at the time that Resident #63 sustained the fall with injury in November of 2024. The Director of Nursing Services stated that based on review of the incident report, Resident #63 was noted to have fallen in the room and noted to have swelling to their hip. The Resident #63 was referred to the hospital where they were found with a hip fracture. The Director of Nursing Services further stated that injuries of unknown origin are reportable to the state including abuse concerns, sentinel events and death. They stated that unwitnessed falls with injury are not reportable to the New York State Department of Health. On 10/01/2025 at 10:42 AM, the Administrator was interviewed and stated that unknown injuries which includes a large bruise, laceration or fracture on a resident are reported to the New York State Department of Health. If a resident had an unwitnessed fall with injury and a conclusion as to how they sustained that injury is reached quickly, then it will not be reported to the state because it is clear to the facility as to what happened. 2.) Resident #145 had diagnoses of Vascular Dementia, Muscle Weakness, and Personal History of Traumatic Brain Injury. The Significant Change Minimum Data Set 3.0 assessment dated [DATE] documented Resident #145 had severely impaired cognition. A nurse's note dated 04/06/2025 at 5:56 AM documented that Resident #145 was found sitting on their bed with a cut to their head, with confusion and restlessness. There was no spills or hazard on the bedside. There was no change in range of motion and no loss of consciousness. The facility Resident Incident/Accident report dated 04/06/2025 documented that Resident #145 had a laceration to right side of head. The incident was unwitnessed, and Resident #145 was unable to explain what happened due to confusion. There was no documented evidence that the facility reported Resident #145's injury of unknown source to the New York State Department of Health. On 09/30/2025 at 10:26 AM, the Director of Nursing stated during the interview that they were not the Director of Nursing when the incident involving Resident #145 occurred. They stated that allegations of abuse and injury of unknown origin must be reported to the New York State Department of Health within 2 hours of being made aware. On 09/30/2025 at 10:38 AM, the Administrator was interviewed and stated they were not aware of the incident until 09/26/2025 when the State Surveyor requested the incident report. The Administrator stated that the facility had to report injury of unknown origin within 2 hours to the New York State Department of Health. The Administrator further stated the Director of Nursing was responsible for reporting. 3.) Resident #12 was admitted to the facility with diagnosis of Unspecified Dementia with behavioral disturbances. The Comprehensive Minimum Data Set assessment dated [DATE] documented Resident #12 had severely impaired cognition and required supervision with ambulation. A nurse's progress note dated 05/30/2025 at 3:00 PM documented that the Registered Nurse was called to the unit and upon arrival noted Resident #12 lying on their left side in the hallway by room [ROOM NUMBER]P. The resident was noted with bleeding from the nose and left eyebrow laceration. The resident was sent to the hospital. The Accident/Incident Investigation dated 06/05/2025, documented that on 05/30/2025 at approximately 2:40 PM, the nurse who was in room [ROOM NUMBER] responded to a sound from the hallway, and observed Resident #12 lying on the floor with active bleeding noted from the nose and the left side of the forehead. The resident was observed walking in the hallway at around 2:30 PM. Computed tomography scan performed at the hospital showed facial fracture and the facial laceration required five stitches. The facility concluded that the investigation had revealed there was no cause to believe an alleged resident abuse, mistreatment, or neglect had occurred. A nurse's progress note dated 06/24/2025 at 7:42 PM documented that the unit manager was called to the unit at approximately 5:45 PM and found Resident #12 on the floor next to their bed with bleeding noted from the top of their head. The resident was assessed with 2 lacerations approximately 1 centimeter each. The resident was transferred to the hospital. The Accident/Incident Investigation dated 06/30/2025 documented Resident #12 had an unwitnessed fall and was unable to tell what had happened. Resident #12 was found lying on the floor next to their bed. Bleeding noted on top of Resident #12 head. Area cleaned with normal saline and bandaged. Resident #12 was documented to have 2 (two) lacerations at 1cm. Resident #12 Designated Representative was notified. Resident #12 was transferred to the hospital and returned with a diagnosis of Subdural Hematoma along with 3 (three) staples to the top of the head. There was no documented evidence that the 2 fall incidents with injury were reported to the New York State Department of Health. On 10/01/2025 at 1:00 PM, the Administrator was interviewed and stated that an incident must be reported to the New York State Department of Health when a resident had an unwitnessed fall, and the resident cannot explain what happened. 10 NYCRR 415.4(b)(2)

Based on interview and record review conducted during the Recertification Survey from 09/24/2025 to 10/01/2025, the facility did not ensure a comprehensive person-centered care plan was reviewed and revised to address a resident's needs. This was evident for 2 (Residents #164 and #116) of 38 total sampled residents. Specifically, 1) Resident #164's comprehensive care plan was not reviewed and revised to reflect Resident #164's behavior problem, and 2) Resident #116's comprehensive care plans were not reviewed and revised to reflect the elopement/wandering behavior.The findings include: The undated facility policy titled Care Plans - Comprehensive documented the care plans are revised as changes in the resident's condition dictate. The policy also documented care plans are reviewed at least quarterly. 1.) Resident #164 was admitted to the facility with diagnoses which included Unspecified Dementia, Schizoaffective Disorder, and Anxiety Disorder. The Significant Change Minimum Data Set assessment dated [DATE] documented Resident #164 was severely impaired cognition and had no behavior symptoms. The Minimum Data Set also documented Resident #164 and their representative participated in the assessment. The comprehensive care plan related to behavior problem (screaming/yelling/cursing) was initiated 03/30/2021 and last reviewed 05/05/2022 documented the interventions included to administer medications as ordered, monitor/document side effects and effectiveness of medications, and anticipate and meet needs. The Behavior Note dated 05/02/2025 documented Resident #164 was observed screaming, yelling foul languages, attempting to hit staff, and throwing fluids on the floor. The Behavior Note dated 05/09/2025 documented Resident #164 was observed screaming loud outburst using inappropriate language towards staff. The Behavior Note dated 05/09/2025 documented Resident #164 was noted screaming and yelling loud, using profanities at the staff while in the dining room. It also documented Resident #164 having some outburst towards other residents in the dining room. The Behavior Note dated 05/27/2025 documented Resident #164 was noted using foul language towards staff and screaming and yelling at staff while in dining room. The Behavior Note dated 06/5/2025 documented Resident #164 was screaming, yelling, and shouting profanities. There was no documented evidence Resident #164's comprehensive care plan related to behavior problem was reviewed and/or revised to reflect Resident #164's behavior problem status after 05/05/2022. On 09/29/2025 at 10:42 AM, Certified Nursing Assistant #1 was interviewed and stated Resident #164 was alert and oriented to person and place. Certified Nursing Assistant #1 also stated Resident #164 once a while screams and curses the staff when they do not get they want. On 09/29/2025 at 11:29 AM, Registered Nurse #1 was interviewed and stated Resident #164 was easily agitated and required more redirection. Registered Nurse #1 also stated that Resident #164 curses at staff. Registered Nurse #1 stated the unit registered nurse supervisor was responsible to review the comprehensive care plans at least every 3 months and as needed to address resident's care. Registered Nurse #1 reviewed the care plan of behavior problem and stated it documented that thee last review was on 05/05/2022. On 09/30/2025 at 10:17 AM, the Director of Nursing was interviewed and stated care plans had to be reviewed at least every 3 months and as needed and must sign off on each reviewed care plan. 2.) Resident #116 was admitted to the facility with diagnosis that included Hypertension, Non-Alzheimer's Dementia, Anxiety, Psychotic Disorder, Syphilis, [NAME] Matter Disease, Human Immunodeficiency Disease and Mood Disorder. The Quarterly Minimum Data Set assessment dated [DATE] identified Resident #116 with severe impairment in cognition. The assessment documented that Resident #116 required supervision or touch assistance for activities of daily living and have no behaviors, with wander guard in place. The physician's order dated last reviewed 9/23/2025 documented order for Wander guard on right wrist check for placement every shift. A review of Resident #116's administration records dated 6/2025, 7/20205, 8/2025 and 9/2025 documented that wander guard was checked every shift. A resident comprehensive care plan for elopement risk/wanderer related to disoriented to place, Dementia, dated was created for Resident #116 on 09/17/2023 and last reviewed 10/9/2024. A medical progress notes dated 09/04/2025 documented to continue to monitor, evaluate, assess, treat, Resident #116, continued to have psychotic behavior, wandering in hallway this morning, easily redirectable. There was no documented evidence that Resident #116's elopement risk/wanderer care plan was reviewed and revised since 10/09/2024 after each Minimum Data Set assessments or to reflect Resident #11's ongoing wandering behavior. On 09/29/2025 at 11:41 AM, Registered Nurse #3 was interviewed and stated they are responsible for initiating and updating all care plans in the unit. They stated that care plans are updated quarterly, annually, significant change and after episodic occurrences. The Registered Nurse stated they do not document the updates directly in the care plan, but they make one general note in the resident's progress notes. Registered Nurse #3 stated that Resident #116's last quarterly assessment was this past June, so they wrote general note stating the care plan was reviewed. On 10/01/2025 at 11:55 AM, the Director of Nursing was interviewed and stated that Registered Nurses are responsible to review and update care plans at least quarterly, annually, and when there is significant change. The Director of Nursing stated when a resident's care plan is reviewed, the Registered Nurse will sign off that the care plans were reviewed and place a summary note in the care plan. 10 NYCRR 415.11(c)(2) (i-iii)

