Every finding on record at Lockport Rehab & Health Care Center

Based on interview and record review conducted during a survey, the facility did make prompt efforts to resolve grievances for two (2) (Residents #5 and #6) of two (2) residents reviewed for missing property. Specifically, there was lack of follow-through and resolution for Resident #5 and Resident #6's reports of missing property. The findings are: The policy titled Resident Personal Property and Inventory, last reviewed on 08/04/2025 and approved by the Administrator 1/26 documented the facility shall maintain a system to inventory, label, and safeguard resident property to minimize the risk of loss, theft, or damage. In the event of lost property, a grievance form must be completed; the Administrator or designee will investigate the loss; if the facility is found to be responsible, the facility will replace the item or reimburse the resident for the fair market value. The policy titled Reporting and Investigation of Personal Property Lost or Damaged revised 01/26, documented the purpose was to assure that all reasonable efforts have been made to account for the location and/or condition of a resident's personal property. The individual first aware of a missing item is responsible to ensure initiation of investigation and prepare the Personal Property Loss/Damage Report is completed. The policy titled Grievance Policy revised 01/26, documented in accordance with Resident Rights residents have a right to voice grievances and that all grievances are acted upon in a timely manner. Grievance Form will be completed and directed to appropriate department or individual for response- not to exceed 21 days. 1.Resident #5 had diagnoses which included chronic obstructive pulmonary disease (lung disease), dementia and schizophrenia (brain disorder). The Minimum Data Set (a resident assessment tool) dated 01/09/2026 documented the resident was cognitively intact, understood, understands. The Minimum Data Set, dated [DATE] documented that it was very important to them to take care of their personal belongings or things. Review of a yellow spiral notebook titled Communication Book at the [NAME] Nurses Station on 03/09/2026 at 10:30 AM, revealed a documented entry dated 02/28/2026 that Resident #5's missing blanket was cream, not blue. Review of a Personal Property Loss/Damage Report provided by the Director of Social Work on 03/09/2026 at 11:45 AM, documented a report for Resident #5 was initiated on Sunday 02/22/2026 by the Director of Activities. The report documented Resident #5's family member reported the loss of a crochet lap blanket. The social worker outcome/resolution was not completed. There was no documentation that the facility was actively working toward resolution of this complaint/grievance. Review of Progress Notes dated 12/01/2025 to 03/11/2026, documented no evidence of missing personal property. During an interview on 03/05/2026 at 10:59 AM, Resident #5 stated they were missing a blanket made for them by their niece. They stated everyone is aware and a lost report was done. They stated the blanket has been missing for a few weeks and has not been returned and they minded. During interviews on 03/06/2026 at 3:15 PM and 03/09/2026 at 10:58 AM, Resident #5 stated they have not heard anything about their blanket, and it has been three (3) weeks. They stated they minded not having it because their niece made it for them and it could not be replaced. The resident described blanket as crochet, two (2) colors beige and a very light orchid color. 2.Resident #6 had diagnoses which included chronic obstructive pulmonary disease (lung disease), diabetes, and obesity. The Minimum Data Set, dated [DATE] documented the resident was cognitively intact, understood, and understands. The Minimum Data Set, dated [DATE] documented that it was very important to them to take care of their personal belongings or things. Review of copied spiral notebook paper provided by Housekeeping/Laundry Director on 03/09/2026, revealed a handwritten note that was dated 9/5 and documented Resident #6 is missing two (2) pairs of pants. One is black and the other is blue. There was another handwritten note dated 02/26/2026 that Resident #6 said they were missing two (2) pairs of pants, blue and black like the pair they have in their closet. Review of Progress Notes dated 09/01/2025 to 03/11/2026 documented no evidence of missing personal property. During an interview on 03/05/2026 at 11:53 AM, Resident #6 stated they have two (2) pairs of pants that have been missing for over six (6) months. They described them as sweatpants but silky, one pair was black, and the other was navy blue. They stated they reported it to someone in September and had just mentioned it to laundry again last week. During an interview on 03/09/2026 at 8:46 AM, Resident #6 stated their pants have not been found or returned to them and it is upsetting. During interviews on 03/09/2026 at 8:41 AM and 11:20 AM, Laundry Aide #1 stated when it is brought to their attention by staff, or a resident that laundry is missing they look in the laundry department. They stated if they cannot find missing laundry they write it in the laundry communication book, so other laundry aides are aware. Laundry Aide #1 stated they were not aware of any lost reports or grievances being completed for missing items. They stated they were not aware of any missing pants for Resident #6. During an interview on 03/09/2026 at 9:03 AM, Registered Nurse #1, [NAME] Wing Unit Manager stated when a residents' personal property goes missing it should be documented in the resident's electronic medical record, family should be notified, and staff search for the items. They stated other departments are notified by email communication. Registered Nurse #1, [NAME] Wing Unit Manager stated they were not aware of any forms that need to be completed for missing personal property. They stated they were not aware of the process when missing personal property is not located and should be aware of the policies, processes so they can respond appropriately. They stated Resident #5 had been missing their blanket for some time, months, maybe two (2) months, and it has not been located. They were not aware of Resident #6's missing pants. During an interview on 03/09/2026 at 10:24 AM, Certified Nurse Aide #1 stated if a resident was missing something out of their room, they would check the resident's room. If they were unable to locate something they would document, it the unit communication book. They stated it was important to locate missing resident property because it was their belongings. During an interview on 03/09/2026 at 11:30 AM, Housekeeping/Laundry Director stated they do not have or maintain inventory records for residents' personal belongings. They stated when something is reported missing, they place it in the communication book with a description. They stated most times things are found. Housekeeping/Laundry Director stated if something is not found a lost report is filled out and given to interdisciplinary team members to complete, then the social worker ends up with the lost report. They stated they were aware that Resident #6 has been missing pants but were not aware if a lost report was completed. They stated a lost report was initiated for Resident #5's missing blanket last month. During an interview on 03/09/2026 at 11:37 AM, the Director of Social Work stated that when a resident's property is missing, a nurse will let them know and they initiate the form Personal Property Loss/Damage Report, based on the information received. They stated it is discussed, shared with each department during morning meeting. The Director of Social Work stated they did not know what the process was if missing personal property was not located. They stated that policies and procedures were available to them but that they were not familiar with the grievance process and would have to talk with the Administrator about it. The Director of Social Work stated they were aware of Resident #5's missing blanket, but not aware that Resident #6 was missing pants. During an interview on 03/10/2026 at 1:50 PM, the Director of Social Work stated they spoke with Resident #6 who informed them of their missing pants. They stated a personal property loss report was not completed to their knowledge at the time Resident #6's reported them missing. They stated laundry placed a note regarding Resident #6's missing pants into their communication book. They stated it was important to complete grievance forms to have a paper trail, record of missing property because it was the resident rights, this is their home. During an interview on 03/10/2026 at 1:56 PM, Licensed Practical Nurse #1 stated if they were notified of missing personal property, they would get the nursing supervisor involved and they would look for the reported missing item. They stated they were unaware of there being a form that needs to be completed for missing property. They stated residents have the right to have their personal property maintained, this is their home and personal belongings are important to them. They stated missing property needs to be located or replaced by the facility. During an interview on 03/11/2026 at 12:00 PM, the Director of Nursing stated there were no documented inventory records for Resident #5 and Resident #6 and there should be. They stated it was important for resident's personal belongings to be inventoried because they are significant to the resident and all they have. They stated completing grievances was important because it is the residents' voice, letting the residents know their concerns are known, being investigated and being addressed. The Director of Nursing stated they did not know why grievances were not initiated for Resident #5, Resident #6 and that they should have been. During an interview on 03/11/2026 at 12:24 PM, the Administrator stated they expected if any personal property was lost or missing, the policy would be followed. They stated the Grievance Officer, the Director of Social Work, should be notified and a grievance completed and followed appropriately. They stated it was important for every missing item to have a grievance attached. They stated it could be construed as misappropriation and the goal is to investigate to rule out misappropriation. 10 NYCRR 415.3(d)(1)(ii)

Based on observation, interview, and record review conducted during a survey, the facility did not ensure residents were assessed for risk of entrapment from bed rails prior to installation, risks and benefits of bed rails were reviewed with the resident or resident representative, and informed consent was obtained prior to the installation of bed rails for one (1) (Resident #87) of three (3) residents reviewed. Specifically, Resident #87's bed rail was loose and not secure to the bedframe and the resident was not assessed for risk of entrapment from the bed rails. Additionally, the risks and benefits of bed rail use were not reviewed with the resident or their representative and consent was not obtained prior to bed rail use. The finding is: The policy and procedure titled Bed Assist Devices revised 11/2024 documented bed assist devices are mobility devices used to aid in resident independence with bed mobility and/or to improve resident participation in bed mobility during care. Occupational Therapy and Physical Therapy will assess resident's bed mobility skills and their ability to appropriately utilize the bed assist device. Therapy will obtain consent for bed assist device from appropriate responsible party or resident and review the risks and benefits from the use of bed rails. Therapy will document the results of training and notify nursing staff. Residents' ability to continue to use the bed assist device will be monitored quarterly. Resident #87 had diagnoses that included osteomyelitis (infection of the bone) of vertebra (bones forming spinal column), right hemiparesis (weakness of one side of body), and urinary tract infection. The Minimum Data Set (a resident assessment tool) initiated on 03/08/2026, that was in progress, documented Resident #87 had moderate cognitive impairment. The Order Summary Report for 03/01/2026-03/31/2026 documented an order dated 03/06/2026 to encourage the resident to change position when in bed turn to side, off of their bottom. There was no order for side rail use documented.The Kardex Report (a guide used by staff to provide care) dated 03/11/2026 documented Resident #87's bed mobility was substantial/maximal assist of one (1) staff with bilateral bed assist bars for rolling. For lying to sitting on the side of the bed the resident needed substantial/maximal assist of one (1) staff with bilateral bed assist bars for rolling and assistance of two (2) staff for supine (lying on back) to/from edge of bedThe comprehensive care plan initiated 03/04/2026 documented Resident #87 had limited physical mobility related to a sacral ulcer (skin wound) and history of a stroke. Interventions initiated on 03/04/2026 documented substantial/maximal assist of one (1) staff with bilateral bed assist bars for rolling in bed, and assistance of two (2) staff for supine to the edge of bed.The Physical Therapy Evaluation and Plan of Treatment dated 03/04/2026 documented Resident #87 was laying supine in bed and rolled with a moderate assist of one (1) and used bed assist bars to offload and pressure relief. Equipment during tasks included using bedrails bilaterally. There was no documentation that the risks or benefits of the use of side rails were discussed that informed consent was obtained prior to their use, and that an entrapment risk was completed. Review of Progress Notes dated 03/03/2026 through 03/09/2026 revealed no documented evidence that Resident #87 was provided with education on the risks and benefits of the bed assist devices or that informed consent was obtained prior to their use.Physical Therapy Evaluation and Plan of Treatment and Treatment Encounter Notes dated 03/04/2026 through 03/10/2026 did not document evidence that Resident #87 was provided education on risks and benefits of the bed assist devices or that informed consent was obtained prior to use. There was no documentation that an entrapment risk was completed.During observations on 03/05/2026 at 11:39 AM, 03/09/2026 at 8:53 AM, and 03/10/2026 at 10:23 AM, Resident #87's bed had bilateral bed assist devices at the head of the bed. The bed assist device on the right side of the bed was loose, easily moved back and forth away from the mattress. When the bed assist device was pulled/pushed away from the side of the mattress there was a gap of three (3) inches between the mattress and the bed assist device. The bed assist device on the left side of bed was loose and did not move away from the mattress.During an interview and observation on 03/10/2026 at 10:37 AM, Certified Nurse Aide #3 stated that the therapy department issues bed assist devices for the resident's beds. They stated there was nothing they ever had to do with the bed assist devices. They stated they make sure they are in place, locked and in the up position on the bed. Certified Nurse Aide #3 observed the right-side bed assist device on Resident #87's bed, stated it was loose, and it would not be safe to hold on to as it could fall off the bed. They stated they were not aware the bed assist device was loose, and that they usually get another staff member to assist with Resident #87's bed mobility. During an interview and observation on 03/10/2026 at 10:46 AM, Licensed Practical Nurse #1 stated they were responsible for making sure bed assist devices were in place and secure to the resident's bed. They stated they were not aware of any side rail assessments that were completed by nursing and were not responsible for assessing for siderail entrapment. Licensed Practical Nurse #1 stated physical therapy determined if a resident should have bed assist devices. They stated they were not aware of any concerns with Resident #87's bed assist devices until Certified Nurse Aide #3 reported it to them. Upon observing Resident #87's bed assist devices they stated the left side bed assist device was not completely tightened, and that the right-side bed assist device had more give, moved away from the mattress creating a space between the mattress and the bed assist device. Licensed Practical Nurse #1 stated it was important for the bed assist devices to be secure for safety, as residents utilize them for turning/positioning.During an interview on 03/10/2026 at 10:57 AM, Registered Nurse #1, [NAME] Wing Unit Manager stated they were not responsible for completing any assessments related to bed assist devices. They stated if they were notified of a bed assist device not working properly, they would notify the maintenance department through an electronic work order. Registered Nurse #1, [NAME] Wing Unit Manager stated the bed assist devices are only used to assist with bed mobility, they are not used as a fall prevention or restraint. Registered Nurse #1, [NAME] Wing Unit Manager stated a loose bed assist device was a safety concern and could be considered an entrapment risk if not secured properly.During an interview and observation on 03/10/2026 at 11:09 AM, the Director of Maintenance stated bed assist devices are put on beds by the maintenance department and taken off beds as needed. They stated they are usually notified by therapy via a work order when bed assist devices need to be applied to a resident's bed. They stated whenever a resident is discharged , the bed assist devices are removed by housekeeping or maintenance. The Director of Maintenance stated they check the bed assist devices on residents' beds twice a year with the therapy department. They stated checks of the bed assist devices involve utilizing a measurement kit to check for gaps between the mattress and the rail. Upon observing Resident #87's right side bed assist device they stated it was a little bit loose, there was a gap between the mattress and rail and there should not be.During an interview on 03/10/2026 at 11:24 AM, the Director of Rehab Services stated therapy completes an assessment for the use of bed assist devices as part of their initial evaluation of a resident upon admission. They stated physical therapy assesses bed mobility and determines if the use of bed assist devices will improve and/or maintain bed mobility and assist with transfers. They stated there is no formal consent received by residents or resident representative for the use of the bed assist devices and no form was completed for entrapment. They stated risks and benefits for bed assist device use are reviewed with residents at the time of placement by therapy. During an interview on 03/10/206 at 1:35 PM, Resident #87 stated they never received any education on concerns related to the use of the bed assist devices on their bed and the bed assist devices helped them with their mobility in bed.During an interview on 03/10/2026 at 3:05 PM, the Director of Nursing stated if bed assist devices were deemed appropriate, therapy would speak to family and residents, and the rails would be put on by maintenance. The Director of Nursing stated it was therapy's responsibility to speak to the family and residents to explain risks and benefits and obtain consents. They stated therapy was responsible for placing a progress note in the medical record of who they spoke to and that they explained risks and benefits. The Director of Nursing stated they would expect a note to be documented in the residents' chart, to ensure this was done. They stated therapy was also responsible for assessing for entrapment and completing follow up assessments of bed assist devices to assess for risk of injury or harm. The Director of Nursing stated if nursing had a concern with the bed assist device, they would expect them to notify maintenance through an electronic work order. During an interview on 03/10/2026 at 3:16 PM, the Director of Rehabilitative Services stated entrapment tests were initially performed by the maintenance department upon installation and subsequently tested quarterly by therapy staff. Therapy staff conducted entrapment tests using the device manufacturer's Bed System Measurement Device Test Results Worksheet. The entrapment test criteria for a passed or failed result were based on the manufacturer's recommendations. The Bed System Measurement Device Test Results Worksheet was not saved in the resident's file and was discarded after the test was conducted.During an interview on 03/11/2026 at 10:25 AM, the Director of Maintenance stated Resident #87's bed was moved from another room, and the assist bars were already installed from the previous resident who used the bed. The Director of Maintenance stated there was no work order in the facility's system for installation and assessment of the assist bars because the bed rails were already installed on the bed.During an interview on 03/11/2026 at 2:02 PM, the Administrator stated they would expect staff to follow the facility's policy and follow the manufacturer's specifications. 10 NYCRR 415.12(h)(1)

