Every finding on record at Oceanview Nursing & Rehabilitation Care Center

Based on observation, record review, and interviews conducted during the abbreviated survey (NY00353729), the facility failed to ensure the resident was free of significant medication errors. This was evident for one (1) out of three (3) residents sampled (Resident #1). Specifically, on 09/06/2024, Licensed Practical Nurse #1 administered 150 milligrams of Methadone instead of 35 milligrams of Methadone to Resident #1. Resident #1 was alert and stable with no complaints of pain or discomfort and was escorted for scheduled hemodialysis therapy. The findings are: The Facility Policy and Procedure titled Medication Administration, dated August 2023, documented the purpose of the policy is to ensure that residents receive medications in a safe and efficient manner and to avoid medication errors include wrong resident, wrong dose and wrong time. The Facility Policy and Procedure titled Medication Administration, reviewed and updated September 2024, included details of the five rights for prevention of medication errors and specifies the facility's hours of medication administration. The Facility's Occurrence Investigation dated 09/06/2024, documented on September 6, 2024, Licensed Practical Nurse #1 administered medications to Resident #1 which included Methadone liquid, at approximately 8:00 AM prior to going to dialysis. Resident #1 left the facility for dialysis without any complaints. Resident #1 was admitted to the facility with a diagnosis of End Stage Renal Disease, Chronic Obstructive Pulmonary Disease and history of Opioid Use Disease. The Minimum Data Set (an assessment tool) dated 09/05/2024, documented Resident #1 as cogitatively intact but required assistance with most activities of daily living. A Physician Order dated order of 09/04/2024, for Resident #1 was Methadone Intensol, 10 milligrams per milliliter oral concentrate, give 3.5 milliliters/ 35 milligrams by oral route once daily. Scheduled every day at 9:00 AM. Medication Administration Records of Resident #1 dated September 6, 2024, documented Licensed Practical Nurse #1's signature indicating Methadone solution was administered by Licensed Practical Nurse #1. A Baseline Care Plans dated 09/03/2024, documented intervention to offer all medications as prescribed by the Medical Doctor. A Progress note 09/06/2024 at 10:40 AM, written by Registered Nursing Supervisor #1 documented on 09/06/2024 at approximately 9:00 AM, Licensed Practical Nurse #1 reported Resident #1 received the wrong dose of Methadone. Resident #1's dose was 35 milligrams liquid methadone daily but was given a dose of 150 milligrams that belonged to Resident #2. Resident #1 was picked up at 8:09 AM, and transported to the center for hemodialysis. Nurse Supervisor #1 informed the dialysis center of the medication error. Resident #1's adult child (the Complainant), the attending physician, and the social worker were informed. A Progress Note date 09/06/2024 at 8:53 AM, written by Registered Nurse Supervisor #2 documented Resident #1 went to hemodialysis at 8:09 AM, transported by ambulette. Blood Pressure was 80/54, Temperature was 97.2 degrees Fahrenheit and Respirations were 18. Resident was alert and responsive. Licensed Practical Nurse #1 left the faciity on [DATE], without providing the facility with a written statement and did not return to the facility. During a telephone interview on 02/14/2025 at 3:37 PM, the Attending Physician #1 at the nursing home stated Resident #1 was in the facility for three days with several comorbidities and therefore there was a potential that a higher dosage of Methadone could impact Resident #1 clinical status. Narcan was available that could have been given, if it was known that the Resident #1 received the higher dosage before leaving for dialysis. The resident was transferred to the hospital from the dialysis center and was no longer under the care of the nursing home attending physician. During an interview on 2/14/2025 at 2:37 PM, Nurse Supervisor #1 stated on 09/06/2024 at about 9:00 AM, Resident #2, who is on Methadone informed them someone was taking their Methadone. Licensed Practical Nurse #1 informed Nurse Supervisor #1 the wrong dose was given to Resident #1. Resident #1 had already left for dialysis. The Director of Nursing was informed, the dialysis center was called, but Resident #1 had not yet arrived at the center. Nurse Supervisor #1 also stated the methadone was stored in each resident's individual bag and is locked in a cabinet separate from other narcotics. The liquid in the bottles of methadone is visible and the resident's name is at the top of the bottle. During an interview on 2/14/2025 at 3:20 PM, the Director of Nursing stated Registered Nurse Supervisor #1 notified them of the medication error, and an investigation was started immediately. Methadone medication bottles are labelled by the clinic