Based on observation, record review, and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food safety. This was evident during the kitchen observation task and dining observation for one (1) (Unit 8) of 7 units observed. Specifically, 1.) The kitchen staff's facial hair was not fully covered during food preparation, 2.) Enteral feedings were not discarded past it's used by date, and 3.) Certified Nursing Assistant #8 was handling residents' food with bare hands. The findings include:1.) The facility policy and procedure titled Dietary/Food Handling dated 01/2025 documented clean uniforms must be worn daily. Hairnets or caps must be worn effectively to keep hair from contacting exposed food, clean equipment, utensils and linens. On 09/24/2025 at 9:40 AM, [NAME] #1 was observed chopping chicken with their beard net not fully covering their beard. On 09/26/2025 at 10:07 AM, [NAME] #1 was observed cooking fish on the stove with their sideburns not properly covered and their beard restraint was not fully covering their beard. During an interview on 09/26/2025 at 10:33 AM, [NAME] #1 stated they were not aware that their facial hair was not fully covered. On 09/29/2025 between 11:20 AM and 11:40AM, Dietary Aide #2 was inspecting the tray line with their mustache not properly covered. The Assistant Administrator was also in the kitchen with no hair net. During an interview on 09/29/2025 at 11:39 AM, Dietary Aide #2 stated their mustache should be covered so hair would not fall in resident's food. During an interview on 09/29/2025 at 11:41 AM, the Assistant Administrator stated that they were in the kitchen to inspect the trays and was not aware they are supposed to wear a hair net. During an interview on 10/01/2025 at 10:42 AM, the Food Service Director stated they did not notice the Assistant Administrator not wearing a beard net while they were on the tray line. However, hair and beard nets must be used in the kitchen and that the beard net should cover all beards, mustache, and sideburns. 2.) The undated facility policy and procedure titled Food Storage documented all foods will be properly stored in a safe, sanitary manner. Foods are to be rotated using the First-In, First-Out method. On 09/24/2025 at 10:02 AM, a box of shredded lettuce with a best if used by date of 09/20/2025 was observed in the refrigerator. A box of cucumber that were soft and moldy were also noted in the kitchen refrigerator. During an interview on 09/26/2025 at 10:37 AM, Dietary Aide #3 stated that they inspect the food items every week and throw the old ones. They stated they did not notice the expired food items in the refrigerator. During an interview on 09/26/2025 at 10:45 AM, the Food Service Supervisor stated they inspect the kitchen for expired food items twice weekly, on Mondays and Fridays. They stated they toss any expired food. During an observation on 09/24/2025 at 10:25 AM, enteral feedings with a used by date of 09/01/2025 was stored in the dietary emergency food storage area. During an interview on 09/24/2025 at 10:31 AM, the Central Supply Coordinator stated they get weekly delivery of enteral feeding supplies, and they store the new deliveries behind the old ones. On 10/01/2025 at 11:55 AM, the Administrator was interviewed and stated that enteral feedings with a use by date of 09/2025 can be used until the end of September. 3.) The facility policy and procedure titled Serving of Food dated 08/2025 documented food shall be prepared and served in a manner that prevents food borne illness. On 09/24/2025 between 12:18 PM and 12:33PM, Certified Nursing Assistant #8 was observed peeling a banana for Resident #210 with bare hands. The aide was also observed unwrapping Resident #131's bread with bare hands. They did not perform hand hygiene between residents. During an interview on 09/24/2025 at 2:52 PM, Certified Nursing Assistant #8 stated they did not realize they were touching the resident's food with their bare hands. During an interview on 09/24/2025 at 2:58 PM, Licensed Practical Nurse #1 stated they monitor the dining room during mealtimes. They stated that staff should not touch food with bare hands. On 09/30/2025 at 9:57 AM, the Infection Preventionist was interviewed and stated hand hygiene is very important and must be adhered to by all staff in the facility. 10 NYCRR 415.14 (h)

Based on observation, record review, and interviews, the facility failed to ensure that all injuries of unknown origin were thoroughly investigated. This was evident for 1 (Resident #145) of 3 residents reviewed for Notification of Change out of 38 sampled residents. Specifically, on 04/06/2025, Resident #145 was observed with a laceration on the right side of their head. The facility initiated the investigation but failed to thoroughly investigate the incident to rule out abuse and/or neglect. The findings include:The facility policy titled Investigating Unexplained Injuries which was last revised on 12/2024 documented an investigation of all unexplained injuries (including bruises, abrasions, and injuries of an unknown source) will be conducted by the risk manager, director of nursing services, and/or other individual appointed by the administrator, to ensure that the safety of the residents had not been jeopardized. Resident #145 had diagnoses of Vascular Dementia, Muscle Weakness, and Personal History of Traumatic Brain Injury.The Significant Change Minimum Data Set 3.0 assessment dated [DATE] documented Resident #145 had severely impaired cognition, no behavior symptoms, and one major injury of falls since admission or Prior assessment. A nurse's note dated 04/06/2025 at 5:56 AM documented that Resident #145 was found sitting on their bed with a cut to their head, with confusion and restlessness. There was no spills or hazard on the bedside. There was no change in range of motion and no loss of consciousness. The facility Resident Incident/Accident report dated 04/06/2025 documented that Resident #145 had a laceration to right side of head. The incident was unwitnessed, and Resident #145 was unable to explain what happened due to confusion. A review of the facility investigation revealed that the investigation was not completed to rule out abuse and / or neglect. On 09/30/2025 at 10:26 AM, the Director of Nursing was interviewed and stated they were not Director of Nursing when the alleged incident with Resident #145 happened. On 09/30/2025 at 10:38 AM, the Administrator was interviewed and stated they were not aware of the incident until 09/26/2025 when the State Surveyor requested the incident report. The Administrator stated they reviewed the incident report and found the investigation was not completed. The Administrator further stated the investigation had no documentation about the environment in Resident #145's room and had no facility investigation summary. The Administrator stated they have a different Director of Nursing when the incident occurred, and they were not able to explain why the incident was not investigated thoroughly.10 NYCRR 415.4(b)(3)

Based on observation, record review, and interview the facility failed to ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident in one (1) of 1 resident observed for respiratory care. Specifically, on 09/25/2025, Enhanced Barrier Precautions were not maintained during tracheostomy suctioning. The findings include:The facility's policy and procedure titled Enhanced Barrier Precautions with a revised date of 03/24/2025 documented that in addition to standard precautions, Enhanced Barrier Precautions will be considered for residents who are at high risk of both acquisition of and colonization with Centers for Disease Control and Prevention multidrug resistant organisms. The Enhanced Barrier Precautions refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Resident #1 was admitted to the facility with diagnosis that included Multiple Sclerosis and Epilepsy. A medical progress note dated 09/28/2025 documented that Resident #1 had tracheostomy. On 09/25/2025 at 12:27 PM, Respiratory Therapist #1 was observed in Resident #1's room performing tracheal suctioning and was only wearing gloves and surgical mask. During an interview on 09/25/2025 at 12:30 PM, Respiratory Therapist #1 stated that they went to check on Resident #1, and the resident was pointing to their throat and needed suctioning. They stated they normally would put on face shield and gown when suctioning a resident. During an interview on 10/01/2025 at 1:18 PM, the Director of Respiratory Services stated that respiratory therapists must wear a gown, face shield, mask, and gloves during respiratory suctioning. They stated Enhanced Barrier Precaution signs are posted in resident's room if they are on precautions. 10 NYCRR 415.19 (a) (1-3)

Based on observation, record review, and interviews, the facility failed to ensure that a comprehensive person-centered care plan for each resident was developed and implemented, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident in 1 of 8 residents reviewed for Accidents (Resident #116) and 1 out of 5 residents reviewed for Unnecessary Medications (Resident #164). Specifically, 1.) Resident # 116 had no comprehensive care plan developed to address ongoing disruptive behaviors. 2.) Resident #164 had no comprehensive care plan developed for anticoagulant therapy. The findings include: The undated facility policy and procedure titled Comprehensive Care Plans documented a comprehensive care plan includes measurable objectives, and timetables to meet the resident's medical, nursing, mental and physiological needs to develop for each resident. The policy further documented that the facility would develop and maintain a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. 1.) Resident #116 was admitted to the facility with diagnoses that included Hypertension, Non-Alzheimer's Dementia, Anxiety, Psychotic Disorder, Syphilis, [NAME] Matter Disease, Human Immunodeficiency Disease and Mood Disorder. The resident Quarterly Minimum Data Set assessment dated [DATE] identified Resident #116 with severe impairment in cognition. Resident #116 required supervision or touch assistance for activities of daily living, living, had no behaviors, and with wander alert device in place. On 09/24/2025 at 10:52 AM, Resident #116 was observed yelling and screaming in the hallway using profanity stating they will get a gun and shoot. The resident constantly walked back and forth on the unit. The staff redirects the resident but still continued to walk back and forth on the unit. 09/24/2025 12:25 PM, Resident #116 was in the dining area using profanity, and stated they have a grenade and will blow someone's head off. The Unit Manager had to step in front of resident to redirect behavior, and the resident left the dining area. 09/29/2025 at 11:04 AM, Resident #116 was observed yelling and screaming on the unit without reason. The staff moved Resident #116 away from other residents. The resident was easily redirected. A nurse's progress note dated 05/30/2025 at 9:41 PM documented that Resident #116 continues with behavioral monitoring. The resident continues to curse, yell and scream at staff and other residents for no apparent reasons. A nurse's progress note dated 06/24/2025 documented that Resident #116 was monitored for behavior issues; was noted to have outburst in the first-floor dining room screaming. A nurse's progress notes dated 07/21/2025 at 11:18 PM documented that Resident #116 displayed radical behavior during the shift, was very aggressive with neighbor residents. A nurse's progress note dated 09/28/2025 at 12:54 PM documented that Resident #116 was screaming and yelling. A review of Resident #116's comprehensive care plan had no documented evidence that a care plan was created to address resident #116 behaviors of verbal aggression, yelling screaming, using profanities or threatening behaviors. On 09/29/2025 at 11:41 AM Registered Nurse #3 was interviewed and stated resident is alert to self on most days and on some day is totally disoriented. Registered Nurse #3 stated at times resident conservation cannot be understood, and have behaviors of yelling screaming, cursing, goes in and out of room's weather invited or not, not aggressive physically but very aggressive verbally. Registered Nurse #3 stated resident at times verbalize says someone will shoot the place or did you not see they come with the gun. Registered Nurse stated resident will verbalize someone have knife at throat and will redirect the resident and resident is easily redirected if staff remains calm and the resident will become calm. Registered Nurse #3 stated the resident's behavior is constant and staff must constantly redirect the resident. Resident Manger stated is responsible for initiating and updating all care plans for the units. They stated that Resident #116 had no care plan developed to address their behavior and that this was an oversight. On 10/01/2025 at 11:55 AM, the Director of Nursing was interviewed and stated the unit registered nurses were responsible to create applicable care plans for the residents. Director of Nursing also stated a care plan is required for a resident with ongoing behaviors such as Resident #116. 2) Resident #164 was admitted to the facility with diagnoses which included Unspecified Dementia, Unspecified Atrial Fibrillation, and Acute Embolism and Thrombosis of Unspecified Deep Veins. The Significant Change Minimum Data Set assessment dated [DATE] documented Resident #164 was severely impaired cognition, had diagnosis of atrial fibrillation and deep venous thrombosis, and was taking anticoagulant. The physician order initiated 06/27/2025 documented Resident #164 was prescribed Eliquis 5 milligrams, 1 tablet by mouth two times a day for deep venous thrombosis. The Medication Administration Record for September 2025 documented Eliquis 5 milligrams, 1 tablet was administered twice daily every day. A review of the current Comprehensive Care Plans revealed that a care plan for anticoagulant and deep venous thrombosis was developed for Resident #164. On 09/29/2025 at 11:29 AM, Registered Nurse # 1 was interviewed and stated the unit registered nurse supervisor was responsible for creating the comprehensive care plan. Registered Nurse #1 also stated a comprehensive care plan was required if a resident was taking anticoagulant to monitor for bleeding status. Registered Nurse #1 reviewed the care plans for Resident #164 and was not able to find any care plan related to anticoagulant therapy for Resident #164. On 09/30/2025 at 10:17 AM, the Director of Nursing was interviewed and stated the unit registered nurses were responsible to create applicable care plans to address residents' care and needs. They stated that a care plan is required for resident's taking anticoagulant like Eliquis. Director of Nursing reviewed the care plans for Resident #164 and stated they were not able to explain why the care plan related to anticoagulant was not developed for Resident #164. 10 NYCRR 415.11(c)(1)