Based on observation, record review, and interview conducted during the survey, the facility did not store food in accordance with professional standards for food service safety. Specifically, one (1) (West Wing Unit) of two (2) unit nourishment refrigerators contained unlabeled, out of date food and drink items, and personal food was stored with residents' food. The finding is: The policy titled Dietary Sanitation revised 02/26, documented its purpose was to prevent the incidence of food borne illness through safe food handling procedures. Stored foods to be held or leftovers should not exceed a 72-hour period in refrigeration. Leftovers should be covered, labeled and dated, put in the freezer right away or if put in refrigerator, use within 72 hours (3 days) or discard. Juices, iced tea should be used within seven (7) days. All food items must be dated once they are opened. The policy and procedure titled Dietary Services revised 01/26, documented the facility stores, prepares, distributes and serves food under sanitary conditions, and in accordance with the sanitary requirements. Observation of the [NAME] Wing Unit nourishment refrigerator on 03/06/2026 at 11:03 AM revealed the following items:-opened, used 32 fluid ounce container of thickened dairy drink dated 12/5 in black marker with best if used by date 02/12/2026. -opened, used 32 fluid ounce container of thickened dairy drink dated 1/16 in black marker. -opened, used 64 fluid ounce opened container of apple juice dated 2/20 in black marker. -one (1), 5.3-ounce unopened, unlabeled personal vanilla yogurt best by date [DATE]. During an interview on 03/06/2026 at 11:12 AM, Certified Nurse Aide #3 stated the items in the nourishment refrigerator come from the kitchen. They stated whoever opens a beverage container would be responsible for dating it. They stated it was important for food to be labeled because stuff goes bad. Certified Nurse Aide #3 stated personal food items should be labeled with a name, so they know who it belongs to. They stated you would not want to give someone's personal food to somebody else. They stated food and beverages in the refrigerator should be dated and labeled because they are only good for so long. During an interview and observation on 03/06/2026 at 11:19 AM, the Registered Dietician stated they were responsible for checking the nourishment refrigerators, since yesterday. They stated food and beverages should be labeled and dated and are only good for three days. They stated after three days of being opened, food and beverages should be thrown away to prevent food born illness. Upon observation of outdated beverages, they removed them from the refrigerator stating they were bad and beyond three days old. They removed the personal yogurt stating they were unable to say where it came from and that it was expired. During an interview on 03/11/2026 at 11:07 AM, Food Service Worker #1 stated all kitchen staff were responsible for labeling, dating food and beverages when opened. They stated once opened they are only good for three days. After the third day they should be disposed of to prevent food borne illness. During an interview on 03/11/2026 at 12:24 PM, the Administrator stated they expected facility policy to be followed regarding labeling and dating of food and beverages. They stated after 72 hours; it should be discarded. 10 NYCRR 415.14(h)

Based on observation, interview, and record review conducted during a survey, the facility did not ensure regular inspections of all bed frames, mattresses, and rails were conducted as part of a regular maintenance program to identify areas of possible entrapment (when a person is trapped in a hospital bed's rails, mattress or frame, preventing them from moving) for two (2) (Residents #1 and #71) of three (3) residents reviewed for side rail use. Specifically, Residents #1 and #71's bed rails were checked for possible zones of entrapment using a bed system measurement device that lacked a measurement component per the manufacturer's specifications. Additionally, the facility did not ensure Residents #1 and #71's bed rails, which were used and purchased separately from the bed frames, were compatible. The findings are:The policy titled Bed Assist Devices, revised 11/2024, documented the Maintenance Department, OT (Occupational Therapy) Department or Housekeeping will be involved in the placement and removal of the bed assist devices. Along with performing an Entrapment Gap Tool Test when applied to the bed, and on a monthly audit for entrapment.The policy titled Bed Entrapment Prevention and Assessment, signed by the Administrator 01/2026, documented the facility shall conduct regular assessments of bed systems (frames, mattresses, and rails) to ensure they meet the dimensional safety to prevent resident injury. Every resident bed in the facility will undergo a formal entrapment measurement audit annually. The facility will utilize specialized measurement tool. All inspection results, including specific measurements, must be documented in the Preventative Maintenance logs.1. Resident #1 had diagnoses that included dementia, osteoporosis (disease that causes bones to become weak) and muscle weakness. The Minimum Data Set (a resident assessment tool), dated 02/13/2026, documented the resident was understood, understands, and had moderately impaired cognition. Resident #1 was independent with rolling left and right in bed and required substantial maximal assistance for lying to sitting on side of bed. No bed rail use was indicated in the assessment.The comprehensive care plan, revised 03/07/2026, documented Resident #1 had limited physical mobility related to weakness. Interventions initiated on 02/14/2023, included resident required partial moderate assistance of one (1) staff member with bilateral bed assist bars for supine (lying flat on back) to sit at edge of bed; and was modified independent for rolling in bed with bed assist bars.Intermittent observations made on 03/05/2026 at 9:57 AM, 03/09/2026 at 10:23 AM, and 03/10/2026 at 10:25 AM revealed Resident #1's bed was positioned with one side up against the wall in their bedroom, and the bed had bilateral assist rails.During an observation on 03/10/2026 at 11:52 AM, a manufacturer's label revealed Resident #1's bed had bilateral bed assist rails that did not have a manufacturer's label and were affixed with screws to the underside of the bed springs and the surface of the bed springs with a wooden board above the pivot point of the head of the bed.2. Resident #71 was admitted to the facility with multiple sclerosis and sepsis. Review of the Minimum Data Set (a resident assessment tool) dated 1/22/2026 documented that Resident #71 was cognitively intact, understood by others, and understands others. Further review of the Minimum Data Set documented that Resident #71 required substantial assistance from staff to move right to left while in bed.The comprehensive care plan revised 01/21/2026, documented Resident #71 had limited physical mobility related to altered mental status and weakness. Interventions initiated on 02/07/2023 included the resident required substantial maximal assistance of one (1) staff member with bilateral bed assist bars for rolling.During an observation on 03/11/2026 at 8:15 AM, Resident #71's bed was positioned with one side up against the wall in their bedroom, and the bed had bilateral assist rails. The bed rails were noted to be slightly loose at the base but did not come out of the base. The bed assist rails, and bed frame did not have a manufacturer's label and the bilat assist rails were affixed with screws to the underside of the bed springs and the surface of the bed springs with a wooden board above the pivot point of the head of the bed.During an interview on 3/11/2026 at 8:36 AM with Resident #71, they stated that the bed assist bars were on the bed when they were admitted into the facility. They stated that they have seen maintenance check the bed assist rails but could not remember if they measured the bed rails.Review of the undated Owner's Assembly, Operation and Maintenance Manual for the beds used by Residents #1 and #71, provided by the Director of Maintenance on 03/10/2026, documented replacement mattresses and bed side rails with dimensions different than the original equipment supplied or specified by the bed manufacturer may not be interchangeable. Variations in bed side rail design and thickness or density of the mattress could cause entrapment. Only authorized replacement parts were to be used.Review of the Bed System Measurement Device Instruction Manual, retrieved from the manufacturer's website on 03/10/2026, documented the measurement device included one (1) cone, one (1) cylinder, and one (1) digital scale. Test methods included four (4) test zones, and the tests may be performed in any order, as long as all tests on all rails were completed. Additionally, the instruction manual documented the digital scale was used to apply 12-pounds of force to the cone in tests 1 and 2, and annual calibrations of the measurement device were recommended.During an observation and interview on 03/10/2026 at 1:47 PM, the Director of Maintenance stated the facility used a bed system measurement device to assess risk for entrapment on bed assist rails. The Director of Maintenance stated the maintenance department performed an entrapment test upon bed assist rail installation, and the therapy department performed bed assist rail entrapment tests quarterly thereafter using the measurement device. They stated the maintenance department installed bed assist rails in pairs and residents either received two (2) bars or no bars because the mattress would drift if only one (1) bar was installed. The Director of Maintenance stated there was no manual available for the measurement device and it was missing the scale. The Director of Maintenance stated because the facility used the same rails for all beds, the scale was not necessary and was probably lost inside someone's desk.During an interview on 03/10/2026 at 3:16 PM, the Director of Rehab Services stated entrapment tests were initially performed by the maintenance department upon installation and subsequently tested quarterly by therapy staff. They stated therapy staff conducted entrapment tests using the device manufacturer's bed system measurement device test results worksheet and the entrapment test criteria for a passed or failed result was based on the manufacturer's recommendations. The Director of Rehab Services stated the bed system measurement device test results worksheet was not saved in the resident's file and was discarded after the test was conducted. They stated the entrapment measurement device did not need to be calibrated, they were not familiar with the scale component, and they had used the device without the scale since they had been working at the facility over the last six years.During an interview on 03/11/2026 at 9:40 AM, Physical Therapy Assistant #1 stated all bed assist rail assessments and entrapment tests should be tested quarterly. They stated therapy staff were trained to use the entrapment measurement device by a demonstration from the Director of Rehab Services; not all zones were applicable when testing for entrapment, and they were not familiar with the scale component for the entrapment measurement device.During an interview and review of bed assist rail schematics on 03/11/2026 at 10:25 AM, Maintenance Technician #1 stated they never read the warning from the Owner's Assembly and Maintenance Manual for the beds used by Resident's #1 and #71 regarding the use of manufacturer's parts. The beds were implemented by the facility in the year 2000, and the bedrails had been installed on the beds over the past 15 years. During an interview on 03/11/2026 at 2:02 PM, the Administrator stated they would expect staff to follow the facility's policy and follow the bed manufacturer's specifications. They were not aware of the specificity of using the manufacturer's bed rails for the beds. If the manufacturer stated specific equipment was needed, they would follow the manufacturer's specifications for safety reasons. 10NYCRR 415.29(b)