the resident usually attends in the community. The Director of Nursing stated they requested Licensed Practical Nurse #1 to write a statement before leaving on 09/06/2024 but it was not done. A verbal statement written by the Director of Nursing stated Licensed Practical Nurse #1 was unsure which name was seen on the bottle of Methadone from which Resident #1was given the Methadone. During a telephone interview on 2/20/2025 at 4:36 PM, Licensed Practical Nurse #1 responded and identifying themselves as Licensed Practical Nurse #1, but after being informed of reason for the call, they ended the call. 10 NYCRR 415.11(c)(3)(i) Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance with this specific regulatory requirement on 09/19/2024, prior to and during the time of this survey. A Plan of Correction was not required for this citation. The facility took corrective actions and was found to be in substantial compliance prior to the surveyor's onsite visit on 2/14/2025. The facility immediately called the dialysis center and informed them of the medication error as the resident was already in transit to the center. Licensed Practical Nurse #1 was removed from the schedule and their agency contacted. Office of Professions was notified. The Policy on Medication Administration in effect on September 6, 2024, was revised and updated. The Facility provided in-service to all Registered Nurses and Licensed Practical Nurses on the five Rights of medication administration on 9/6-9/18/2024, and was ongoing for any new staff. The facility performed Audits of Medication Records weekly for eight weeks and no issues were identified. Audits were done monthly for three months and there were no irregularities. A Quality Assurance Performance Improvement Meeting was held 9/19/2024 to discussed methadone and medication administration. Four Licensed Practical Nurses and three Registered Nurses stated that they are knowledgeable about the Medication Administration Policy and the five rights to prevent medication errors. There were no further reported medication errors.

Based on observation, record review, and interview during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure maintenance services necessary to maintain a sanitary, orderly and comfortable interior were provided to the residents. This was evident during environmental observation. Specifically, resident rooms were observed with mismatched paint, uneven floor, and ripped door kick plate, mattress in disrepair, and broken side tables. The findings include but are not limited to: The facility's undated policy titled Environmental Services documented it is the policy of the facility to safely and properly clean floor surfaces, the purpose of the procedure was to provide guidelines for cleaning and disinfecting resident rooms. The policy documented housekeeping surfaces, including tabletops, will be cleaned on a regular basis when spill occurs and when these surfaces are visibly soiled. During observation on 03/02/2025 between 10:00 AM and 2:00 PM and on 03/07/2025, the following were observed: 1. [NAME] Wing room [ROOM NUMBER] had a ripped door kick plate, with the first half of the panel missing. 2. [NAME] Wing room [ROOM NUMBER] had mismatched paint and stained and uneven floor. 3. Resident's Main dining room had uneven floor and floor tiles were discolored. 4. East Wing room [ROOM NUMBER] had unpainted walls, and bedside table was in disrepair. 5. East Wing room [ROOM NUMBER] had broken and worn looking bedside tables, and mattress in disrepair. 6. The baseboard in the hallway and the porter's closet were observed with dirt and grime. The Maintenance and Housekeeping logbook showed no documentation of repairs needed in [NAME] Wing room [ROOM NUMBER], #18, and in the resident's Main Dining room. On 03/07/2025 at 9:41 AM, during environmental rounds with the Surveyor, the Director of Housekeeping and Maintenance stated terminal cleaning is performed on a daily basis, cleaning 2 rooms per day in each unit. They stated they were waiting for the resident in room [ROOM NUMBER] on the East Wing to get out of bed before they paint the wall. The Director stated they swap the old bed side tables when in disrepair and that they change the mattress, if needed, during terminal cleaning. They stated they were in the process of doing a building refresh program when the State Surveyor walked in for survey. On 03/07/2025 at 11:33 AM, the Director of Housekeeping and Maintenance was interviewed and stated they were in the process of cleaning and replacing the tiles when the State Surveyors walked in. The Director stated the missing half panel of the door kick plate will be replaced and that the rooms with uneven floors and discolored tiles will be replaced with new ones to match the rest of the floor. On 03/07/2025 at 11:45 AM, the Administrator was interviewed stated repairing and fixing is a big challenge for them since the facility is an old building. They stated they will do what is right for the residents because this is the residents' home, and the environment should be taken care of properly. The Administrator stated they will make sure the concerns will be corrected. 10 NYCRR 415.5(h)(2) 44864