Based on observations, record review, and staff interviews conducted during the Recertification/Complaint survey conducted from 1/4/24 to 1/10/24, the facility did not ensure that the resident was offered the opportunity to participate in the revision and/or review of the comprehensive care plan. Specifically, resident and resident's representatives were not consistently invited to participate in their care plan meetings. This was evident for 1 resident reviewed for care plans out of 38 residents. (Residents #112). The findings are: The facility policy titled Care Planning-Interdisciplinary Team last revised on 1/2023 documented, the resident, the resident's family and/or the resident legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. Resident #112 was admitted with diagnoses that included Vascular Dementia, Anxiety, Hemiplegia, and Hemiparesis. The Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident was severely cognitively impaired and was dependent on staff for most Activities of Daily Living. The Annual Minimum Data Set also documented that only the resident participated in the assessment. On 1/4/23 at 11:02 AM, during an interview Resident #112 stated that no one had discussed discharge planning with them and they had not been invited to attend any care plan meetings. The Care Plan Conference Summary dated 11/16/2023 did not document that Resident #112 and/or their representatives participated in the meeting. There was no documented evidence in the electronic medical record that Resident #112 had been invited to or participated in the care plan meetings. On 01/09/24 at 3:14 PM, an interview was conducted with Social Worker #2 who stated that Resident #112 was invited to care planning meetings verbally however the invitations and response to the invitations are not documented. Social Worker #2 also stated that residents are invited to the care planning meeting by verbal invitations and resident representatives are mailed or hand delivered letters of invitations. Resident #112 is usually open to attending the meetings and the representative/family sometimes attends. Resident #112 discharge wishes were verbalized during rounds but were not discussed or followed up on during the care plan meetings. On 01/10/24 at 11:13 AM, an interview was conducted with the Director of Social Services who stated that they cover care planning meetings when the assigned Social Worker is not available, along with other members of applicable departments. The Director of Social Services also stated that Resident #112 had not verbalized any concerns regarding discharge to them personally. The Director of Social Services further stated that invitations to the care planning meetings are not documented only attendance to the meetings is documented. 415.13(f)(1)(v)

Based on observations, record review and interviews conducted during the Recertification survey from 1/4/24 to 1/10/24, the facility did not ensure that the resident received services that accommodated the resident's needs and preferences. Specifically, the call bell in Resident #237's bathroom did not work. The findings are: Resident #237 was admitted to the facility with diagnoses which included Vascular Dementia, Psychotic Disturbance, and Depression. The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented that Resident #237 had moderately impaired cognition, required partial/moderate assistance when performing Activities of Daily Living and supervision for mobility and transfers. The Comprehensive Care Plan for focus resident is at High Risk for Falls last revised on 10/27/23 included interventions of be sure call light is within reach and encourage to use it for assistance as needed, needs prompt response to all requests for assistance, and assist with toileting upon awakening, before/after meals and at bedtime. On 01/04/24 at 10:11 AM and on 01/08/24 at 10:04 AM, an observation was conducted of the resident bathroom. The call device was observed to be in-active, with no observed power to the device. No substitute device or means of emergency communication was observed in the area. On 01/04/24 at 10:11 AM and on 01/08/24 at 10:04 AM, Resident #237 refused to be interviewed. On 01/08/24 at 11:55 AM, an interview was conducted with Registered Nurse #6 who stated that they were not aware that the call system in the shared resident bathroom was not working and had no power. On 01/08/24 at 02:21, an interview was conducted with Certified Nursing Assistant #5 who stated that they were not aware that the call system in the shared resident bathroom was not working and had no power. On 01/08/24 at 02:56 PM, an interview was conducted with Registered Nurse #7 who stated they were not sure about the status of the call device and was not certain if another device was provided for either of the residents to use to call for staff if needed. On 01/08/24 at 03:33 PM, an interview was conducted with the Director of Maintenance who stated that the resident's roommate pulled the call system from the wall on 12/28/23. The area was covered by a metal plate however this would affect the call device in the shared resident bathroom as there was now no power to the device. On 01/09/24 at 03:32 PM, a follow-up interview was conducted with the Director of Maintenance who stated that the facility's plan is to rewire the bathroom call device directly to room [ROOM NUMBER]. This is corrective action. Was anything put in place for resident to contact staff until repairs could be made? 415.5 (e)(1)

Based on observations, interviews, and record reviews during a Recertification/Complaint survey from 1/4/23 to 1/10/23, the facility did not ensure that assessments accurately reflected the residents' status. Specifically, the admission assessment did not reflect the presence of a colostomy device that was used for a resident. This was evident for 1 of 1 resident reviewed for Urinary Catheter out of a sample of 38 residents. (Resident #24) The findings are: The facility's policy regarding Minimum Data Set (MDS) Guideline for Completion last reviewed 10/01/23 documented, It is the policy of all Allure Facilities to ensure accurate and timely completion of MDS/Comprehensive Care Plan (CCP) for all residents in accordance with the Federal and State Operation Manual. Resident #24 was admitted to the facility with diagnoses which include Obstructive Uropathy, Unspecified Hydronephrosis, and Chronic Obstructive Pyelonephritis. The Admission Minimum Data Set 3.0 assessment dated [DATE] documented that Resident #24 was moderately cognitively impaired, had no behaviors and did not reject care. Resident required dependent assistance with most Activities of Daily Living, had an indwelling catheter and was frequently incontinent of bowel. On 1/4/23 at 10:32 AM, Resident #24 was interviewed and stated that they had a urinary device in place and experienced pain and discomfort regularly. The Comprehensive Care Plan titled resident has alteration in gastro-intestinal status related to neoplasm of rectum, malignant neoplasm of colon with Colostomy, fistula of intestine was created 10/31/23 and revised 12/27/23. The goal was to not have complications related to ostomy presence through review date. Interventions included: avoid activities that involve bending, discuss concerns with resident/family members, ensure privacy, provide ostomy care as ordered, monitor for complications. The Admission Nursing Summary dated 10/30/23 documented that resident had bilateral nephrostomy tube and colostomy on the right side of the abdomen. The Admission Minimum Data Set assessment did not reflect that Resident #24 had an ostomy in place. On 01/10/24 at 02:12 PM, an interview was conducted the Director of Minimum Data Set assessments who stated that the MDS nurse completes the observations, data collection on entry and is responsible for ensuring the accuracy of the assessment. The Director of Minimum Data Set assessments also stated that the nurse responsible for completing the Admission Minimum Data Set assessment for Resident #24 was no longer an employee of the facility. The Director of Minimum Data Set assessments further stated that they are only responsible to signs off on the assessments and do not check for the accuracy of the document. 415.11 (b)

Based on observations, interviews, and record review conducted during the Recertification and Complaint Survey (NY00297824) from 01/03/2024 to 01/10/2024, the facility did not ensure that menus and dietary preferences were followed. This was evident for 2 (Resident #463 and Resident #125) of 4 residents reviewed for Food out of 38 total sampled residents. Specifically, 1). Resident #125 did not receive food items listed on their tray ticket during mealtime, and 2). Resident #463 did not receive a cheese sandwich as preferred. The findings are: The facility's policy titled Resident food preferences, last revised 1/23, documented that the dietician will visit residents periodically to determine if revisions are needed regarding food preferences. The nursing staff will inform the kitchen about resident requests. 1.Resident #463 was admitted to the facility with diagnoses that include Atrial Fibrillation and Coronary Artery Disease. The 5-day Minimum Data Set 3.0 assessment dated [DATE] documented that resident's cognition as modified independence, Brief Interview for Mental Status score of 12, no swallowing disorder, and on a therapeutic diet. The Minimum Data Set 3.0 assessment also documented that Resident #463 required partial/moderate assistance for eating. The Comprehensive Care Plan for Nutrition created 12/21/23 documented Resident #463 has a therapeutic diet with goals that include Resident will consume more than75% of meals. Interventions include to provide food preferences as desired. The Physician's Orders dated 12/20/23 documented Resident #463's diet as no added salt, regular texture, thin consistency. On 01/10/24 at 12:03 PM, the State Surveyor observed Resident #463 sitting at the nursing station with an escort. While sitting at the nurse's station, the State Surveyor observed Licensed Practical Nurse #1 make a telephone call to the kitchen and inform the Food Service Director that Resident #463 was requesting a cheese sandwich to take to an outside appointment. Licensed Practical Nurse #1 then told Resident #463 that they would not be able to get a cheese sandwich at this time since the kitchen was serving a meat lunch, so they cannot meet that request. The Licensed Practical Nurse #1 then offered Resident #463 a tuna or a peanut butter sandwich, to which Resident #463 replied that they do not like tuna nor peanut butter and insisted that they only want a cheese sandwich. Resident #463 also stated that they will just remain hungry if they cannot get a cheese sandwich. At approximately 12:05 PM, Food Service Director was interviewed via phone and stated that it was not possible for Resident #463 to receive a cheese sandwich even if there were cheese sandwiches available. The Food Services Director stated that since the kitchen was serving a meat lunch according to kosher principles, they are not able to serve a cheese sandwich, which is dairy. The State Surveyor then observed the resident leaving the unit with an escort without any food items. A nursing note dated 1/10/24 documented that resident is alert and verbally responsive no complaints voiced, via wheelchair, accompanied by her escort. Left the unit at 12:15 PM for scheduled Cardiology appointment. On 01/10/24 12:13 PM, a follow-up interview was conducted with the Food Service Director who stated that because the facility is a Kosher facility, they were unable to provide the resident with a cheese sandwich. The Food Service Director also stated that they thought that the resident was going to have the sandwich on a tray on the unit and was not aware that the resident was going to an outside appointment. The Food Service Director further stated that once they realized that the resident was going out, they asked the Rabbi about giving the sandwich in a brown bag, which would have been acceptable, but the resident had already left the facility, without a sandwich. The Food Service Director stated that usually the staff would ask for a bagged lunch, however in this case, they were not made aware that the resident was leaving, and they thought that this request was that the sandwich would have been eaten on the unit. On 01/10/24 at 01:03, Licensed Practical Nurse #1 was interviewed and stated that at 11:30 AM, they asked Resident #243 if they wanted to have a lunch tray, but Resident #243 refused, and stated they wanted a Swiss cheese sandwich. Licensed Practical Nurse #1 also stated that they called downstairs to the kitchen, and spoke with the Food Service Director, who said they would send the sandwich. Licensed Practical Nurse #1 further stated that they called the kitchen again at 12:00 noon, since Resident #463 was about to leave for an outside appointment and had not received the sandwich. Licensed Practical Nurse #1 said that the Food Service Director then told them that they were preparing a meat lunch so they cannot get a cheese sandwich and offered a tuna and or a peanut butter sandwich. The Food Service Director said that the Rabbi said that this is a Kosher facility and that Resident #463 is unable to get a cheese sandwich at this time. Licensed Practical Nurse #1 stated Resident #463 only wants a cheese sandwich, and that they are going out to an appointment. On 01/10/24 01:15 PM, Registered Nurse #1 was interviewed and stated that once the resident has an outside appointment, they get a lunch bag. Registered Nurse #1 also stated that they were not aware that Resident #463 did not have any lunch bag prior since the kitchen would either bring it up or leave it at the front desk. Registered Nurse #1 further stated that Resident #463 did not eat lunch before they left the unit for their appointment and should have gotten something to take on the appointment. Registered Nurse #1 stated that sometimes they would have the sandwich prepared ahead of time. 2. Resident #125 was admitted to the facility with diagnoses that included End Stage Renal Disease, Diabetes Mellitus and Hemiparesis. The Quarterly Minimum Data Set 3.0 assessment dated [DATE], documented resident had intact cognition, was on a therapeutic diet, and participated in goal setting. The Physician's Orders dated 6/19/23 documented Resident #125's diet as no concentrated sweets, renal, no added salt, low potassium diet. The Comprehensive Care Plan for Nutrition created on 5/17/21 documented Resident #125 was on a therapeutic diet. Goals included Resident #125 will maintain adequate nutritional status, and interventions included provide and serve diet as ordered, no concentrated sweets, renal, no added salt, low potassium diet, Regular texture, thin consistency (double vegetable portions). On 01/03/24 at 12:45 PM during a Dining Observation, Resident #125 was observed lying in bed in their room. The lunch meal ticket documented 1/2 cup peas and carrots, 1 piece banana, 1/2 cup cucumber and onion salad, 1/2 cup penne pasta, 6 oz chicken broth,7 oz sausage and peppers, Resident #125's meal tray did not have a 1/2 cup peas and carrots, 1 piece banana, and the 1/2 cup cucumber and onion salad present on the tray. On 01/03/24 at 12:55 PM, the Registered Dietician was interviewed and stated that Resident #125 did say at times the seltzer and other items were sometimes missing on their tray. The Dietician also stated that when the resident did mention the missing items, they notified dietary staff about the concern. The Dietician further stated that they meet with the Resident #125 often to discuss any concerns. On 01/10/24 at 03:23 PM, the Food Service Director was interviewed and stated that the Kitchen supervisor double checks to ensure accuracy, and staff will notify them if there are any discrepancies. The Food Service Director also stated that they have been working with the dietician to ensure accuracy and that the dietary workers are made aware that they are to check the tickets. On 01/10/24 at 3:03 PM, the Administrator was interviewed and stated that the facility is working to ensure all residents receive the proper meal. The Administrator also stated that the dietary team has to audit trays every meal and that they work hard to ensure all residents receive the correct trays. The Administrator further stated that the staff on the unit also checks the trays. 415.14(c) (1-3)