Based on observation, interview and record review conducted during a Standard survey completed on 3/11/2026, the facility did not ensure that posted nurse staffing information contained the required information on a daily basis. Specifically, the actual hours that licensed nurses and Certified Nurse Aides worked and the resident census were not included in the posted staffing information. The finding is:The policy titled Daily Posting of Staffing Information and Resident Census dated 01/2026 documented that the facility will post daily staffing information and resident census. It documented that the 11:00 PM-7:00 AM shift will initiate the daily staffing report, include the schedule of all Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides who are scheduled to work the day of the report, the total hours of each category will be included, at the beginning of each shift the Nursing Supervisor or designee will update report and add current resident census.An observation of the Daily Staffing Report at the reception desk on 03/10/2026 at 10:00 AM, revealed the report for 03/06/2026 documented the names of the nursing staff working for the 7:00 AM to 3:00 PM, the 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM shifts. There was no documentation of the resident census and the nursing staff actual hours.Review of the Daily Staffing Report from 02/06/2026 to 3/10/2026 revealed there were no documented hours for nursing staff and no documented resident census. During an interview on 03/10/2026 at 1:30 PM with the Nursing Secretary, they stated that they stopped putting the number of nursing hours and the resident census since they started sending that information to their corporate headquarters sometime in February 2026. They stated that they did not realize that information was supposed to be posted daily.During an interview on 03/10/2026 at 1:35 PM with the Director of Nursing, they stated that the nurse staffing information and the resident census should be posted on the daily staffing sheet. Interview on 03/11/2026 at 12:34 PM with the Administrator, they stated they expect the staff to post the nursing staff hours and the resident census on a daily basis.10NYCCR 415.13

Based on observation, record review and interview conducted during the Standard survey completed on 6/4/24 the facility did not ensure residents had the right to choose activities, schedules, and health care consistent with their interests, assessments, and plan of care for one (Resident #9) of two residents reviewed for choices. Specifically, Resident #9 was provided with a shower once a week in the evening instead of twice a week during the day as care planned and preferred. The finding is: The policy and procedure titled Resident Rights reviewed 5/24 documented each resident was ensured the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The policy and procedure titled Quality of Life dated 4/92 documented the resident has the right to choose activities, schedules, and health care consistent with their interests, assessments and plans of care and the right to make choices about aspects of their life in the facility that are significant to the resident. Resident #9 had diagnoses including depression, anxiety, and diabetes mellitus. The Minimum Data Set (MDS- a resident assessment tool) dated 3/9/24 documented Resident #9 always understood, always understands, and was cognitively intact. The Minimum Data Set documented, Resident #9 required partial/moderate assistance for showering and there were no refusals of care. The Minimum Data Set, dated dated dated [DATE] documented it was very important for Resident #9 to choose between a tub bath, shower, bed bath or sponge bath. The comprehensive care plan dated 2/27/24, documented Resident #9 had an activity of daily living self-care performance deficit. Interventions included supervision for bathing, baths on Tuesday and Friday between 6AM-2PM. Review of the kardex (a guide used by staff to provide care) dated 6/3/24 documented Resident #9's bathing was on Tuesday and Friday between 6AM-2PM. Review of the 6-2 PM Shower Schedule dated 5/24/24 located at the nurse's station, lacked documented evidence of Resident #9's care planned shower schedule. Review of the 2-10 PM Shower Schedule dated 5/24/24, documented Resident #9 was to receive a shower on Tuesday between 2-10 PM. During an observation and interview on 5/29/24 at 9:20 AM, Resident #9 stated they always got a shower at about 8:30 PM and then they went straight to bed. Resident #9 stated because their shower was given at that time, they were unable to watch their television shows before bed and that was upsetting for them. Resident #9 stated they had told the certified nursing aides that they would like a shower twice a week and during the day shift, but nothing was ever done about it. Resident #9 stated they were told they were only allowed one shower per week, and they wanted another shower during the week so they could feel clean. During an interview on 6/3/24 at 10:29 AM, Resident #9 stated they never were offered nor received a shower on 5/31/24 (Friday). During an observation and interview on 6/3/24 at 10:45 AM, Certified Nursing Aide #1 stated they knew when a resident was due for a shower because it would show up on the electronic charting program and there was a book on the unit with the shower schedule in it. Certified Nursing Aide #1 stated the showers would show up on the kardex too, but they used the electronic charting program to let them know if a resident was scheduled for a shower that shift. Certified Nursing Aide #1 demonstrated on the electronic charting program and showed that the bathing task would not show up if the resident was not scheduled for a shower that shift. Certified Nursing Aide #1 demonstrated how to access the kardex using their electronic device. Certified Nursing Aide #1 stated the kardex showed that Resident #9 should have a shower on Tuesdays and Fridays between 6 AM and 2 PM. Certified Nursing Aide #1 opened the book with the shower schedule and stated the shower schedule did not match the kardex. Certified Nursing Aide #1 stated the nurses were responsible for updating the care plan, kardex, and shower schedule. Certified Nursing Aide #1 stated the staff should treat all residents the way they wanted to be treated because it was their dignity. During an interview on 6/3/24 at 10:55 AM, Certified Nursing Aide #2 stated there was a bath schedule in the book at the nurses' station and in the residents' kardex. Certified Nursing Aide #2 stated they usually looked at the book with the bath schedule in it to know if a resident was scheduled for a shower. Certified Nursing Aide #2 stated the bath schedule and the kardex should probably match, and it would be the unit manager who changed that. Certified Nursing Aide #2 stated Resident #9 should get their shower when they preferred because it was their right. During an interview on 6/3/24 at 11:05 AM, Licensed Practical Nurse #1 stated the care plan and the shower schedule in the book should both match and since it was in the care plan, it was possible that someone knew Resident #9's wishes to have a shower twice a week during the day shift. During an interview on 6/3/24 at 11:09 AM, Registered Nurse Supervisor #1 stated if Resident #9 had told someone they wanted their shower twice a week during the day shift and it was in the care plan, it was possible that someone knew that was what Resident #9 wanted. Registered Nurse Supervisor #1 stated if Resident #9 had switched rooms and the care plan was not updated, someone should have still asked them what their preference was for bathing. Registered Nurse Supervisor #1 stated this was Resident #9's home and they should receive their shower when they would like it. Registered Nurse Supervisor #1 stated the Director of Nursing had updated the shower scheduled on 5/24/24. Registered Nurse Supervisor #1 stated the Director of Nursing, Supervisor, and/or Unit Manager had access to update the bathing schedule. During an interview on 6/4/24 at 8:25 AM, the Director of Nursing stated if a resident had indicated to staff they were not happy with the schedule, then the schedule should have been changed to accommodate their request. The Director of Nursing stated that when Resident #9 was on the rehabilitation unit, their shower schedule was twice a week during the day shift and when they moved to their current unit, their shower schedule went down to once a week. The Director of Nursing stated the shower schedule should have been discussed during a care plan meeting. The Director of Nursing stated Resident #9's shower schedule should have been discussed with Resident #9 when they transferred from one unit to the other because it was their preference. During an interview on 6/4/24 at 8:48 AM, the Administrator stated it was expected that the nursing staff involved in the transfer of Resident #9 from one unit to the other would have had a conversation with Resident #9 about their preferences. The Administrator stated when Resident #9 had spoken to the certified nursing aide about their shower, the certified nursing aide should have told the licensed practical nurse. The Administrator stated this was important for Resident #9's comfort and their preferences should have been honored. 10 NYCRR 415.5 (b) (1,3)

Based on observation, interview, and record review conducted during a Standard survey completed on 6/4/24, the facility did not ensure that each resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for one (Resident #29) of three residents reviewed. Specifically, Resident #29 had long thick jagged fingernails with dark brown debris underneath on their left contracted (loss of joint mobility) hand, and long jagged fingernails with chipped polish and dark brown debris underneath on their right hand. The finding is: The policy and procedure titled Nail Care dated 2/23, documented the facility will provide appropriate nail care to all residents. Nails would be observed daily by staff providing direct AM care, would be trimmed weekly on bath day, and residents with special needs (diabetic and residents on blood thinners) will have nails trimmed by the nurse weekly. 1. Resident #29 had diagnoses including vascular dementia, obstructive hydrocephalus (excessive accumulation of cerebral spinal fluid on the brain), and history of multiple pulmonary emboli (blood clots in the lungs). The Minimum Data Set (a resident assessment tool), dated 4/12/24, documented the resident was severely cognitively impaired, was always understood and always understands, exhibited no behaviors, such as, rejection of care, and was a substantial/maximum assistance for personal hygiene. The comprehensive care plan revised on 4/24/24, documented Resident #39 had an activities of daily living self-care performance deficit, had contractures of the left hand, was a partial/moderate assistance for personal hygiene, and substantial/maximum assistance for bathing. The care plan also documented that Resident #29 was on blood thinners. Review of the treatment administration records from 3/1/24-5/31/24 revealed no documentation related to nail care. Review of the certified nurse aide task documentation from 4/1/24- 5/31/24 revealed Resident #29 received personal hygiene care daily and was either dependent or required substantial/maximum assistance with care. There were no documented care refusals. During an observation on 5/29/24 at 11:56 AM, Resident # 29 was sitting in their wheelchair in the dining room. The nails on their right hand were long and jagged, had chipped nail polish and dark brown debris underneath. Their left hand was contracted, with the left thumb nail long, thick, and dark yellow, curled upward. During an observation and interview on 5/31/24 at 7:59 AM, Resident #29 was sitting in their wheelchair in the dining room. The nails on their left hand were all thick, yellow, and jagged with chipped polish. The left thumb nail was long, thick, and dark yellow, curled upward. Nails on the right hand were long with chipped polish. The right thumb nail was cracked and jagged. Resident #29 stated they did not recall when someone last cleaned or trimmed their nails. During an interview on 5/31/24 at 10:34 AM, Certified Nurse Aide #2 stated that nails were usually checked for cleanliness during morning care every day and they were trimmed on shower/bath days. They stated that the aides were responsible for cleaning and trimming nails, but the nurse had to trim nails for residents that were on blood thinners. During an interview on 5/31/24 at 2:35 PM, Licensed Practical Nurse #3 stated that it was the responsibility of the nurse to trim Resident #39's fingernails because they were on a blood thinner, and that nails should be trimmed on the resident's shower/bath day. They stated that they were aware of the thick, long nails on the resident's left hand. Licensed Practical Nurse #3 stated that Resident #29 did not like their nails trimmed so they would try distraction when they attempted to trim them. They stated that it was important to keep resident's nails trimmed and clean to prevent them from injuring themselves and to prevent bacteria from growing underneath, especially because Resident #29's left hand was contracted. During an interview and observation on 5/31/24 at 2:39 PM, Registered Nurse #1 stated it was the responsibility of the nurse to trim the nails of residents that were on blood thinners. Nails should be checked daily and trimmed on shower/bath days. They stated it was important to keep resident's nails trimmed to prevent infection and/or injuries to themselves, especially a resident with a contracted hand because their nails could dig into their hand and cause a wound. Registered Nurse #1 observed Resident #29's nails and stated they were very thick, too long and should be trimmed, especially their left hand because it was contracted. During an interview on 6/3/24 at 10:56 AM, the Director of Nursing stated that they expected staff to check/clean resident's nails daily with morning care and to trim nails on their shower/bath day. Nail care was important because unkempt nails could be a source of infection or cause injury. It was also a dignity issue for residents that can't speak for themselves. The Director of Nursing stated it was especially important to keep nails clean and trimmed when the hand was contracted because it could lead to a pressure area and infection. 10 NYCRR 415.12 (a)(3)