Based on observation, record review and interview conducted during the Recertification Survey 01/03/2024 to 01/10/2024, the facility did not ensure that the most recent hospice plan of care was provided for a resident. Specifically, the Hospice Assessment, Plan of Care and Hospice team interdisciplinary notes were not provided to the facility and available for review for Resident #87. This was evident for 1 of 1 resident reviewed for Hospice out of 38 sampled residents. The findings are: The facility policy and procedure titled Hospice Program with a revision date of 1/23 documented that King [NAME] Center contracts for hospice services for residents who wish to participate in such programs. The policy also documented that when a resident participates in the hospice program, a coordinated plan of care between King [NAME] Center, Hospice Agency, and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status. The Agreement for Hospice Care to Skilled Nursing Facility residents signed between Visiting Nurse Services of New York Hospice and King [NAME] on April 30, 2015, Article 3 Section 2.4 documented that the Hospice shall develop, review, and revise a Hospice Plan of Care for each Hospice resident which reflect the participation of the Hospice, Skilled Nursing Facility and the Hospice resident and family to the extent possible. Hospice will furnish Skilled Nursing Facility with a copy of the Plan of Care and will identify the services to be furnished by Skilled Nursing Facility, and those services to be provided by Hospice. The agreement also documented that would be communication between Hospice and Skilled Nursing Facility to ensure that the needs of Hospice residents are addressed and met 24 hours a day. Resident #87 was admitted with diagnoses that included Non-Alzheimer's Dementia, Anxiety Disorder, Depression, and Senile Degeneration of the Brain. The Minimum Data Set 3.0 assessment dated [DATE] documented that the resident was severely cognitively and dependent on staff for all Activities of Daily Living. On 01/08/2024 at 4:26 PM, Resident #87 was observed in their room, in bed asleep, and appeared frail and weak in appearance. On 01/09/2024 at 2:00PM, Home Health Aide #6 (Hospice) sat with Resident #87 in the dining room. The Physician's order dated 12/14/2023 documented renewal of an order for Hospice Care which had been initiated on 08/13/2023. 8an admission assessment, Comprehensive Care Plan, or the Plan of care for the Hospice Home Health Aide. On 01/09/2024 at 11:30AM, Licensed Practical Nurse #2 was interviewed and stated that they did not know where the Hospice documents for Resident #87 were. During an interview on 01/09/2024 at 11:35AM, Registered Nurse Supervisor #8 stated they did not know where the hospice documents were. Registered Nurse Supervisor #8 also stated that the Hospice Nurse comes in weekly, converses with the staff, but does not give any update on the resident's condition. Registered Nurse Supervisor #8 then reviewed Resident #87's medical record and presented an untitled, handwritten document dated 9/14/23, 9/21/23 and 9/28/23, each note titled RN visit made. There were no other documents from the Registered Nurse or any of the other members of the Hospice interdisciplinary team. On 01/10/2024 at 2:12 PM, a telephone interview was conducted with the Hospice Registered Nurse #9 who stated that Resident #87 was last visited on 12/29/2023. Hospice Registered Nurse #9 also stated that they make weekly visits, coordinate with the nursing home staff, and do Home Health Aide supervision every 2 weeks. Registered Nurse #9 further stated that the Home Health Aide provides companionship, holds the resident's hand, converses, and provides psychosocial-emotional support, makes observation of any changes and reports this to the nurse. Hospice Registered Nurse #9 stated that they are responsible for all transmitting all documents to the facility within 48 hours after each visit. During an interview on 01/09/2024 at 2:22 PM, Home Health Aide #6 stated that they did not receive a copy of Resident #87's Plan of Care, and Hospice Registered Nurse #9 gave them instructions to observe the resident, check their nasal cannula, offer them water or juice, and report any changes to the nursing home staff. 415.12

Based on observations and interviews conducted during the Recertification Survey from 01/03/2024 to 01/10/2024, the facility did not ensure that the nurse staffing information was posted appropriately. Specifically, the posting of daily nurse staffing information was not posted in a prominent area which was readily accessible to residents and visitors. The finding is: The facility policy and procedure titled Posting Daily Nurse Staffing Information dated 1/23 documented that it is the policy of our facility to ensure nurse staffing information is readily available in a readable format to residents and visitors at any given time. During observations conducted on 01/03/2024, 01/05/2024 and 01/08/2024, the State Surveyor was unable to locate the postings of the daily nurse staffing levels for each shift or any signage instructing residents or visitors where it was located. On 01/09/2024 at 12:30 PM, the State Surveyor asked the Director of Nursing where the staffing information was located and was shown the posting located in the hallway posted next to the staff bulletin board, near the time clock. This area was not readily accessible to residents or visitors. On 01/10/2024 at 1:30 PM, the Staffing Coordinator was interviewed and stated they were responsible for posting the nursing staffing information daily. The Staffing Coordinator also stated that the information is posted near the employee time clock as this is where the former Staffing Coordinator placed it. The Staffing Coordinator further stated that they were not aware that the notice was to be posted where it is visible for visitors, families, and residents. On 01/10/2024 at 1:35PM, the Director of Nursing was interviewed and stated that as far as they know the staffing information has always been posted in the hallway next to the bulletin board near the time clock. The Director of Nursing further stated the notices would be accessible to residents who go to activities and the rehabilitation center and not all residents and visitors. The Director of Nursing further stated that it did not occur to them that the notice has to be posted in an accessible location for visitors, families, and residents. 415.13

Based on record reviews and interviews conducted during Recertification and an Abbreviated survey (NY 610 and NY 209), the facility did not ensure that person-centered care plans with measurable goals, time frames, and interventions were developed to address resident's concerns. Specifically: 1) A care plan was not developed to address a resident's oxygen use. 2) A care plan was not developed to address a resident with aggressive behavior. 3) A Care Plan was not developed to address a resident's actual skin breakdown and risk for further skin breakdown. 4) A Care Plan was not developed with interventions documneted to prevent further skin breakdown. This was evident for 4 residents out of a total of 38 sample residents reviewed. (Resident #105, #209, #306 and #25) The findings include: The facility policy and procedure titled Baseline Care Plan dated 01/2021 states that upon completion of initial assessment/screening, each discipline shall identify the resident's specific needs. Basic care needs such as wound care, tube feeding, [CONDITION(S)], and [CONDITION(S)]/ventilator. The policy further states that each discipline, based on identified resident's needs and strengths, will develop an initial care plan addressing safety concerns, risks, and barriers to resident goals. The initial care plan may include skin integrity actual or/and at risk, behavior, and therapy needs. 1) Resident # 105 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] identified Resident #105 cognition as severely impaired never/rarely made decision. Section O of the MDS indicated that Resident # 105 was receiving Oxygen. On 11/04/2021 at 9:30 AM, Resident # 105 was observed resting in bed with Oxygen at 2 liters nasal cannula in use. On 11/05/2021 at 10:02 AM, Resident #105 was observed out of bed in Geri chair with Oxygen at 2 liters nasal cannula in use. On 11/08/2021 at 9:45 AM, Resident #105 was observed out of bed in Geri chair with Oxygen at 2 liters nasal cannula in use. Physicians' Orders dated 10/2021 documented administering Oxygen 2 liters via nasal cannula every shift. There was no documented evidence that a Comprehensive Care Plan had been developed and implemented with the appropriate interventions to address the use of Oxygen. A Nurse's Progress Note dated 10/29/2021 at 12:54 AM documented that Resident #105 is on Oxygen at 2L via nasal cannula. The Head of the bed is elevated at 30 degrees while in bed. A Reparatory Therapy Note date 10/24/2021 at 5:47 PM documented that oxygen saturation maintained above 95% with Oxygen. During an interview on 11/10/2021 at 12:12 PM the Unit Manager #1 (UM #3) stated that Resident # 105 is on Oxygen because of shortness of breath and low oxygen saturation. The resident is on Oxygen 2 liters via nasal cannula. UM, #3 said that the care plan for Oxygen was initiated on 11/07/2021 and did not know why the resident did not have a care plan in place before. UM, #3 noted that all the registered nurses are responsible for initiating care plans. During an interview on 11/10/2021 at 2:12 PM, the DON stated that a care plan should be initiated on admission, including a baseline care plan. The unit manager reviews the admission packet and initiates the care plan. The unit manager or the supervisor is responsible for initiating and updating the care plan when changes occur. 2) Resident # 209 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] identified Resident # 209 cognition as intact with a Brief Interview of Mental Status (BIMS) score of 15. A Nurse's Progress Note dated 02/25/2020 at 6:24 PM documented that Resident # 209 exhibited aggressive behavior towards another resident. A Nurse's Progress Note dated 02/25/2020 at 6:53 PM documented that Resident # 209 was transferred from the 4th floor to the 7th floor and is on 1:1 monitoring. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident # 209 care plans revealed no documented evidence that a Comprehensive Care Plan was initiated to address Resident # 209 aggressive behavior. During an interview on 11/10/2021 at 12:49 PM, the Assistant Director of Nursing (ADON) stated that Resident #209 was aggressive towards another resident. The resident was placed on one-to-one supervision pending transfer to another floor. There was no care plan in place, and there should have been an aggressive behavior care plan initiated. During an interview on 11/10/2021 at 2:12 PM, the DON stated that a care plan should be initiated on admission, including a baseline care plan. The unit manager reviews the admission packet and initiates the care plan. The unit manager or the supervisor is responsible for initiating and updating the care plan and changes. 3) Resident # 306 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #309 has moderately impaired cognition. The resident requires extensive assistance of two persons for bed mobility and transfer. The resident needs total dependence, and two persons assist for toileting. Admission summary dated 12/23/2019 documented the resident has a pressure ulcer on the sacrum. Patient Review Instrument (PRI) dated 12/20/2019 documented stage 1 pressure ulcer. A Nurse's Progress Note dated 12/23/2019 documented pressure ulcer to the sacrum. A Wound Care Note dated 01/03/2020 documented Deep Tissue Injury (DTI) of the Right heel, wound size: 4.5 x 4.5 cm and DTI of the Left heel, wound size: 4 x 5.5 cm. There was no documented evidence that Comprehensive Care Plan (CCP) had been developed and implemented upon admission with the appropriate interventions to address the resident's actual skin breakdown and risk for further skin breakdown. The CNA Accountability Sheet dated 12/2019 to 02/2020 did not reflect any evidence that Resident # 309 was turned and positioned every two hours. There was no documentation that the heels were offloaded. A Comprehensive Care Plan dated 01/03/2020 was initiated with interventions that include administering treatments as ordered and monitoring for effectiveness. Staff to Treat pain as per orders before treatment/turning etc., to ensure comfort. The comprehensive care plan did not include turning and positioning every two hours and offloading heels. During an interview on 11/09/2021 at 11:24AM, Certified Nursing Assistant # 1 ( CNA #1) stated that Resident #309 was admitted with sacrum pressure ulcer needed total dependence and two persons for activities of daily living. The resident was supposed to be turned every two hours. CNA #1 stated I do not remember when turning and positioning and booties were placed. During an interview on 11/09/2021 at noon, the Wound Care Nurse stated the nursing note documented that Resident #309 had Deep Tissue Injury (DTI) of bilateral heels. The resident was at risk of developing ulcers. Preventive measures should have been implemented. The resident should have been turned and repositioned every two hours and heels offloaded. The wound team recommendations are communicated with the nursing supervisor, and the nursing supervisor would initiate a care plan with the recommended interventions. On 02/03/2020, the Wound Care Nurse recommended an air mattress, elevated legs to float while in bed, draw sheet in use to prevent shearing while in bed. During an interview on 11/09/ at 12:44PM, Unit Manager #1 (UM #1) stated that a care plan for impaired skin integrity should have been implemented with appropriate interventions. Turn, and positioning schedule should have been documented in the CNA tasks. Booties should have been placed on Resident #309's feet. During an interview on 11/09/2021 at 12:41 PM, the Assistant Director of Nursing (ADNS) stated that the care plan is supposed to be initiated upon admission. If there are any changes, the care plan should be updated. Care plans are updated with any changes in the resident's status. If a resident is at risk of skin breakdown or has skin impairments, a care plan should be initiated upon admission with the appropriate interventions. The interventions should include turning and position every two hours, offloading heels, nutrition supplements, air mattresses, and skin checks. Turn and positioning, skin checks, and offload heels should be documented in the CNA accountability. During an interview on 11/10/2021 at 10:29AM, the Director of Nursing (DNS) stated that care plans are initiated on admissions and changes. The Interdisciplinary Team meets to discuss each resident's care plan. The care plan should include appropriate interventions to prevent further skin breakdown. Resident # 309 should have had impaired skin integrity with interventions such as turn and positioning, offload heals, nutrition supplements, air mattress to prevent the wound from getting worse and further skin breakdown. 4) Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented that Resident # 25 was severely impaired. Resident #25 extensive assistance of two persons assist for bed mobility, transfers, and toilet use. Resident #25 was at risk for developing a pressure ulcer/injury. The Patient Review Instrument dated 03/19/2021 documented that Resident #25 has multiple areas of ecchymosis on the body, including the bilateral upper extremities and lower extremities, upper thighs, and left side back overlying scapula. Skin/Wound Note dated 03/26/2021 documented ecchymosis to bilateral upper extremities. Skin/Wound Note dated 04/19/2021 documented reddish-purple bilateral upper extremities to the sacral area measured 3 centimeters (cm) x 8 cm. Air mattress was in place. Skin/Wound Note dated 05/06/2021 documented that Resident #25 has an unstageable wound of sacrum; It is documented offloading, turn and positioning are ongoing, and draw sheet in use to prevent shearing while in bed and elevated to float feet while in bed, The Comprehensive Care Plan (CCP) titled Potential/actual impairment to skin integrity r/t fragile skin, sacral skin breakdown was initiated on 03/26/2021. The interventions include: Avoiding scratching, keeping hand/body parts from excessive moisture, Keeping skin clean/dry, and Using a draw sheet or lifting device to move the resident. The Comprehensive Care Plan (CCP) titled Stage 4 Sacrum Pressure Ulcer Development related to immobility was initiated on 05/06/2021. The interventions include administering medications as ordered, administering treatments, monitoring dressing, requiring supplemental protein, amino acids, vitamins, and minerals to promote wound healing, and requiring pressure relieving/reducing device on bed/chair. The CCP titled Potential/actual impairment to skin integrity related to fragile skin, sacral skin breakdown, and the CCP titled S4 Sacrum Pressure Ulcer Development r/t immobility did not include interventions, preventative measures specific to turn and to position every two hours and positional device used for offload. The CCP titled S4 Sacrum Pressure Ulcer Development r/t immobility did not include preventative measures specific to a positional device used for offload. During the recertification survey, intervention to turn and position every two hours was created and initiated on 11/08/2021. During an interview on 11/08/2021 at 10:17 AM, the Certified Nursing Assistant #2 (CNA #2) stated that Resident #25 is non-ambulatory and dependent on two staff for Activities of Daily Living (ADLs) has a sacrum pressure ulcer. CNA #2 said that Resident #25 has a movement disorder and does not stay on the side after turn and repositioning. Therefore, pillows and special mattresses are in place to relieve pressure. She further stated that repositioning tasks every two hours are documented in the Point Click Care (PCC). During an interview on 11/08/2021 at 2:11 PM, the Licensed Practical Nurse #2 (LPN #2) stated that Resident #25 has an air mattress, turned, and repositioned every two hours, pillows for offload and is seen by the wound care team every week. LPN #2 also stated that CNAs are responsible for turning and repositioning every two hours and documenting in Point Click Care (PCC). LPN#2 said that the CNA task to document turning and repositioning every two hours was not found in that CNA tasks in PCC for Resident #25. During an interview on 11/10/2021 at 10:00 AM, Unit Manager # 2 ( UM #2) stated that preventive interventions for at-risk skin impairment should include positional devices pillows, heel booties for offloading, air mattress, and turn and positioning program. UM, #2 was unaware that the CNA task to turn and position every two hours was not implemented upon admission for Resident #25 and was overlooked. During an interview on 11/10/2021 at 11:19 AM, the Director of Nursing Service (DNS). DNS stated that all residents, including those at risk for impaired skin integrity, are assessed upon admission and preventative measures including turn and positioning, offload heels, special mattress, and dietary needs are implemented on the initial care plan meeting. DNS further stated that the unit manager is responsible for implementing CNA's tasks and monitoring to ensure the unit staff. 415.11 (c) (1)

Based on observation and interviews conducted during the Recertification survey, the facility did not ensure that a resident was cared for in a manner that maintained or enhanced their dignity. Specifically, a resident's Foley catheter bag was uncovered and exposed to public view. This was evident for 1 of 38 sampled residents (Resident #170). The finding is: The facility policy and procedure titled Catheter Care Urinary dated 08/2021 did not indicate how staff would assist residents with Foley catheter care to maintain their dignity and privacy. Resident # 170 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] identified Resident #170 with cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of 10/15. Section H of the MDS indicated that Resident #170 has an indwelling Foley catheter On 11/10/2021 at 10:50 AM, Resident # 170, who resides on the 6th floor, was seen in a wheelchair with other residents on the 3rd-floor hallway. Foley catheter tubing and drainage bag with urine were resting on Resident # 170's lap, uncovered in public view. A recreation staff was wheeling Resident # 170 to the 3rd-floor day for mass with other residents. A Comprehensive Care Plan (CCP) initiated on 06/19/2021 documented that Resident #170 has an indwelling foley catheter. The interventions include positioning the catheter bag and tubing below the bladder level and away from the door and monitoring output as per facility policy. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse's Progress Note dated 11/06/2021 at 11:15AM documented Genito Urinary consult requested to change Foley catheter. During an interview on 11/10/2021 at 10:58AM, Unit Manager #4 (UM #4) stated that a resident with a Foley catheter should have a dignity bag. During an interview on 11/10/2021 at 11:06AM, the Licensed Practical Nurse #3 (LPN #3) stated that residents with Foley catheters are given a leg bag when they are out of bed. Resident #170 was supposed to have a leg bag so that the catheter would not be visible. The leg bag is used, so other people will not see that the resident has a Foley catheter. During an interview on 11/10/2021 at 11:13AM, Certified Nursing Assistance #4 (CNA #4) said that a leg bag is applied in the morning for residents with Foley catheters. Resident #170 has a Foley catheter and came out of bed without an assistant; that is why Resident #170 did not have a leg bag. Resident #170 was supposed to have a leg bag when out of bed to a wheelchair. CNA #4 did not know that Resident #170 was out of bed and not on the floor. During an interview on 11/10/2021 at 11:19AM, Unit Manager #1 (UM #1) stated that Resident # 170 usually gets a leg bag when out of bed. UM, #1 does not know why Resident # 170 has no leg bag. All the staff is aware of the policy in the facility. The nursing staff on the floor know that residents with Foley catheters must have a leg bag when out of bed. A recreation staff picked up the resident from the unit for mass and I am not aware if recreation staff is aware of the leg bag policy. During an interview on 11/10/2021 at Noon, the Recreation Aide stated Resident #170 Foley catheter was supposed to be covered in a privacy bag. The recreation staff was busy with other residents and did not notice that Resident #170 did not have the privacy bag. During an interview on 11/10/21 at 2:18 PM, the Director of Nursing (DON) stated that residents out of bed with Foley catheters should have a dignity bag for privacy. The staff should have made sure Resident #170 had a dignity bag when the resident came out of bed. The DON will continue to in-service the staff on the use of the dignity bag. 415.5(a)