Based on record review and interview conducted during a Complaint investigation (Complaint #NY00323467) during the Standard survey completed on 6/4/24, the facility did not ensure that a resident who was fed by enteral means (method of feeding that uses the gastrointestinal (GI) tract to deliver part or all a person's caloric requirements) received the appropriate treatment and services to prevent possible complications for one (Resident #127) of one resident reviewed for feeding tubes. Specifically, the facility did not provide the tube feed formula as per the hospital discharge summary. The finding is: The policy and procedure titled Enteral Feeding/Gastrostomy (a tube that passes through the abdominal wall into the stomach) - Jtube (jejunostomy tube- a tube placed through the abdominal wall into the small intestine)- Nasogastric Tube (tube inserted through the nose into the stomach) - Duodenal Feeding Tube (a tube inserted into the small intestine) reviewed 05/23 documented the purpose was to provide adequate prescribed nutritional intake by way of a Gastrostomy Tube. The policy and procedure titled Physician Orders reviewed 03/24 documented a system is established and maintained for transcription and advisement of all physician orders by a licensed nurse and the purpose is to assure accurate and timely implementation of orders. Resident #127 admitted with diagnoses of malignant neoplasm (malignant tumor that tends to spread to other parts of the body) of the tonsil and right lung, diabetes mellitus, and dysphagia (difficulty swallowing). Review of the Speech and Language Pathologist progress note dated 9/7/23 documented Resident #127 was alert and oriented and within normal limits cognitive communicative functions. The Base Line Care Plan dated 9/6/23 documented Resident #127 had nutritional needs related to enteral feeding. The goals listed included Resident #127 would tolerate tube feedings without complications. Interventions included: provide tube feeding and water flushes as ordered. The diet order was nothing by mouth. Additionally, the Base Line Care Plan documented, Resident #127 was at risk for signs and symptoms of hypoglycemia (low blood sugar) related to diabetes mellitus. Interventions included monitor blood sugars and to provide diet as ordered. Review of the hospital discharge summary dated 9/6/23 documented Resident #127 was to continue feeds/formula: Glucerna 1.2 at 70 cubic centimeters per hour and free water flush 150 cc (cubic centimeters) every four hours. Additionally, the hospital discharge summary documented Resident #127 had a diagnosis of diabetes mellitus and should be reevaluated for initiation of therapy now that feeds were going well. The hospital discharge summary documented Resident #127 had a barium swallow study that showed Resident #127 had a nonfunctional swallow. Review of the Order Summary Report documented an order on 9/6/23 nothing by mouth (NPO) diet. There were no orders to continue the feed/formula as per the discharge summary. Review of the nursing progress note dated 9/6/23 at 4:55 PM, Licensed Practical Nurse Supervisor #1 documented peg tube placement was verified via stethoscope and Resident #127 had no complaints of pain, nausea, or abdominal distension. Review of the nursing progress note dated 9/6/23 at 5:28 PM, Licensed Practical Nurse Supervisor #1 documented Resident #127 arrived at the facility at 4:55 PM and the on call made aware. Review of the nursing progress note dated 9/6/23 at 7:28 PM, Licensed Practical Nurse Supervisor #1 documented new order from Nurse Practitioner #1 Humalog (a type of insulin) sliding scale for diabetes mellitus. Finger Sticks three times a day before meals. Review of the nursing progress note dated 9/6/23 at 11:38 PM, Licensed Practical Nurse #2 documented they spoke with Nurse Practitioner #1 regarding Resident #127 having a peg tube, no orders for feeds and no formula/feed. A new order was received to check blood sugars every four hours and give glucagon if blood sugar falls below 70. Continue 150 cubic centimeter water flush every four hours to maintain patency. As per discharge instructions from hospital, this writer did 150 cubic centimeter water flush at night with nightly meds. Admission orders to be clarified in AM. Review of the Nutritional assessment dated [DATE] documented Resident #127 was dependent upon enteral feeding due to highly unsafe swallow/dysphagia caused by underlying malignancy; multiple co-morbidities including diabetes. Additionally, the Nutritional Assessment documented a suggestion of Glucerna 1.2 at 30 cubic centimeters per hour increasing by 10 cubic centimeters every eight hours for a total goal of 70 cubic centimeters per hour. Review of the Medication Administration Record dated 9/1/23 through 9/30/23 documented Glucerna 1.2 at 70 cubic centimeters via peg tube began at 8:00 AM on 9/7/23. Review of the Medication Discrepancy Form dated 9/7/23 documented the date of the error was 9/6/23 by Licensed Practical Nurse Supervisor #1. It was documented, Resident #127 arrived at the facility at 4:55 PM, was nothing by mouth with continuous G-tube feeding of Glucerna 1.2 at 70 cubic centimeters per hour. The Medication Discrepancy Form documented the possible harmful effects to Resident #127 included failure to provide adequate hydration and nutrition. During an interview on 5/31/24 at 7:17 AM, Licensed Practical Nurse #2 stated there were no orders for the feed/formula in the electronic medical record. At about 11:30 PM they noticed it was missing and they contacted the Nurse Practitioner. The Supervisor (LPN #1) should have contacted the Nurse Practitioner or the Physician earlier. License Practical Nurse #2 stated Resident #127 should have had a feed given to them soon after admission because it was ordered from the hospital as a continuous feed. During a telephone interview on 5/31/24 at 9:58 AM, License Practical Nurse Supervisor #1 stated the hospital was supposed to send a supply of tube feed/formula with Resident #127. License Practical Nurse Supervisor #1 stated they called and left a voicemail for the on-call provider stating Resident #127 arrived without any feed supply from the hospital. License Practical Nurse Supervisor #1 stated the on-call provider never returned their phone call. License Practical Nurse Supervisor #1 stated they did not attempt to notify the Director of Nursing, pharmacy, or hospital that the feed was not available and should have. During a telephone interview on 5/31/24 at 10:18 AM, the Nurse Practitioner stated they expected the nursing staff to follow orders, attempt to obtain the feed ordered, and notify them soon rather than later regarding missing feed. During a telephone interview on 5/31/24 at 10:58 AM, the Registered Dietitian stated sometimes the hospital would supply some of the feed for enteral feeds, but that agreement needed to be very definite. The Registered Dietitian stated the facility was usually aware of new admissions around noon and that would be adequate time for the facility to obtain feed/formula. The Registered Dietitian stated the facility had different options for feed already at the facility. The Registered Dietitian stated if they were not at the facility when a new admission with an enteral feed admitted , then the nursing staff could call them for recommendations, especially if the specific feed was not available. The Registered Dietitian stated for Resident #127 to go 15 hours without their continuous enteral feed was concerning. The Registered Dietitian stated Resident #127 should have been given an appropriate substitute for their feed and water flushes would not be considered an appropriate substitute. During an interview on 6/4/24 at 8:30 AM, the Director of Nursing stated they were alerted that Resident #127 was admitting to the facility with a peg tube and the hospital was supposed to send the feed. The Director of Nursing stated there were other types of feed that were on hand at the facility that could have been used. They stated, Licensed Practical Nurse Supervisor #1 was under the impression that the feed was coming from the pharmacy around 9:00 PM but it never came in. The Director of Nursing stated Licensed Practical Nurse Supervisor #1 should have called them or the Registered Nurse on call. The Director of Nursing stated they would have reached out to the Registered Dietitian for recommendations of rates and dilutions. 10 NYCRR 415.12(g)(2)

Based on interview and record review completed during a Standard survey conducted from 6/22/22 through 6/28/22, the facility did not inform the resident's representative of a need to alter treatment significantly for one (Resident #55) of one resident reviewed for notification of change. Specifically, Resident #55 was placed on an antipsychotic medication ([MEDICATION(S)]) for aggression related to dementia and the responsible party was not notified prior to initiation of the medication. The finding is: The policy and procedure (P/P) titled Notification of Change in Resident Condition/ Status revised date 3/22 documented the facility will assure that communication with Resident's responsible family member and physician is made in the event of a change in condition and/or status. The Resident's responsible family member will be notified if the resident's physical, communicative, psychosocial and/or functional status changes unexpectedly or substantially. The resident's plan of care must be altered significantly. 1. Resident #55 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 5/12/22 documented Resident #55 was severely cognitively impaired, was sometimes understood and sometimes understands. Review of the undated Care Profile documented the niece was Resident #55's responsible party. Review of the untitled comprehensive care plan with revised date 5/20/22 documented Resident #55 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Documented interventions included to administer medications as ordered, monitor and document for side effects and effectiveness with initiated date of 5/10/22. Review of the Psychiatry Consult- Initial Psychiatric Evaluation dated 5/9/22 documented [CONDITION(S)] medication recommendations: begin [MEDICATION(S)] tab 2.5 mg (milligrams) by mouth (po) twice a day (BID) for organization of thoughts, an aggression related to dementia. Monitor tolerability and efficacy. Review of the Health Status Note completed by Licensed Practical Nurse (LPN) #1 Unit Manager (UM) dated 5/10/22 documented Psych Nurse Practitioner (NP) in to see Resident #55 5/9/22 with recommendations to start [MEDICATION(S)] 2.5 mg po BID. After reviewing with the physician, Resident #55 to start the medication ([MEDICATION(S)]) as ordered. Review of the Progress Notes dated 5/9/22 - 5/20/22 revealed there was no documented evidence that the responsible party was notified that Resident #55 was started on [MEDICATION(S)]. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #55 as ordered 5/11/22 to 5/18/22, until the medication was discontinued on 5/18/22. During a telephone interview on 6/23/22 at 8:23 AM, Resident #55's niece (responsible party) stated they were called on 5/18/22 to come in as Resident #55 was unresponsive. At that time, they spoke to the Nurse Practitioner (NP) who told them that they felt the resident went unresponsive and that the two falls they had were because of the [MEDICATION(S)] the resident was recently placed on. The niece stated that they were never informed of the resident being started on [MEDICATION(S)] until that call with the NP on 5/18/22. During an interview on 6/27/22 at 1:55 PM, the Director of Nursing (DON) stated they would have expected the staff to have contacted the health care proxy (HCP) of any new orders for [CONDITION(S)] medication and that a phone call to the family would be warranted. During a telephone interview on 6/27/22 at 4:46 PM, LPN #1 UM stated they did not contact the family when the new medication [MEDICATION(S)] was ordered. LPN #1 stated if they would have notified the family, they would have documented it in the chart and if it wasn't documented they did not do it. 415.3(f)(iv)