Based on record review and interviews conducted during Recertification and an Abbreviated survey (NY 209) the facility did not ensure that an injury of unknown origin was reported within a timely manner to the New York State Department of Health (NYSDOH). Specifically, a resident was noted with swelling and bruising to the left wrist on 02/20/2020, and an x-ray revealed a left wrist fracture on 02/21/2020. The facility reported the injury to the NYSDOH on 02/28/2020, eight days after the resident was noted with swelling and bruising of the left wrist. This was evident 1 resident out of a total of 38 sample residents reviewed. (Resident #166). The findings include: The facility undated policy and procedure titled reporting Abuse to Facility Management states that each covered individual, including employee, facility consultants, attending physicians are to promptly report any suspicion of a crime or suspected incident of neglect or resident abuse, including injuries of unknown source to facility management. The policy further states that each covered individual is required to report not later than 2 hours after forming the suspicion. If the event that causes the suspicion results in serious bodily injury, or not later than 24 hours, if the event that causes the suspicion does not result in serious bodily injury. When an alleged case of mistreatment, injuries of unknown sources is reported, the Administrator will notify the reporter that a report has been filed with the NYS Dept. of Health. Resident # 166 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] identified Resident #166 with cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of 4 out of 15. A Physician's Note dated 02/20/2020 at 11:10AM documented that Resident #166 was seen for swelling of the left hand. It is documented that Resident #166 has [CONDITION(S)] and cannot give history. The left wrist and hand are tender, and the resident is guarding the hand. Examination revealed slight bruising to the forearm and [CONDITION(S)]. Doppler study ordered to rule out DVT. X-ray ordered to rule out a fracture. A Nurse's Progress Note dated 02/20/2020 at 11:4AM documented that Resident #166 was seen by the Medical Doctor for swelling of the left hand. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse's Progress Note dated 02/21/2020 at 4:52PM documented that left-hand [CONDITION(S)] is warm to touch, painful (grimace on facial expression). X-ray is done, and the result is pending results. Radiology results of the left wrist dated 02/21/2020 revealed an acute fracture of the distal ulna without significant displacement. A Nurse's Progress note dated 02/21/202 at 8:30 PM documented that an x-ray of the left wrist demonstrated a fracture at the distal ulna and severe [CONDITION(S)] A Nurse's Progress Note dated 02/21/2020 at 8:37 PM documented that Telehealth notified. A Telehealth Note dated 02/21/2021 at 8:37PM documented that an x-ray shows an active fracture, distal ulna. The plan includes splint, ice, elevating the arm orthopedic referral, and Tylenol 650 mg oral every 6 hours for pain. A Nurse's Progress Note dated 02/21/2020 at 11:05 PM documented that a splint is in place in the left hand due to a left wrist fracture. Tylenol 650mg was given for pain. Left hand elevated on two pillows. A Care Plan dated 02/22/2020 documented an Alteration in Musculoskeletal status related to fracture of the left wrist. The interventions include a resting hand splint applied to the left hand, doing range of motion active and passive to the left hand, and checking for pulses every shift. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Unclear of as the cause. Swelling and slight bruising present. Splint, ice, elevation, orthopedic referral, and Tylenol were ordered. The facility Investigation Findings dated 02/27/2020 documented that on 02/24/2020 to 02/25.2020, video surveillance reviewed revealed that on 02/20/2020, 6:30 AM footage showed an altercation between Resident #166 and Resident #209 in the day room with no staff present. The facility investigation concluded that the evidence showed that Resident #209 was aggressive towards Resident #166. A Care Plan dated 02/28/2020 documented that Resident #166 experienced aggressive behavior towards another resident. The interventions include approaching the resident from the front in a calm and friendly manner and providing emotional support and reassurance. During an interview on 11/10/21 at 12:49PM, the Assistant Director of Nursing (ADN) stated that Resident # 166 had discoloration and swelling to the left wrist on 02/20/2020. The doctor was informed, an x-ray was ordered, and the results showed a fracture to the left wrist. An investigation was initiated, and the surveillance camera footage dated 02/24/2020 to 02/25/2020 revealed that Resident # 209 held Resident # 166 left hand and twisted it in the dining room with no staff present. The ADN stated that they did not think it would be abuse, so it was not reported immediately. The ADN also noted that the facility should report injury of unknown origin within 24 hours and does not know why it was not reported. During an interview on 11/10/2020 at 2:24 PM, the Director of Nursing (DNS) stated that an initial incident report would be reported to NYSDOH within 24 hours and then continue with the investigation. The incident should have been reported within 24 hours. During an interview on 11/10/2021 at 3:38 PM, the Administrator stated that if an abuse incident is suspected, it must be reported to NYSDOH in 2 hours. 415.4(b)

Based on record review and interviews conducted during the Recertification survey, the facility did not ensure that a resident's assessment was accurate. Specifically, the Minimum Data Set (MDS) 3.0 assessment inaccurately documented that a resident was not on Hospice Care. This was evident for 1 out of 1 resident's reviewed for Hospice Care out of an investigative sample of 38 residents. (Resident #202) The findings are: The facility undated Policy and Procedure titled 'MDS Guideline for Completion' states that it is the policy of all Allure Facilities to ensure accurate and timely completion of the MDS/CCP for all residents. The policy also documented that the RN Assessment Coordinator or Designee is responsible for timely transmission/review of MDS assessments to CMS. Resident #202 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change MDS dated [DATE] documented in Section O, instructs to check all the following treatments, procedures, and programs that were performed during the last 14 days. In Section O Letter K, Hospice Care does not have a check. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS Summary Note dated 09/27/21 documented that Significant Change due to Hospice Care starts from 9/27/21. Social Worker note dated 09/27/21 documented that resident was admitted to Hospice Care with a start date of 9/27/21. On 11/08/21 at 4:17PM, an interview was conducted with the Director of MDS who stated that the MDS Significant Change dated 09/27/21was done because Resident #202 was started on Hospice Care. Stated that as the MDS assessor, it is their responsibility to ensure accuracy and should be checked on completion, but in this case, it was missed. and that the Hospice Care section should have been checked. Stated that as the Director of MDS, it was signed it off as assessment completion of the MDS after verification of checks and balances. On 11/09/21 at 9:40 AM, an interview was conducted with the MDS Assessor who stated that as the assessor, they can do MDS throughout the building and that the information for the MDS is retrieved from the chart, including the Physicians orders and the progress notes. Stated that they were responsible for completing Section O of the MDS dated [DATE] for the Resident #202. They also said that they wrote the MDS Summary note dated 09/27/21, but must have missed letter K in Section O, which indicates that the resident is on Hospice Care while a resident and should have been checked off. 415.11

Based on record reviews and interviews conducted during recertification and complaint (NY 610) survey, the facility did not ensure that a resident receives care consistent with professional standards of practice to prevent pressure ulcers and does not develop pressure ulcer unless the individual's clinical condition demonstrate that they were unavoidable. Specifically, two residents at risk for pressure ulcers were not provided with preventive skin care to prevent skin breakdown and pressure ulcers upon admission. This was evident for 2 out of a total of 38 sample residents reviewed. (Resident # 309 and #25) The findings include: The facility policy titled Prevention of Pressure Ulcers, dated 08/2021, documented interventions and preventive measures for a person in bed include changing position at least every two hours or more frequently if needed, using a special mattress if needed, and raising the head of the bed for meals, treatments, and medical necessity. The care process should include efforts to stabilize, reduce or remove undying risk factors, monitor the interventions' impact, and modify the interventions as appropriate. 1) Resident # 309 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #309 has moderately impaired cognition. Resident #305 requires extensive assistance of two persons for bed mobility and transfer. The resident needs total dependence, and two persons assist for toileting. Patient Review Instrument (PRI) dated 12/20/2019 documented Stage 1 pressure ulcer. Braden Scale dated 12/23/2019 documented that Resident # 309 is at a moderate risk of developing ulcers. Admission summary dated 12/23/2019 documented that Resident # 305 has a pressure ulcer on the sacrum. The Certified Nursing Assistant (CNA) Accountability Sheet dated 12/20/2019 to 02/2020 did not reflect any evidence that the resident was turned and positioned every two hours. There was no documentation that the heels were offloaded. There is no documented evidence that turn and positioning schedule and offload of heels were ever implemented from admission until discharge. The Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound Care Note dated 01/03/2020 documented Deep Tissue Injury ( DTI) to the Right heel that measured 4.5 centimeters ( cm) x 4.5 cm and DTI to the Left heel, which measured 4 cm x 5.5 cm. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse with normal saline, pat dry and apply calcium alginate to the area, and cover with a dry protective dressing., Alteration in Skin Integrity Care Plan was developed on 01/03/2020. During an interview on 11/09/2021 at 11:24 AM, Certified Nursing Assistant #1 (CNA # 1) stated that Resident # 309 was admitted with a pressure ulcer to the sacrum. Resident # 309 was supposed to be turned and repositioned every two hours. CNA #1 did not remember when turning and positioning and booties were put into place. During an interview on 11/09/2021 at noon, the Wound Care Nurse (WCN) stated that Resident 309 was admitted with a pressure ulcer to the sacrum. There was no documentation of DTI to the heels on admission. DTI to bilateral heels was documented in the nursing notes on 01/6/2020. The wound care nurse further stated Resident # 309 was at risk of developing ulcers. Therefore, preventive measures should have been put in place. Resident # 309 should have had protective booties to offload the heels and turned and positioned them every two hours. The wound care team recommendation is communicated with the nurse supervisor. The nursing supervisor would initiate a care plan with the recommended interventions. An air mattress elevates legs to float while in bed, and a draw sheet in use to prevent shearing while in bed was recommended on 02/03/2020. During an interview on 11/09/2021 at 12:44 PM, Unit Manager #1 (UM #1) stated Resident # 309 was at risk for developing pressure ulcers. Therefore, a care plan for impaired skin integrity should have been implemented with appropriate interventions upon admission. The turning and positioning schedule should have been placed in the CNA tasks. Booties should have been placed on the resident's feet. During an interview on 11/09/2021 at 12:41 PM, the Assistant Director of Nursing Services (ADNS) stated that if a resident is at risk of skin breakdown or has skin impairments, a care plan is supposed to be initiated upon admission with the appropriate interventions. The interventions should include turning and positioning every two hours, offloading heels, nutrition supplement, air mattress, and skin checks. Turning and positioning skin checks and offload heels should have been documented in the CNA accountability. During an interview on 11/10/2021 at 11:06 AM, the Nurse Practitioner (NP) stated that Resident # 309 had a pressure ulcer to the sacrum. The stage of the ulcer was not documented in the admission notes. If a resident has a wound, we recommend that the facility implement a pressure-relieving mattress, turning, positioning every two hours, changing right after soiled, nutrition supplements, and heel protectors. In addition, the wound care NP stated that I am not sure why the appropriate interventions were not put into place. There should have been interventions in place to prevent DTIs of the heels. During an interview on 11/10/2021 at 10:29 AM, the Director of Nursing Services (DNS) stated that Resident # 309 should have had an actual impaired skin integrity care plan with appropriate interventions to prevent the wound from getting worse and to prevent further skin breakdown. The interventions should include turning and positioning, offload heals, nutrition supplements, and an air mattress. An actual care plan should have been in place upon admission with the appropriate interventions. 2) Resident #25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident #25 was cognitively severely impaired. The resident required the total assistance of two persons assist for bed mobility, transfers, and toilet use. Resident #25 was at risk for developing pressure ulcer/injury and has a Stage 4 pressure ulcer/Injury. On 11/03/2021 at 11:14 AM, Resident #25 was observed lying on back in bed. Surveyor did not observe pillows nor heel booties. On 11/03/2021 at 1:14 PM, Resident #25 was observed lying on back in bed. Surveyor did not observe pillows nor heel booties. On 11/3/21 at 3:04 PM, Resident #25 was observed lying on back in bed. Surveyor did not observe pillows nor heel booties. There was no privacy curtain. On 11/5/21 at 8:20 AM, Resident #25 was observed lying in the same position in bed. Surveyor did not observe pillows nor heel booties. On 11/8/21 at 8:46 AM, Resident #25 was observed lying in a supine position in the room. On 11/9/21 at 7:25 AM, Resident #25 was observed lying supine, with a slight head turned towards the window. The Comprehensive Care Plan (CCP) titled Potential/actual impairment to skin integrity related to fragile skin, and sacral skin breakdown was initiated on 03/26/2021. The interventions include avoiding scratching, keeping hand/body parts from excessive moisture, keeping skin clean/dry, and using a draw sheet or lifting device to move the resident. The Comprehensive Care Plan (CCP) titled Stage 4 Sacrum Pressure Ulcer Development related to immobility was initiated on 05/06/202. The interventions include administering medications ordered, administering treatments, monitoring dressing, requiring supplemental protein, amino acids, vitamins, minerals to promote wound healing, and require pressure relieving/reducing device on bed/chair, Skin/Wound note dated 03/26/2021 documented ecchymosis to Bilateral Upper Extremities (BUE). Skin/Wound Note dated 04/19/2021 documented reddish-purple BUE to sacral measured 3 centimeters (cm) x 8 cm. Air mattress/pump is placed. Skin/Wound Note dated 05/06/2021 documented the Resident #25 has an unstageable wound of sacrum; It documented offloading, turning, and positioning are ongoing and draw sheet in use to prevent shearing while in bed, also legs elevated to float feet while in bed, The Wound Care Progress Note dated 10/20/2021 documented that Resident #25 has a Stage 4 Pressure Ulcer to the sacrum measured 3.2cm length x 4cm width x 0.6cm depth. The treatment plan includes cleansing, dressing daily. According to facility pressure ulcer prevention protocol, the resident is to continue with pressure redistribution mattress and pressure relief/offloading program. The Wound Care Progress Note dated 10/27/2021 documented that Resident #25 has a Stage 4 Pressure Ulcer to the sacrum that measures 3cm length x 4cm width x 0.5cm depth. The treatment plan includes cleansing, dressing daily. According to facility pressure ulcer prevention protocol, the resident is to continue with pressure redistribution mattress and pressure relief/offloading program. The Wound Care Progress Note dated 11/03/2021 documented that Resident # 25 has a Stage 4 Pressure Ulcer to the sacrum. 3.3cm length x 3.5cm width x 0.3cm depth. The treatment plan includes cleansing, dressing daily. According to facility pressure ulcer prevention protocol, the resident is to continue with pressure redistribution mattress and pressure relief/offloading program. The Certified Nursing Assistant (CNA) Accountability Record dated 06/04/2021 to 10/20/2021 documented turning and positioning and placing pressure-reducing devices every two hours. The CNA Accountability Record revealed no documentation of turning and positioning every two hours and placing pressure-reducing device tasks on the following dates: 04/01/2021 to 06/03/2021, and 10/21/2021 to 11/08/2021. During an interview on 11/08/2021 at 10:17 AM, a Certified Nursing Assistant #2 (CNA #2) stated that Resident #25 is non-ambulatory, totally dependent on two staff for Activities of Daily Living ( ADLs). Resident #25 has a sacral pressure ulcer. CNA #2 stated that Resident #25 has a movement disorder and does not stay on the side after turning and repositioning. Therefore, pillows and special mattresses are in place to relieve pressure. Resident #25 is repositioned every two hours, and it is documented in the Point Click Care (PCC). During an interview on 11/08/2021 at 2:11 PM, Licensed Practical Nurse #2 (LPN #2) stated that Resident #25 has an air mattress, is turned, and repositioned every two hours, pillows for offload and is seen by the wound care team every week. LPN #2 also stated that the CNAs are responsible for turning and repositioning the resident every two hours and document in PCC. LPN#2 then stated that the CNA task to document turning and repositioning every two hours was not found in CNA tasks in PCC for Resident #25. During an interview on 11/10/2021 at 10:00 AM, Unit Manager #2 (UM #2) stated that residents at risk for skin impairment would be assessed upon admission and discussed in care plan meeting to prevent skin breakdown. Preventive interventions are then implemented and documented in the computer by the staff who will be providing care. UM #2 stated that preventive interventions for at-risk skin impairment should include the use of positional devices pillows, heel booties for offloading, air mattresses, and turning and positioning programs. UM, #2 stated I am not aware that the CNA task to turn and position every two hours was not implemented upon admission for Resident #25 and overlooked. During an interview on 11/10/2021 at 11:19 AM, an interview was conducted with the Director of Nursing Service (DNS). The DNS stated that all residents, including those at risk for impaired skin integrity, are assessed upon admission and preventive measures including turning and positioning, offload heels, special mattress, and dietary needs are implemented on the initial care plan meeting. The unit manager is responsible for implementing CNA's tasks and monitoring to ensure the unit staff. 415.12 (c) (1-2)

Based on observation and interviews during the recertification survey, the facility did ensure a resident's personal privacy was maintained. Specifically, a resident was observed in the room without a privacy curtain. This was evident for 1 resident out of a total of 38 sampled residents reviewed. Resident #25 Resident #25 was admitted to the facility on [DATE] with diagnoses that include [CONDITION(S)], [CONDITION(S)] with behavioral disturbance and Dysphagia. The Quarterly Minimum Data Set (MDS) dated [DATE], documented that resident was cognitively severely impaired. The resident required total assistance of two persons assist for bed mobility, transfers, and toileting. On 11/3/21 at 11:14 AM, Resident #25 was observed lying on back in bed. Surveyor did not observe pillows nor heel booties. There was no privacy curtain. On 11/3/21 at 1:14 PM, Resident #25 was observed lying on back in bed. Surveyor did not observe pillows nor heel booties. There was no privacy curtain. On 11/3/21 at 3:04 PM, Resident #25 was observed lying on back in bed. Surveyor did not observe pillows nor heel booties. There was no privacy curtain. On 11/5/21 at 8:20 AM, Resident #25 was observed lying in the same position in bed. Surveyor did not observe pillows nor heel booties. There was no privacy curtain. On 11/5/21 at 11:20 AM, Resident #25 was observed in Geri chair and getting hair combed by a CNA. There was no privacy curtain. On 11/5/21 at 1:47 PM, Resident #25 was not in the room. There was no privacy curtain. Resident #25 was observed in Geri chair in the dining room. On 11/8/21 at 8:46 AM, Resident #25 was observed lying in a supine position in the room. There was no privacy curtain. On 11/9/21 at 7:25 AM, Resident #25 was observed lying in a supine position, with head slight turn towards the window. Observed privacy curtain in the room for Resident #25. On 11/9/21 at 9:55 AM, Resident #25 was not in the room. Observed privacy curtain in the room for Resident #25. On 11/8/21 at 2:11 PM, an interview was conducted with LPN #2. She stated that Resident #25 should have a privacy curtain and was not aware that privacy curtain was missing in the room. On 11/8/21 at 3:18 PM, an interview was conducted with Housekeeping Director. Housekeeping Director stated Resident #25 did not have the privacy curtain in the room because the privacy curtain was being washed and did not provide backup curtain. On 11/10/21 at 11:19 AM, an interview was conducted with Director of Nursing Service (DNS). She stated all residents in the semi-private rooms should have privacy curtains and there should have been back up curtains to replace soiled curtain. 415.29