Based on observation, interview and record review completed during a Standard survey started 6/22/22 and completed 6/28/22, the facility did not ensure the resident's rights to be free from abuse for one (Resident #55) of two residents reviewed for abuse. Specifically, Resident #55 was bitten on the left (L) hand sustaining a skin tear measuring 3 x 3.5 by Resident #75 who has a history (hx) of physical aggression towards other residents and staff. The findings are: The policy and procedure (P/P) titled Abuse Prevention with revision date 8/21 documented it is the policy of the facility to implement and maintain an abuse prevention program. Physical abuse defined as striking, pinching, kicking, shoving, bumping or unwanted sexual attention. The purpose is to prevent incidents of abuse, neglect, involuntary seclusion, and misappropriation of property for all residents. The P/P titled Resident to Resident dated 3/22 documented the staff will identify potentially harmful situations and create a plan of care which prevents resident to resident abuse with the purpose to assure the safety of all residents. 1. Resident #55 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 5/12/22 documented Resident #55 was sometimes understood, sometimes understands and was severely cognitively impaired. During observations made throughout survey from 6/22/22 to 6/28/22 between 8:00 AM to 3:00 PM Resident #55's left hand was bandaged. Resident #55 wandered up and down the hallways, sometimes into other residents' rooms or they sat in a chair near the nursing station. At times Resident #55 would continuously and repetitively talk non-sense words. When addressing Resident #55, they only talked gibberish and were unable to make conversation. Resident #55 appeared to be calm when approached. Review of the untitled Comprehensive Care Plan revealed there were no documented interventions for ensuring a safe environment for the resident who was cognitively impaired, had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Incident Note dated 6/19/22 completed by Registered Nurse (RN) #1 Unit Manager documented Resident #55 was wandering on the unit and was bitten by another resident (#75) on the back of the left hand leaving a skin tear. The skin tear measurement was documented as approximately 3 x 3.5 (with no reference to length, width, or height), the skin tear was cleansed and covered with dry clean dressing (DCD). The Nurse practitioner (NP) on call was updated with new orders (N.O.) to send Resident #55 to the hospital for [CONDITION(S)] shot and to start antibiotic (ABT) if the resident representative was in agreement. The Resident's representative was called, and message left to call facility on update and new orders. Resident 55's niece doesn't want resident sent to emergency department (ED) for the injection. Pharmacy able to supply [CONDITION(S)] injection. NP notified. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)]- [MEDICATION(S)]- Acellular [MEDICATION(S)] (vaccination, infection prevention) injection 1 application intramuscular (IM) x1 for human bite. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #55's left thigh. Review of the Progress Note completed by the NP dated 6/20/22 documented Resident #55 was seen due to (d/t) human bite over the weekend. Resident #55 was ambulating on the unit and was bitten by another resident (#75). The interaction was witnessed, and Resident #55 was not being aggressive to the other resident in anyway. Resident #55 does not seem to have any pain, dizziness, mood changes, or gastrointestinal (GI) upset. Resident #55's left hand with large skin tear and no redness. Resident #55 has been started on [MEDICATION(S)] [MEDICATION(S)]; [CONDITION(S)] shot to be updated. Topical wound care. Monitor for infection. Review of the Progress Note completed by the NP dated 6/22/22 documented Resident #55 was seen for follow-up of human bite on their hand. Resident remains afebrile (not feverish), without pain at site, no shortness of breath (sob), no chest pain, no nausea/ vomiting (N/V). Resident #55 is with good active range of motion (AROM) to left hand without discomfort. Left hand skin tear is dry, no redness, no drainage. 2. Resident #75 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #75 was understood, understands and was severely cognitively impaired. In addition, the MDS documented verbal behavioral symptoms were directed toward others and other behavioral symptoms not directed toward others. During an observation on 6/22/22 at 12:30 PM Resident #75 was lying in their bed with the sheets over their head. Resident was silent and would not respond to questions. On 6/23/22 at 9:20 AM Resident #75 was sitting up in bed with breakfast tray in front of them. Resident #75 conversed calmly at first, but then became agitated and started yelling to Get out. On 6/24/22 at 9:00 AM Resident #75 was in their room lying in bed. When addressed the resident immediately became very agitated and started to yell. Review of current Comprehensive Care (unknown date) documented Resident #75 had behavioral symptoms and makes threats to the safety of others when upset. Resident #75 insults and repeatedly will tell roommate they are going to kill them. Physical altercation between Resident #75 and roommate on 9/18/20. At that time Resident #75 was moved to a private room. Behavioral problems documented (verbal and physical aggression towards other residents and staff). On 6/21/22 resident #75 was placed on 1:1 at all times when out of bed. Review NYS DOH (New York State Department of Heath) No Action Necessary ([NAME]) Automated Complaint Tracking System (ACTS) Complaint/ Incident Investigation Reports for Resident #75 documented the resident has had multiple altercations with other residents. In addition, on 6/7/22 at 12:35 PM Resident #75 grabbed tightly on Resident #55's right hand in the dining room as Resident #55 was walking past Resident #75. Incident was unprovoked. Two certified nurse aides assisted to get Resident #75 to release their grip on Resident #55. Resident #75 was given [MEDICATION(S)] 5mg intramuscular (IM) and remained on 15-minute checks when out of their room. Review of the Potential Abuse Investigation signed by RN #1 Unit Manager (UM) and dated 6/19/22 documented Resident #75's statement They (Resident #55) touched me, on the shoulder, so I licked them. Asked Resident #75 why was there blood and they became loud and said, I bit them!! When I asked Resident #55 if they were afraid, they responded non-sense words and appeared calm. They used their left hand to eat ice cream. The two residents were separated. Resident #75 was placed in their room, with 1:1 (one on one) supervision when out of their room. Resident #55's left hand (dorsum) over 3rd knuckle was cleansed and dressed with TAO (triple antibiotic ointment). Care plan was followed. Summary of findings documented Resident #55 doesn't exhibit or verbalize any fear of being here. Resident #75 will be 1:1 when out of their room. Is this a reportable incident was marked yes- if yes notify Director of Nursing (DON) or Administrator immediately. Time and date notified 6/19/22 at 9:15 AM. Review of the Investigation of Incident completed by the Administrator on 6/19/22 documented date and time of occurrence 6/19/22 at approximately 9:15 AM. Persons involved in incident included Resident #75 and Resident #55. Injuries included Resident #55 was bitten on the left hand leaving a skin tear measuring 3 x 3.5 (no reference to length, width, or height). Area (skin tear) was cleaned and covered with DCD. NP ordered a [CONDITION(S)] injection. Synopsis of incident: Resident #55 was ambulating by Resident #75. Resident #75 reached out, grabbed Resident #55's left hand, raised it to their mouth and bit it. Residents were immediately separated, and Resident #75 was placed in their room and was to have 1:1 when out of their room. Resident #55 had their left hand cleansed and covered. They did not show signs of fear of Resident #75. We will have Resident #55 monitored for psychosocial wellbeing every (q) shift for 48 hours. Resident #75 had psych consult on 6/15/22 with a medication change. Activities to evaluate Resident #75 to see if they can implement non-pharmacological interventions. Conclusion after investigation and interviews was left blank. Final actions and plans to prevent recurrence: Residents were immediately separated. Resident #75 is 1:1 when out of their room. Activities to evaluate Resident #75 to see if they can implement non-pharmacological interventions: hobbies, likes, music, TV, etc. Investigation complete. Review of Witness Statements dated 6/19/22 and signed by RN #1 UM documented certified nurse aide (CNA) #2 observed Resident #55 ambulating by Resident #75. Resident #75 reached out, grabbed Resident #55's left hand, raised it to their mouth and bit the hand. Resident #75 was placed in their room. CNA #2 said Resident #75 initiated the contact and that Resident #55 never even talked to Resident #75 prior to the incident. During an interview on 6/27/22 at 12:21 PM, RN #1 UM stated they were called over to the unit because there was an incident. Resident #55 had a skin tear over the knuckle of their left hand as Resident #75 bit them. Certified Nurse Aide #2 (CNA) witnessed the incident and told me that Resident #55 was walking by Resident #75, who then grabbed Resident #55's hand like they were going to kiss them but then proceeded to bite it. The residents were separated, an incident report was initiated, new orders were obtained, and the Administrator and Director of Nurses (DON) were notified. During an interview on 6/27/22 at 1:51 PM, the DON stated Resident #75 has had multiple altercations with other residents prior to this one. Resident #75 has been care planned each time there has been an incident to prevent further altercations. This incident on 6/19/22 was reportable as it would be considered abuse. During an interview on 6/28/22 at 11:10 AM, the Administrator stated the incident on 6/19/22 between Resident #75 and resident #55 was definitely considered a resident to resident and was reportable but there needs to be intent to harm for it to be considered abuse. Resident #75 has a BIMS (brief interview for mental status) of 5 and are cognitively impaired and does not purposely try to hurt other residents. Additionally, stated Resident #75 has had altercations in the past with other residents. 415.4(b)(1)(i)

Based on interview and record review completed during a Standard survey started 6/22/22 and completed 6/28/22, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the appropriate officials (including the State Survey Agency). Specifically, two (Residents #55 and 75) of two residents reviewed for abuse were involved in a resident-to-resident altercation which was not reported timely to the New York State (NYS) Department of Health (DOH) as required. The finding is: The policy and procedure (P/P) titled Abuse Prevention with revision date 8/21 documented it is the policy of the facility to implement and maintain an abuse prevention program. Physical abuse defined as striking, pinching, kicking, shoving, bumping or unwanted sexual attention. The purpose is to prevent incidents of abuse, neglect, involuntary seclusion, and misappropriation of property for all residents. The P/P titled Resident to Resident dated 3/22 documented the staff will identify potentially harmful situations and create a plan of care which prevents resident to resident abuse with the purpose to assure the safety of all residents. Any incident of resident-to-resident abuse will be investigated using the Potential Abuse Investigation form. If deemed to be reportable event per guidelines of the Nursing Home Incident Reporting Manual the incident will be reported to NYSDOH via HERDS (Health Electronic Response Data System) system. 1. Resident #55 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 5/12/22 documented Resident #55 was sometimes understood, sometimes understands and was severely cognitively impaired. 2. Resident #75 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #75 was understood, understands and was severely cognitively impaired. Review the Potential Abuse Investigation signed by Registered Nurse (RN) #1 Unit Manager (UM) and dated 6/19/22 documented Resident #75's statement They (resident #55) touched me, on the shoulder, so I licked them. Asked Resident #75 why was there blood and they became loud and said, I bit them!! When I asked Resident #55 if they were afraid, they responded non-sense words and appeared calm. They used their left hand to eat ice cream. The two residents were separated. Resident #75 was placed in their room, with 1:1 (one on one) supervision when out of their room. Resident #55's left hand (dorsum) over 3rd knuckle was cleansed and dressed with TAO (triple antibiotic ointment). Care plan was followed. Summary of findings documented Resident #55 doesn't exhibit or verbalize any fear of being here. Resident #75 will be 1:1 when out of their room. Is this a reportable incident was marked yes- if yes notify Director of Nursing (DON) or Administrator immediately. Time and date notified 6/19/22 at 9:15 AM via e-mail. Review of the NYS DOH Automated Complaint Tracking System (ACTS) Complaint/Incident Investigation Report revealed the Date/time of occurrence: 6/19/22 at 9:15 AM. Submitted by facility: 6/19/22 at 2:15 PM. The question is there reasonable cause to believe that abuse, neglect, or mistreatment occurred documented it was undetermined at this time. During an interview on 6/27/22 at 12:21 PM, RN #1 UM stated they were called over to the unit because there was an incident. Resident #55 had a skin tear over the knuckle of their left hand as Resident #75 bit them. Certified Nurse Aide (CNA) witnessed the incident and told me that Resident #55 was walking by Resident #75, who then grabbed Resident #55's hand like they were going to kiss them but then proceeded to bite it. After speaking with Resident #55, they did not appear to be upset at all over the incident. Resident #55 was asked if they were afraid, but they were just speaking gibberish. Resident #55 was given ice cream and they used their left hand to eat it. Spoke with Resident #75 who stated Resident #55 touched their wheel chair. They then stated they only licked Resident #55's hand. When asked, Then why was there blood? Resident #75 stated they bit resident #55. Resident #75 was taken to their room and was placed on 1:1 when out of their room. The wound was then cleaned up and a dressing was placed on it. The niece of Resident #55, the Nurse Practitioner (NP) on call, and the brother of Resident #75 were all called and notified. The Administrator and DON were notified via e-mail, but it wasn't within the 2- hour time frame. When they did not respond after sending out the e-mails, the front desk called them and then the Administrator got back to me. I am aware of the 2-hour rule of reporting to the DOH now, I thought it was five hours. During an interview on 6/27/22 at 1:51 PM the DON stated it is my expectations that the DON and/or the Administrator are notified immediately by a phone call so that it can be reported within 2-hours to the DOH. We were notified via e-mail which is not the proper way to contact us. I did not even see the e-mail as I was off on vacation. The Administrator was the one who took care of it. The employee who did this was spoken to about alerting us via phone instead of an e-mail because this needed to be sent in to the DOH within 2-hours. Yes this incident was reportable to the state within 2-hours of the time of the notification. During an interview on 6/27/22 at 3:03 PM the Administrator stated it would be my expectation for staff to notify me by the phone so that I have the 2-hours to report this. I try to make sure they are reported timely. When notified by phone of the incident, it was then reported to the DOH right away. The staff member who sent the e-mail instead of calling me, was educated immediately regarding the 2-hour reporting requirements. 415.4(b)(4)