Based on staff interview and record review conducted during the recertification survey, the facility did not ensure that person-centered care plans with measurable goals, time frames and interventions were developed to address resident's concerns. Specifically, 1). a care plan was not developed to address a resident's of Non-Alzheimer's Dementia, Anxiety Disorder and Depression, and 2). a care plan was not developed to address a resident's [DIAGNOSES REDACTED]. (Resident # 67 & #74) The findings are: The facility policy and procedure titled Care Plans-Comprehensive dated 1/2/19 documented that the comprehensive care plan includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs as identified in the comprehensive assessment. Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed at least quarterly. 1. Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented that the resident had moderately impaired cognition and no behaviors. The Quarterly MDS assessments dated 02/10/2019 and 12/29/2018 documented in Section N 0410 that resident received Antipsychotic and Antidepressant on 7 of 7 days. Section N 0450 further documented that no gradual dose reduction (GDR) had been attempted and GDR had not been documented by a physician as clinically contraindicated. On 04/24/19 at 10:16 AM, resident #67 was observed in bed in supine, sleeping. O2 in progress via NC from concentrator. No behavior problem exhibited On 04/24/19 at 01:10 PM resident #67 was observed in the dining room eating, able to feed self. Consumed approximately 75% pureed food and 100% fluid given at lunch. Resident was alert and able to make simple needs known, requested more water from staff which was provided. Oxygen therapy in place via NC. No signs of distress noted. On 04/26/19 at 09:16 AM resident #67 was observed in bed sleeping. O2 in place via NC. No signs or symptoms of distress noted. On 04/25/19 at 01:13 PM, an interview was conducted with the Certified Nursing Assistant (CNA#1. The CNA stated that she has been working in the facility for the past 2 years and has been taking care of the resident on/off when she floats to the units. CNA stated that she washes the resident, groom and dress her, and takes resident out with 2 assist for lunch. CNA stated that resident likes to eat breakfast in bed. CNA also stated that resident has not been displaying any unusual behavior during care. The CNA further stated the resident will request to be changed and will be annoyed and yell if her needs are not met immediately. 2). Resident # 74 was admitted to the facility 12/06/17 with [DIAGNOSES REDACTED]. The Admission Minimum (MDS) data set [DATE] documented intact cognition, and that resident received an antidepressant during the review period. The Comprehensive Care Plan was reviewed to ensure all care plans were included to address care issues related to the resident's [DIAGNOSES REDACTED]. There was no documented evidence that care plans with measurable objectives, time frames and appropriate interventions were developed to address the care of the resident diagnosed with [REDACTED]. On 04/25/19 at 04:10 PM, Resident # 74 was interviewed. Resident # 74 stated that he is currently feeling depressed and anxious. Resident #74 also stated that he has been depressed for a long time. Resident #74 further stated that he was depressed when he was admitted to the facility. Resident # 74 stated that when he is feeling depressed, the facility staff does not attempt to engage him in activities of interest. 04/26/19 at 10:33 AM, RN # 2 was interviewed. RN # 2 stated that she supervises the unit and oversee the care of the residents. RN #2 also stated that she initiates and updates the care plan every three months. RN #2 further stated that she would ensure the comprehensive care plan addressed all of the resident's [DIAGNOSES REDACTED].#2 further stated that there is no care plan currently in place with measurable goals and interventions to address the resident's mood and behaviors. On 04/26/19 at 10:59 AM, Social Worker (SW) #1 was interviewed. SW# 1 stated that if a resident is alert and oriented she would interview them to determine if they are experiencing signs and symptoms of mood distress. If they display signs of depression, she would document the signs and symptoms of mood disorder in MDS section D. SW#1 also stated that she was not aware that the resident was displaying signs of depression and anxiety. SW#1 stated that a mood care plan should have been created to address the resident's depression and anxiety. 415.11(c)(1)

Based on staff interviews and record review during an abbreviated survey, the facility did not ensure that the resident environment remained free of accident hazards and that a resident received adequate supervision to prevent accidents. This was evidenced by 1 of 4 sampled residents (Resident #1). Resident # 1, who had a history of [REDACTED]. The resident sustained [REDACTED]. The resident expired in the hospital 4 days post incident. This resulted in actual harm that is not Immediate Jeopardy. Complaint ID Number: NY 970 The findings are: Resident#1 was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 Assessment ((MDS) dated [DATE] documented that the resident had moderately impaired cognitive skills with inattention and disorganized thinking. The MDS also documented that the resident required assistance with activities of daily living and self propelled his wheel chair on the unit. A "Fall/Injury" Comprehensive Care Plan (CCP) dated [DATE] documented that the resident had a history of [REDACTED]. Interventions included keeping needed items with in reach, psychotropic medications and encourage the resident to call for assistance if needed. The latest evaluation of the CCP dated [DATE] documented "No falls noted in the past months ...continue plan of care." The CCP did not include interventions regarding supervision by staff for safety. A CCP dated [DATE] documented that the resident had "Altered Feeling/Mood State" manifested by sadness, anxiety and anger. Interventions included administering medications as ordered, give positive reinforcement for appropriate behavior, provide resident and family with emotional support, refer for psychological services, obtain psychiatric evaluations, and provide "diversional" activities. The latest evaluation of the CCP dated [DATE] documented "No change in mood noted ...continue plan of care." The CCP did not include interventions regarding supervision by staff for safety. Interim physician's orders [REDACTED]. The order was discontinued on [DATE]. Monthly physician's orders [REDACTED]. On [DATE] the Ativan was increased to 1 mg every 8 hours. The Nurse's notes dated [DATE] - [DATE] documented that the resident exhibited very anxious and restless behaviors including screaming and yelling, "help me, help me," on a daily basis. On [DATE] the resident could not be calmed down and Haldol was ineffective. On [DATE], the resident is "very restless, confused and has no safety awareness." On [DATE] on the ,[DATE] shift, the resident was awake at 2:00 AM and began to yell repeatedly "open the door, open the door," although the door was already open. On [DATE] at 4:10 PM, the resident is "very confused, very restless, demonstrates unsafe behaviors and needs constant supervision." The Resident Occurrence Report dated [DATE] documented that at approximately 5:10 PM the resident was found sitting on the floor between the wheelchair and the bed in his room. The resident was assessed and no visible injuries were noted. The Fall CCP did not include any updates or interventions regarding this accident. The Resident Occurrence Report dated [DATE] documented that at approximately 4:10 PM on [DATE], the nurse was informed by another resident that Resident #1 was on the floor in the dinning room. Resident #1 was found lying on his right side on the floor in front of his wheelchair in the dinning room. He was unable to give an account of the occurrence. The resident was assessed and no visible injuries were noted. The Fall CCP did not include any updates or interventions regarding this accident. The Resident Occurrence Report dated [DATE] documented that the resident was found lying at the bottom of the stairwell at approximately 2:30 PM with the wheelchair on top of him. Nursing, medical and 911 notifications were immediately initiated and the resident was transferred to the hospital. The Investigation Summary completed by the Director of Nursing (DON), documented that during the day the resident was cooperative with care and was wheeling himself independently on the unit. A few minutes prior to the incident, an insurance representative saw the resident pass by and thought he was going to the dining room. Shortly after this, the insurance representative saw a "boy" running from the stairway calling for help. The front desk was notified and 911 was called. As per the Summary, the resident's medical record was reviewed and revealed that the resident had a fall with out injury on [DATE]. The resident was seen by the medical doctor (MD) and the psychiatrist resulting in medication adjustments. He also had a physical therapy (PT) consult and PT sessions were started 5 times a week. The resident fell again on [DATE] and the plan of care was continued. It was concluded that the "Resident's plan of care was followed." " Preventive measures " included installing alarms on the first floor doors leading to the basement by [DATE]. Staff members will monitor the doors until the alarms are installed. On [DATE] at 9:30 AM a staff member was observed sitting at the door leading to the stairwell where the resident fell . The door was opened by the surveyor and no alarm sounded. During the observation the Administrator arrived. He stated they would be installing an alarm system on the two doors leading to the basement. He further stated that until the alarms are installed, staff members would be physically monitoring the doors 24 hours a day. The Hospital Records dated [DATE]-[DATE] document that the resident was admitted on [DATE] from the facility secondary to a fall down the stairs with the wheelchair. He was noted with frontal scalp swelling and ecchymosis (bruising) around the left orbit (eye socket). Hospital radiology reports documented that the resident was diagnosed with [REDACTED]. The resident received multiple blood transfusions beginning [DATE] thorough [DATE]. The resident's neurosurgical status deteriorated and he was intubated with a DNR (Do Not Resuscitate) order placed. The resident subsequently expired on [DATE]. The ,[DATE] PM Registered Charge Nurse was interviewed on [DATE] at 3:15 PM. She stated that because the resident was very confused and restless he required constant supervision. Increased monitoring or supervision was not implemented. The Registered Nursing Supervisor was interviewed on [DATE] at 11:00 AM. She stated that she was unaware of the fall on [DATE]. She added that the resident did not need one to one supervision and the "staff were checking on the resident." She stated that after the fall in the dinning room on [DATE], she did not have a chance to put any "formal" interventions in place and that his behaviors did not occur that often. She further stated, "this just happened." The ,[DATE] PM Registered Charge Nurse was interviewed on [DATE] at 10:30 AM. She stated that the resident has been declining over the past several months and was very agitated, anxious and in distress all the time. She stated that at the time, the resident had not been on any increased supervision or monitoring routine because she did not feel he required it. She stated that looking back now "it would have been a good idea." The Certified Nursing Assistant (CNA) was interviewed on [DATE] at 11:00 AM. She stated that she was informed at morning report that the resident had a fall on [DATE]. She was not aware of any interventions or supervision that was put into place as a result of the fall on [DATE]. She stated that on [DATE] she gave the resident morning care at 7:15 AM and fed him breakfast at 8:00AM. The resident ate his lunch in the dinning room at 11:45 AM. The CNA stated that she took the resident out of the dinning room at 12:30 PM and brought him to his room. She took her lunch break from 1:45 PM-2:15 PM. The CNA stated that she did her rounds at 2:15 PM and she did not see the resident on the unit. She did not notify the nurse that the resident was not on the unit because she assumed that he was in therapy. The ,[DATE]PM Licensed Practical Nurse (LPN) was interviewed on [DATE] at 1:00 PM. She stated that she was not aware that the resident had sustained a fall on [DATE]. She stated that on [DATE], she last saw the resident moving around in the wheelchair restlessly on the unit at around 1:30 PM. She stated that the resident normally exhibited anxious and restless behaviors. She was unaware if the resident required any supervision or if any interventions were in place to monitor his behaviors. She was also unaware if the resident was permitted off the unit unescorted. The Director of Nursing was interviewed on [DATE] at 2:00 PM. She stated that residents are not usually permitted in the dinning room if staff are not there to supervise. On the [DATE] (when the resident fell in the dining room) the nurse was not able to assign a CNA to supervise the dinning room, but the DON could not state why. When the DON was asked how the resident's behaviors were managed and how he was supervised for safety, she stated that he was seen by the psychiatrist. Regarding supervision, the DON did not give an answer. The Information Technology Staff (ITS) was interviewed on [DATE] at 12:00 PM. He stated that on [DATE] at approximately 2:30 PM he was standing in the business office and a volunteer alerted him that he needed help with a resident who was bleeding. The ITS stated that he followed the volunteer to the back of the staircase and when he opened the door he saw the resident at the bottom of the staircase. He ran down the stairs and removed the wheelchair from on top of the resident and observed him bleeding from his head. Another employee came down the stairs and he borrowed her cell phone to call 911. 415.12 (h) (2)