Based on observation, record review, and interview during the standard Survey started 6/22/22 and completed 6/28/22, the facility did not ensure a resident with an indwelling catheter received the necessary services and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically, Resident #44's indwelling urinary catheter (tube inserted into the bladder to drain urine) was not anchored to prevent excessive tension on the catheter. Additionally, the facility's policy and procedure (P&P) did not address anchoring of the catheter. The finding is: Review of the facility P&P titled Urinary Catheterization dated 10/18, revealed there was no documentation that a resident's urinary catheter was to be anchored to prevent tension on the catheter. 1. Resident #44 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-a resident assessment tool) dated 4/23/22 documented Resident #44 was cognitively intact and had an indwelling urinary catheter. The comprehensive care plan documented Resident #44 had an indwelling catheter related to neuromuscular dysfunction initiated on 7/1/21. Interventions documented included to position the catheter bag and tubing below the level of the bladder, change and irrigate the catheter per order. There was no intervention to anchor the catheter tubing to prevent tension on the catheter. Review of the Order Summary Report dated 6/28/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nurse Progress Notes dated 4/14/22 through 6/26/22 revealed the following: -On 4/14/22 at 2:27 PM, catheter noted to be leaking -On 5/5/22 at 6:47 AM, catheter was leaking -On 6/8/22 at 4:36 AM, resident was wet with urine, attempted to flush the catheter without success, catheter was changed, and a small stone was attached at end of the catheter -On 6/23/22 at 5:08 AM, catheter leaking and was changed -On 6/26/22 at 6:35 PM, catheter changed per as needed order if plugged or leaking During an observation of morning care on 6/27/22 at 9:36 AM, Certified Nurse Aide (CNA) #3 provided catheter care. The catheter tubing had dried blood near the urinary meatus (external opening of the urinary tract) and some streaks of blood in the urine drainage tube. Resident #44 stated, be careful with that, I just had it changed last night. The resident's catheter was not anchored to prevent pulling on the catheter. During an interview on 6/27/22 at 1:51 PM, CNA #3 stated that the nurses were responsible for changing the catheter and making sure the catheter was anchored with a leg strap. During an observation on 6/28/22 at 9:03 AM, with Licensed Practical Nurse (LPN) #2 present, Resident #44 was lying in bed and the catheter was not anchored. LPN #2 stated that the resident should have a leg strap and they would go get one. Resident #44 stated he used to have a leg strap but didn't know what happened to it and would like to have one. During an interview on 6/28/22 at 9:08 AM, LPN #2 stated nurses were supposed to make sure residents had a catheter strap on, to keep the catheter stabilized. LPN #2 stated Resident #44 occasionally had leaking or plugging of their catheter and had orders to flush and change the catheter. LPN #2 stated they didn't know why the resident didn't have a leg strap on or how long the resident didn't have one in place. During an interview on 6/28/22 at 9:34 AM, the Director of Nursing (DON) stated they expected residents with indwelling urinary catheters to have a leg strap in place to prevent pulling of the catheter. The DON stated LPNs should check, but also CNAs should let the nurses know if a resident didn't have one in place. The DON stated that staff should check for a leg strap during incontinent care or during catheter care. During further interview at 1:04 PM, the DON stated they were not aware the facility policy did not include a catheter strap and that the strap was for resident's comfort and safety. 415.12 (d)(2)

Based on interviews and record reviews conducted during the COVID-19 Focused Infection Control Survey (#NY 917) on 6/18/20, the facility did not inform residents by 5:00 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. Specifically, the facility did not provide verbal or written notification when a resident at the facility tested positive for COVID-19 or a resident suffered a COVID-19 related death for two (Residents #4 and #5) of two residents interviewed. This is evidenced by the following: The facility policy and procedure, COVID-19 Communication, dated May 2020, included CMS guidance that facilities must inform residents, their representatives, and families by 5:00 p.m. the next calendar day following the occurrence of either: a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms that occur within 72 hours of each other. A Robo call will be sent to the families/next of kin to comply with this guidance. Review of the facility's discharge report and Robo call scripts revealed that one staff member tested positive for COVID-19 following testing of all staff on 5/21/20, three staff members tested positive for COVID-19 on 5/30/20, one resident tested positive for COVID-19 on 5/31/20, there was one resident death related to COVID-19 on 6/4/20, two residents tested positive for COVID-19 on 6/7/20, and one staff member tested positive for COVID-19 on 6/8/20. 1. Resident #4 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 5/1/20, revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The facility could not provide documented evidence that the resident was notified of new cases of COVID-19 or COVID-19 related deaths in the facility. When interviewed on 6/18/20 at 11:13 a.m., Resident #4 stated the facility contacts their son and daughter about new cases and deaths related to COVID-19. Resident #4 said they get their information from talking with their children. Resident #4 said that no one from the facility has given them any information personally. 2. Resident #5 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 5/2/20, revealed the resident was cognitively intact with a BIMS score of 15. The facility could not provide documented evidence that the resident was notified of new cases of COVID-19 or COVID-19 related deaths in the facility. When interviewed on 6/18/20 at 11:19 a.m., Resident #5 stated the facility has not informed them of any new cases of COVID-19 or COVID-19 related deaths, and they would like to know. Resident #5 said they did not know if the facility was trying to protect them, but they like to know what is going on. When interviewed on 6/18/20 at 11:32 a.m., the Director of Social Work stated that she has not been notifying residents about new COVID-19 cases or related deaths. She said if residents inquired, she would let them know. She said she was not informed that she was responsible for notifying residents. In an interview on 6/18/20 at 11:32 a.m., the Director of Activities stated she has not been notifying residents about new COVID-19 cases or related deaths. She said the activities staff would not be notifying residents of that information during 1:1 visits. She said she was not informed that she was responsible for notifying residents. In an interview on 6/18/20 at 11:35 a.m., the Director of Nursing stated that she was not aware of the requirement to notify residents of new cases of COVID-19 or related deaths prior to that day. She said she realized it was an issue and the facility has tried to keep up with regulation changes as best they can. When interviewed on 6/18/20 at 11:43 a.m., the Administrator stated that she was not aware of the requirement to notify residents of new cases of COVID-19 or related deaths prior to that day. She said the facility does not have a process for notifying residents at that time. (CFR 483.70(b))

Based on interview and record review during the Standard survey completed on 8/30/19, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the lack of documented evidence that verified four (Employee #1, Employee #2, Employee #3, Employee #4) of fifteen files reviewed for background checks had been screened through the New York State Nurse Aide Registry prior to their employment. The findings are: The facility's policy and procedure (P&P) titled Pre-Hire Screening of Employees, revised 7/2019, documented the facility will screen all employees for history of abuse or neglect before hiring, and this will include a search of the Nurse Aide Registry for each prospective employee and the result will be printed. 1. Record review of the personnel file for Employee #1 (Occupational Therapist) revealed Employee #1 was hired on 7/3/19 and Employee #1's file contained a Nurse Aide Registry verification conducted on 7/3/19 for a person with the same first name and different last name. During an interview on 8/29/19 at 3:30 PM, the Human Resources and Payroll Coordinator stated there is no Nurse Aide Registry verification sheet for Employee #1, and the Nurse Aide Registry Verification sheet that appeared in Employee #1's file was for a different person. She further stated she does not know who placed the Nurse Aide Registry verification sheet in Employee #1's file, but it was a mistake. Record review of the automated time and attendance record revealed Employee #1 worked in this facility four days between 7/3/19 and 8/29/19. 2. Record review of the personnel file for Employee #2 (Certified Nurse Aide) revealed Employee #2 was hired on 6/28/19 and the Nurse Aide Registry verification was conducted on 8/14/19. Record review of the automated time and attendance record revealed Employee #2 worked second shift in this facility 25 days between 7/1/19 and 8/14/19. 3. Record review of the personnel file for Employee #3 (Certified Nurse Aide In Training) revealed Employee #3 was hired on 6/28/19 and the Nurse Aide Registry verification was conducted on 7/8/19. Record review of the automated time and attendance record revealed Employee #3 worked first shift in this facility six days between 6/30/19 and 7/8/19. During an interview on 8/30/19 at 12:00 PM, the Director of Nursing stated the Certified Nurse Aide In Training Program contains students who have completed the Nurse Aide Training Program at a sister facility and are [MEDICATION NAME] their clinical skills at this facility, under the guidance of a Certified Nurse Aide, prior to taking their certification exam. 4. Record review of the personnel file for Employee #4 (Certified Nurse Aide In Training) revealed Employee #4 was hired on 6/28/19 and the Nurse Aide Registry verification was conducted on 7/9/19. Record review of the automated time and attendance record revealed Employee #4 worked second shift in this facility one day between 7/1/19 and 7/9/19. During an interview on 8/29/19 at 3:30 PM, the Human Resources and Payroll Coordinator stated she was on vacation around the end of (MONTH) and the first week of July, and she does not believe anyone from the facility was checking the Nurse Aide Registry for new hires in her absence. 415.4(b)(1)(ii)(a)(b)

Based on observation, interview, and record review conducted during the Standard survey completed on 8/30/19, the facility did not ensure that the Pharmacist report any irregularities to the attending Physician and the facility's Medical Director and Director of Nursing for two (Resident #35 and #63) of five residents reviewed for Drug Regimen Reviews. Specifically, the pharmacist did not identify or report antipsychotic ([MEDICATION NAME] and [MEDICATION NAME]) medications prescribed and administered for an excessive duration without an attempt of a gradual dose reduction (GDR). In addition, the lack of documented evidence to warrant its continued use. The policy and procedure (P&P) titled Pharmacy Services - Medication Regimen Review dated 4/18 documented the consultant pharmacist will perform a monthly medication regimen review, documenting the appropriateness of medication regimen and recommendations for change. The findings are: 1. Resident #35 was admitted [DATE] and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS, a resident assessment tool) dated 7/5/19 revealed the resident was severely cognitively impaired was rarely/never understood. Review of a Physician order [REDACTED]. During intermittent observations of the resident on 8/28/19, 8/29/19 and 8/30/19 between 8:30 AM and 3:00 PM revealed the resident was self propelling around the facility in her wheel chair with a lap buddy (cushioned device that fits up the wheel chair to remind a person not to get up unassisted) in place. She was not observed trying to stand or remove the lap buddy. She was not observed throwing food or yelling out. She was observed without the lap buddy while in wheel chair at meals and when supervised at the nurse's station per her care plan. During these times the resident was not observed to have behaviors that would be harmful to herself or others. Review of a Progress Notes dated 11/2/15 at 10:48 AM revealed BMARC (Behavior Modification Assessment Review Committee) recommendations to decrease [MEDICATION NAME] to .5 mg (milligram) in AM and 1 mg PM. Continued review revealed at 11:50 AM it was documented the daughter was contacted regarding the BMARC recommendation and was very opposed to any medication changes. The physician was notified on 11/2/15 of daughter's concern of medication change and discontinued the initiation of the GDR (gradual dose reduction). Review of BMARC recommendations from 7/2018 through 8/2019 revealed there was no recommendation made to GDR the [MEDICATION NAME] and did not document the benefits outweighed the risks. Review of Pharmacy Consultant notes from 11/5/18 through 7/19/19 revealed there was no recommendations for a GDR. Psych meds continue, resident functioning at highest level, quality of life would be negatively impacted. Review of the medical record (progress notes, provider notes, consultant notes) revealed no further GDR had been recommended since 11/2/15. During an interview on 8/28/19 at 9:50 AM, Registered Nurse (RN) Unit Coordinator #1 stated the resident doesn't try to stand up out of the chair anymore. During an interview on 8/30/19 at 9:45 AM, Pharmacist Consultant #1 stated if there was a GDR it would cause the resident harm, she could fall. We don't want to cause her harm. The GDR is contraindicated. She is functioning at her highest level. Review of the medical record from 11/2015 through 8/30/19 revealed there was no documented evidence regarding a fall with injury. The resident had been using a lap buddy (cushioned device that fits the wheel chair to remind a person not to get up unassisted and can be used for positioning if a person tends to lean forward in wheelchair and is in danger of falling forward) for the last five years. 2. Resident #63 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed that the resident was cognitively impaired, usually understood and sometimes understands. Section [NAME] (Behavior) of the MDS revealed the resident had no potential indicators of [MEDICAL CONDITION]. There were no physical behavioral symptoms exhibited. The resident was not at significant risk for physical illness or injury; there was no significant interference with the resident's care, participation in activities or social interactions and there was no impact on others. Section N (Medications) of the MDS revealed the resident received an antipsychotic medication. Review of the Care plan date 5/29/19 (identified as current) documented the resident had a history of [REDACTED]. Interventions included monitor behaviors and pharmacy consultant reviews. Review of the Physician order [REDACTED]. Review of the provider note 7/3/2019 revealed the resident was with advanced dementia and really has no behavioral issues although she does grind her teeth. She is treated with [MEDICATION NAME] (antianxiety medication) and [MEDICATION NAME] due to delusions. Despite discussions with her daughter about the risks of these medications and the potential that she would do fine without them her daughter has expressed significant concerns about instability with GDR attempts and causing her mother undue stress and discomfort if the GDR is unsuccessful. Review of Medication Administration Records dated 11/9/18 through 8/29/19 revealed [MEDICATION NAME] 2 mg was administered at 8:00 AM and 8:00 PM. Review of the monthly regimen reviews dated from 12/20/2018 through 6/17/2019 revealed there was no recommendation made to attempt a GDR of the [MEDICATION NAME]. The pharmacist documented the benefits of current medications clearly outweigh the risks, and that a GDR of [MEDICATION NAME] was done in the past with very poor results. Review of the Behavioral Modification Assessment Record Committee (BMARC) notes dated 8/8/19 revealed the resident was on [MEDICATION NAME] 2 mg/ml, Concentrate (2 mg orally BID) with the last increase being 1/30/17. The last GDR was left blank. There were no behaviors noted, and the resident had been noted to be sleeping more during the day and less verbal. Review of progress notes 6/1/19 through 8/29/19 revealed there was no documented evidence the resident had behaviors that were harmful to herself or others. During intermittent observations from 8/26/19 through 8/30/19 between 8:30 AM and 3:30 PM the resident did not display any inappropriate behaviors or calling out. During an interview on 8/30/19 at 8:27 AM, Licensed Practical Nurse (LPN) Unit Manager #1 stated the resident has never had a GDR of the [MEDICATION NAME]. During an interview on 8/30/19 at 8:35 AM, the Medical Director (MD), stated he does pharmacy reviews monthly in conjunction with the nursing staff. The MD could not recall discussing Resident #63 and did not know why her GDR was not reflected in the Medication Administration Record [REDACTED]? During an interview on 8/30/19 at 9:45 AM, the Pharmacist Consultant #1 stated during the BMARC meetings they do reference the GDR on each resident and, of course I would expect that it had been completed. 415.18(c)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on 8/30/19 the facility did not ensure that residents who use antipsychotic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for two (Resident #35 & 63) of two residents reviewed for antipsychotic medications. Resident #35 received [MEDICATION NAME] ([MEDICATION NAME], antipsychotic medication) 1 mg (milligrams) BID (twice a day) since 1/2015 without a GDR. Resident #63 received [MEDICATION NAME] (antipsychotic medication) 2 mg BID since 10/2017 without a GDR or behavioral documentation for its continued use. The findings are: The facility policy and procedure titled Antipsychotic Medications, and Guidelines for Use dated 5/18 documented the purpose of the policy is to ensure that a patient/resident is not given anti-psychotic medications unless indications of need necessary to treat a specific condition as diagnosed and documented in the medical records; which have been quantitively and objectively documented. The indication for any [MEDICAL CONDITION] medication will be thoroughly documented in the clinical record to include an appropriate supporting [DIAGNOSES REDACTED]. Antipsychotics should not be used for wandering, anxiety, nervousness, unspecified agitation, impaired memory, or fidgeting. Information should be quantitatively and objectively documented. Assess whether the resident's behavioral symptoms is in need of some intervention. Determine whether behavioral symptoms are transitory of permanent. Ruling out environmental causes. Persistent behaviors which are not preventable and could cause harm to the resident or others. 1. Resident #35 was admitted [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 7/5/19 revealed the resident was severely cognitively impaired and rarely/never understood. Review of the Care Plan dated 7/12/19 revealed resident had [DIAGNOSES REDACTED]. Approaches include administer medications as ordered ([MEDICATION NAME] 1 mg BID and [MEDICATION NAME] .5 mg BID), allow to propel around the facility, modify environment if overstimulating, offer snacks, blanket, different setting when agitated, and use tactile approach if resident allows. Review of the Physician order [REDACTED]. Review of a Progress Note dated 11/2/15 at 10:48 AM revealed BMARC (Behavior Modification Assessment Review Committee) recommendations to decrease [MEDICATION NAME] to .5 mg in AM and 1 mg in PM. Continued review of a Progress Note dated 11/2/15 at 11:50 AM revealed the daughter was contacted regarding the BMARC recommendation and was very opposed to any medication changes. The Physician was notified on 11/2/15 PM of daughter's concern of medication change and discontinued the initiation of the GDR. Review of BMARC recommendations from 7/2018 through 8/2019 revealed there was no recommendation to GDR the [MEDICATION NAME] and there was no documented evidence the benefits outweighed the risk. Review of the Progress Notes from (MONTH) 2019 through 8/30/19 revealed the resident had behaviors which included refusing medications. Continued review of the Progress Notes from 1/2019 to present included occasionally throwing food and yelling out. During an interview on 8/30/19 at 9:45 AM, the Pharmacist Consultant stated refusing meds was not a behavior. Review of the Medication Administration Record [REDACTED]. During an interview on 8/30/19 at 8:55 AM, the Physician stated there should have been a GDR within the past five years and doesn't feel the resident has behaviors that warrant the use of an antipsychotic medication, but he has to take into consideration the surrogate/HCP wishes. During an interview on 8/30/19 at 9:05 AM, the Social Worker stated it was her understanding there hadn't been a GDR because the family doesn't want it. During an interview on 8/30/19 at 9:50 AM, the Pharmacist Consultant #1 stated if there was a GDR it would cause her harm, she could fall. We don't want to cause her harm. It is contraindicated. During intermittent observations of the resident on 8/28/19, 8/29/19 and 8/30/19 between 8:30 AM and 3:00 PM revealed the resident was self propelling around the facility in her wheel chair with a lap buddy (cushioned device that fits up the wheel chair to remind a person not to get up unassisted) in place. She was not observed trying to stand or remove the lap buddy. She was not observed throwing food or yelling out. She was observed without the lap buddy while in wheel chair at meals and when supervised at the nurse's station per her care plan. There were no observed behaviors that were harmful to herself or others. During an interview on 8/28/19 at 9:50 AM, Registered Nurse (RN) Unit Coordinator #1 stated the lap buddy was for positioning. In addition, the resident's daughter doesn't want the medication discontinued because she is afraid, she will fall forward. The resident doesn't really try to stand up anymore. 2. Resident #63 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed that the resident was cognitively impaired, usually understood and sometimes understands. Section [NAME] (Behavior) of the MDS revealed the resident had no potential indicators of [MEDICAL CONDITION]. There were no physical behavioral symptoms exhibited. The resident was not at significant risk for physical illness or injury; there was no significant interference with the resident's care, participation in activities or social interactions and there was no impact on others. Section N (Medications) of the MDS revealed the resident received an antipsychotic medication for the past seven days. Review of the Care plan date 5/29/19 (identified as current) documented the resident had a history of [REDACTED]. Interventions included to administer medications as ordered, monitor side effects, monitor mood to determine if problems seem related to external causes and pharmacy consultant reviews. Review of the provider note 7/3/2019 revealed the resident was with advanced dementia and really has no behavioral issues although she does grind her teeth. She is treated with [MEDICATION NAME] (antianxiety medication) and [MEDICATION NAME] due to delusions. Despite discussions with her daughter about the risks of these medications and the potential that she would do fine without them her daughter has expressed significant concerns about instability with GDR attempts and causing her mother undue stress and discomfort if the GDR is unsuccessful. Review of the Physician order [REDACTED]. Review of Medication Administration Records dated 11/9/18 - 8/29/19 revealed [MEDICATION NAME] 2 mg was administered at 8:00 AM and 8:00 PM. Review of progress notes 6/1/19 through 8/29/19 revealed there was no documented evidence the resident had behaviors that were harmful to herself or others. During intermittent observations from 8/26/19 through 8/30/19 between 8:30 AM and 3:30 PM the resident did not display any inappropriate behaviors or calling out. Review of the Behavioral Modification Assessment Record Committee (BMARC) notes dated 8/8/19 revealed the resident was on [MEDICATION NAME] ([MEDICATION NAME]) 2 mg/ml (milligrams per milliliter), Concentrate (2 mg orally BID) with the last increase being 1/30/17. The last GDR was left blank. There were no behaviors noted, and the resident had been noted to be sleeping more during the day and less verbal. During an interview on 8/30/19 at 8:27 AM, Licensed Practical Nurse (LPN) Unit Manager #1 stated the resident has never had a GDR of the [MEDICATION NAME]. During an interview on 8/30/19 at 8:35 AM, the Medical Director (MD), stated he does pharmacy reviews monthly in conjunction with the nursing staff. The MD could not recall discussing Resident #63 and did not know why her GDR was not reflected in the Medication Administration Record [REDACTED]? During an interview on 8/30/19 at 9:45 AM, the Pharmacist Consultant #1 stated during the BMARC meetings they do reference the GDR on each resident and, of course I would expect that it had been completed. During an interview on 8/30/19 at 10:05 AM, the Director of Nursing stated she was aware the resident did not have a GDR related to family wishes to continue the medication. 415.12(1)(2)(ii)

Based on observation, interview, and record review conducted during the Standard survey completed on 8/30/19, the facility did not provide food and drink for resident consumption that was palatable, attractive, and at a safe and appetizing temperature. Specifically, three (Units A, B, C) of five resident units observed for meal service had issues with hot and cold food items that were not served at appetizing temperatures. Residents #A, B, C, D and family representative [NAME] were involved. The findings are: Review of a facility policy titled Dietary Services Philosophy and Objectives dated 3/19 documented staff will endeavor to prepare and serve food that is attractive, at all proper temperatures, meeting the individual preferences of the resident, and properly seasoned unless otherwise restricted. All potentially hazardous food transported from one food service area to another should be kept at 41 degrees Fahrenheit (F) or below (cold foods) or 135 degrees Fahrenheit (F) or above (hot liquid) during transportation. Keep the temperature of prepared foods that are to be served cold at 41 degrees Fahrenheit (F) or below throughout the meal service period. Interviews from 8/26/19 to 8/27/19 revealed the following: - 8/26/19 at 9:59 AM, Family representative [NAME] stated they visit daily and they felt the quality of food has gone way down. Specifically, they use to get name brand jelly and now that get some generic kind that taste awful. - 8/26/19 at 11:15 AM Resident B stated the food is terrible. The meatballs are made from sausage. It's always the same thing beef or pork - 8/26/19 at 12:20 PM, Resident D stated the quality of food has really gone down. They don't get fresh fruit regularly, we get a lot of canned fruit. The resident further stated your lucky if you get your meal hot. - 8/26/19 at 2:31 PM, Resident A stated the food was awful. It's never at the right temperature. - 8/27/19 at 8:52 AM, Resident C stated people that eat in their rooms get cold food. They tell me to go to the dining room and get hot food but I don't want to go to the dining room. Last night the pulled pork sandwich were and the potato wedges were cold. The food doesn't taste good. Observation of the West Wing dining area on 8/28/19 revealed the lunch meal was started to be served at 11:45 PM to those residents eating in their rooms on the West Wing. After all trays were served at 12:14 PM, a test tray was conducted. The Food Service Director (FSD), using a facility digital thermometer, obtained temperatures of the food on the plate as follows: Oven fried chicken- 118 degrees F, was not palatable as it was luke warm, tough to chew, and had little flavor. Brown rice-118 degrees F and was not palatable. It was luke warm, sticky, and bland to taste. Oriental blend vegetables-104 degrees F and were cold to taste. Coffee-125 degrees F and was luke warm. During a follow up interview on 8/28/19 at 12:20 PM, Resident C stated her lunch wasn't very warm. It's never warm Observation of the East Wing dining area on 8/28/19 revealed the lunch meal was started to be served at 12:04 PM to those residents eating in their rooms on the East Wing. After all trays were served at 12:17 PM, a test tray was conducted. The facility Cook, using a facility digital thermometer, obtained temperatures of the food on the plate as follows: Oven Fried Chicken-100 degrees F and was not palatable as it was dry, tuff, and tasteless. Brown Rice-100 degrees F. The rice was sticky and tasted bland. Oriental Blend Vegetables-88 degrees F were not palatable tasted cold and had no flavor. Juice-50 degrees F and tasted luke warm Coffee-120 degrees F and tasted luke warm Interview with the Food Service Director on 8/28/19 at 12:17 stated she randomly picks a unit and waist till the last tray is passed. I proceed to take temps and then ask the residents if everything was ok. The hot foods need to be warm enough to be palatable and the cold food has to be at 41 or below. 415.14 (d)(1)(2)

Based on interview and record review conducted during the Standard survey completed on 8/30/19, the facility did not ensure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline for two (Residents #35, 63) of twenty three residents reviewed for the Minimum Data Set (MDS, a resident assessment tool) accuracy. Specifically, the lack of an accurate assessment to reflect the most recent gradual dose reduction (GDR) of [MEDICAL CONDITION] medications. The findings are: The policy titled MDS 3.0 dated 8/2019, documented the MDS is updated quarterly; a comprehensive assessment is done annually and in the event of a significant change. The Resident Assessment Coordinator and the Regional MDS Consultant will review samples of MDS completed for accuracy. Any errors found on submitted assessments will be corrected and submitted. 1. Resident #63 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively impaired, usually understood and sometimes understands. Section [NAME] (Behavior) of the MDS revealed the resident had no potential indicators of [MEDICAL CONDITION]. There were no physical behavioral symptoms exhibited. The resident was not at significant risk for physical illness or injury; there was no significant interference with the resident's care, participation in activities or social interactions and there was no impact on others. Section N (Medications) of the MDS revealed the resident did receive an antipsychotic medication. The MDS also documented a GDR attempt was completed on 10/25/17. During an interview on 8/30/19 at 8:27 AM, Licensed Practical Nurse (LPN) Unit Manager #1 stated she completed the MDS entry for Resident #63 and stated the last [MEDICAL CONDITION] GDR was conducted on 10/25/17. When asked to identify the GDR for [MEDICATION NAME]. LPN #1 reviewed the medical record and stated, I was looking at the wrong medication, it was [MEDICATION NAME] (antianxiety medication). She has never had a GDR'd for [MEDICATION NAME] (antipsychotic medication). During an interview on 8/30/19 at 10:37 AM, the Registered Nurse (RN) MDS Nurse #1 stated that she does not review each and every entry made on the MDS but reviews the MDS for completeness before submitting it. Also, in section N for Antipsychotic Medication Review she would have expected only medications in this section to be antipsychotic medications. If not, she would submit a correction; then reeducate the individual who made the mistake. 2. Resident #35 was admitted [DATE] and had [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed the resident was severely cognitively impaired and was rarely/never understood. The MDS documented in section N the resident received antipsychotic and antianxiety medications for 7 of 7 days of the look back period. Review of the antipsychotic section revealed the resident received an antipsychotic on a routine basis and that there had been a GDR on 2/20/18. Additionally, the MDS dated [DATE] also indicated a GDR was conducted on 2/20/18. Review of the IDT-BMARC (Interdisciplinary Behavior Modification Assessment Review Committee) report dated 7/17/18 revealed the resident was on [MEDICATION NAME] (antipsychotic) 1 mg (milligram) BID (twice a day) with no change since 2/2014. Additionally, [MEDICATION NAME] (antianxiety) .5 mg with no change since (MONTH) (YEAR). Review of Progress Notes dated 11/2/15 revealed an attempt to initiate a GDR of the [MEDICATION NAME] 1 mg BID to .5 mg in the AM and 1 mg at HS. It was rescinded 62 minutes later due to the daughter's opposition of the order. There never was an actual GDR as the resident would have received her AM dose of the medication. Review of the IDT-BMARC dated 7/17/19 revealed resident remained on the same dose of [MEDICATION NAME] and it had not been changed since 11/1/15. Additionally, she remained on the same dose of [MEDICATION NAME] since 3/15/18. Review of the monthly IDT-BMARC reports and Progress Notes from 7/2018 through 7/2019 revealed the was no documented evidence a GDR was attempted for either medication ([MEDICATION NAME] and [MEDICATION NAME]). During an interview on 8/30/19 at 1:20 PM, the RN MDS Nurse #1 stated she must have made a mistake and looked at the wrong line when filling out the information. 415.11 (b)

Based on observation, interview and record review during the Standard survey completed on 7/24/18, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not update their Legionella Environmental Assessment annually. This affected two (East Wing and West Wing) of two resident units. In addition, one (Resident #30) of three residents observed for infection control practices during resident care had issues with the lack of proper hand hygiene and glove use after the Certified Nurse Aide (CNA) provided bowel incontinence care and improper disposal of used bath water into shared sink. The findings are: 1. Review of the facility's Legionella documents revealed a Legionella Environmental Assessment was completed on 9/4/15. During an interview on 7/23/18 at 9:30 AM, the Administrator stated the most recent Legionella Environmental Assessment she could locate was dated 9/4/15 and was completed by the previous Administrator. At the same time, the Director of Maintenance stated he had not completed any Legionella Environmental Assessment for the building. 2. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS -resident assessment tool) dated 7/16/18 revealed the resident has moderately impaired cognition, required total assistance for toileting, and was always incontinent. Review of the policy entitled Incontinent Care dated 2/18 revealed for stool incontinence after cleaning/rinsing/drying the rectal/buttock area staff are to change the water, wash hands, and apply clean gloves. The policy does not specify how to dispose of used bath water. An observation of morning care, with Licensed Practical Nurse (LPN #2) Unit Manager and a CNA orientee present, on 7/23/18 at 10:30 AM, CNA #2 turned the resident onto her left side and the resident was incontinent of a small amount of soft stool. CNA #2 used a basin of soapy water and a washcloth to clean the resident's buttocks and rectal area. Without changing the soiled gloves and washing her hands, the CNA applied a new, clean incontinent pad and clean brief under the resident and fastened it closed. At 10:38 AM, CNA #2 removed her gloves, donned (put on) new gloves without washing her hands and placed the transfer sling under the resident. At 10:40 AM, CNA #2 disposed of the dirty water from the basin, used to provide the resident with fecal incontinence care, into the shared sink in the resident's room. At 10:41 AM, while wearing the same gloves the CNA #2 (along with orientee) transferred the resident into her wheelchair using the mechanical lift. Still wearing the gloves, CNA #2 combed the resident's hair. The CNA #2 then stripped the bed, removed left hand glove, wrapped the linen into a bundle with right hand, and without washing her hands, exited the room using her ungloved hand to open the resident's room door and walked down to soiled utility room. Using her ungloved hand, CNA #2 touched the door handle and entered to dispose of the soiled linen. The CNA did not wash her hands before exiting the resident's room. During an interview on 7/23/18 at 10:49 AM, CNA #2 stated she was supposed to change her gloves after providing bowel incontinence care, I missed it that time. The CNA also stated she does dump the dirty water into the sink, if someone was in the bathroom. The CNA further stated that she knew she was supposed to use the toilet to dump the dirty water, not the sink. During an interview on 7/23/18 at 2:53 PM the LPN #2 Unit Manager stated she would expect the CNA to wash her hands and change her gloves before putting on a new brief and that it makes sense to dispose of the used water into the toilet, not the shared sink. During an interview on 7/24/18 at 10:02 AM, the Assistant Director of Nursing (ADON) stated after the CNA completely washed the area, she should have removed the gloves, washed her hands, and got a new set of gloves before touching the clean items. The ADON further stated the CNA should have dumped the dirty water into the toilet. 415.19(a)(1)(b)(4) 10 NYCRR Subpart 4-2.3

Based on observation, interview, and record review conducted during the Standard survey completed on 7/24/18, the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promoted maintenance or enhancement of his or her quality of life for one (Resident #7) of 2 residents reviewed for dignity. Specifically, the resident was not provided with assistance as planned while drinking liquids during meals resulting the residents clothing becoming saturated in a common area. The finding is: Review of a policy entitled Quality of Life dated 4/92 revealed the facility promotes care for residents in a manner and in an environment, that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. 1. Resident #7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 6/29/18 revealed the resident has moderate cognitive impairments, sometimes understands and sometimes is understood. The MDS documented the resident required extensive assistance of one person for dressing and eating. An undated Certified Nursing Assistant (CNA) Assignments Summary, documented the resident required extensive assistance of one person for eating. Additionally, the resident was to be assisted by staff with drinking beverages, to prevent spillage. The undated Care Plan Activity Report documented staff were to stay with the resident during meals to help decrease spillage and assist as needed. The Rehab - Occupational Therapy (OT) Part B Progress Note/Discharge Summary (OT) documented recommendations to use valve lid cup for beverages, provide one assist to tip cup and encourage sipping. During an observation on 7/18/18 at 12:35 PM, during the lunch meal the resident was wearing a cloth clothing protector, holding onto a bilateral handled sippy cup (specialized cup to minimize spillage) with one hand, biting at the sippy cup, and speaking while tipping the cup toward her lips, causing the liquid to spill, saturating her clothing. Staff was observed sitting with the resident at this time. During an observation on 7/20/18 at 9:19 AM, Certified Nurse Aide (CNA #6) fed the resident breakfast (food items), then left resident with four sippy cups full of liquid in front of her. The resident was observed holding onto one handle of the bilateral handled sippy cup, biting and speaking while tipping the sippy cup to her mouth, spilling the liquids and saturating her shirt from the neck line to her waist. At 9:34 AM CNA #4 transported the resident from the common area to her room to change her shirt. During an interview on 7/20/18 at 9:35 AM, CNA #4, stated the resident could feed herself because she insisted on holding onto the cups. The resident spilled liquids on herself frequently. Sometimes a chair pad (an absorbent pad, usually used on chairs to protect the seat of the chair from liquids) would be placed under the residents clothing protector during meals to prevent the resident's clothes from being saturated. The facility does not have a special liquid resistant clothing protector, therefore the resident's clothing often needed to be changed after meals because not everyone used a chair pad. During an interview on 7/20/18 at 9:43 AM, CNA #5 stated the resident was an extensive assist with meals but did not need to be continually assisted with the liquids because the resident insisted on independently holding the sippy cups. The resident spilled liquids on herself all the time and her clothing becomes soiled. During an interview on 7/20/18 at 9:47 AM, CNA #6 stated she set up the four sippy cups with liquids after she fed the resident the solid foods because the resident can be left alone to independently drink. The resident always spilled liquids on herself because she chews the sippy cup while she is trying to drink. During an interview on 7/20/18 at 10:00 AM, CNA #7 stated the resident always spilled liquids on herself and someone should stay with the resident so she doesn't spill on herself. Additionally, sometimes she placed a chair pad under the cloth clothing protector, to prevent her shirt from becoming saturated. During an interview on 7/20/18 at 10:21 AM, Registered Nurse (RN #1) Nurse Manager (NM), stated the resident spilled liquids on herself frequently because the resident insisted on independently holding the sippy cup. The resident bites the cup and talks while trying to drink causing the liquids to spill onto her shirt. Sometimes a chair pad or chux (an absorbent / liquid proof disposable product) was used under the cloth clothing protector to protect her clothing from being soiled but it was not consistently used, therefore her shirt needed to be changed frequently because of soiling. The resident doesn't require constant assistance with liquids, but it is a dignity issue if she is frequently saturating her clothing from spilling the liquids during meals. RN #1 stated she will further discuss the level of assistance, cup options and liquid resistant clothing protectors with the therapist. During an interview on 7/20/18 at 1:57 PM, the Occupational Therapy (OT) Department Director stated the staff should have stayed with the resident while she was drinking to help minimize the spilling of the liquids. During an interview on 7/24/18 at 9:52 AM, the Director of Nursing (DON) stated spilling and saturating clothing at meals was a dignity issue. The DON stated the staff were trying to maintain the resident's dignity by using something, but was not aware the CNAs were using chair pads. She further stated a more appropriate clothing protector to prevent the resident's clothing from becoming saturated should be provided and on the care plan for staff. 415.5 (a)