Based on record review and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the facility reported short staffing on weekends for the quarter of July- September 2024 which was confirmed by a review of the Weekend Staffing and the Payroll Based Journal Staffing Data Report. The findings include but are not limited to: The facility policy titled Staffing Guidelines with a last reviewed date of 09/2024 documented that the facility will promote resident quality care and safety by ensuring adequate and competent staffing levels that are based on the facility assessment. The Payroll Based Journal Staffing Data Report for the 4th quarter of 2024 (07/01/2024 to 09/30/2024) documented excessively low weekend staffing was triggered. The Facility Assessment Tool which was last updated on 01/07/2025 documented a facility capacity of 102 residents with a staffing plan by shift as follows: Day shift by units (7:00 AM - 3:00 PM) East Wing: 1 Registered Nurse, 2 Licensed Practical Nurse and 5 Certified Nursing Assistants West Wing: 1 Registered Nurse, 2 Licensed Practical Nurse and 5 Certified Nursing Assistants Evening Shift by Unit: (3:00 PM - 11:00 PM) 1 House Registered Nurse East Wing: 2 Licensed Practical Nurse and 3 Certified Nursing Assistants West Wing: 2 Licensed Practical Nurse and 3 Certified Nursing Assistants Night Shift by Unit: (11:00 PM - 7:00 PM) 1 House Registered Nurse East Wing: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants West Wing: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants The facility assessment does distinguish that on the weekends there is 1 House Registered Nurse for each shift while the number of Licensed Practical Nurses and Certified Nursing Assistants remain the same. Review of the actual weekend facility staffing schedule from 07/01/2024 to 09/30/2024 documented the following: On 07/06/2024 on the 3:00 PM - 11:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the [NAME] Wing. On 07/07/2024 on the 3:00 PM - 11:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the [NAME] Wing. On 07/13/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing. On 07/13/2024 on the 3:00 PM - 11:00 PMshift, there was a shortage of: 1 Licensed Practical Nurse on the [NAME] Wing. On 07/14/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 2 Certified Nursing Assistants on the East Wing and 1 Certified Nursing Assistant on the [NAME] Wing. On 07/14/2024 on the 3:00 PM - 11:00 PM shift, there was a shortage of: 2 Certified Nursing Assistants on the East Wing On 07/21/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing and 1 Certified Nursing Assistant on the [NAME] Wing On 07/27/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing On 08/3/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing and 1 Certified Nursing Assistant on the [NAME] Wing On 08/4/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the [NAME] Wing On 08/4/2024 on the 11:00 PM - 7:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing On 08/10/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the East Wing On 08/10/2024 on the 3:00 PM - 11:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the [NAME] Wing On 08/11/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse and 1 Certified Nursing Assistant on the East Wing On 08/17/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the [NAME] Wing On 08/17/2024 on the 11:00 PM - 7:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the [NAME] Wing On 08/18/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the East Wing and 1 Certified Nursing Assistant on the [NAME] Wing. On 08/18/2024 on the 11:00 PM - 7:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing On 08/25/2024 on the 11:00 PM - 7:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the [NAME] Wing On 09/01/2024 on the 7:00 AM - 3:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the [NAME] Wing On 09/01/2024 on the 3:00 PM - 11:00 PM shift, there was a shortage of: 1 Licensed Practical Nurse on the [NAME] Wing On 09/21/2024 on the 3:00 PM - 11:00 PM shift, there was a shortage of: 1 Certified Nursing Assistant on the East Wing. On 03/02/2025 at 10:00 AM, Resident #67 was interviewed and stated it takes too long for the staff to come when they ask for assistance. On 03/02/2025 at 2:05 PM, Resident #32 was interviewed and stated the facility does not have enough staff and they wait a long time for assistance, especially at nights. 03/05/2025 3:39 PM, Certified Nursing Assistant #4 was interviewed and stated they work from 3:00 PM to 11:00 PM on the weekends and are assigned 15 residents. They stated there are 3 aides usually assigned on their shift but when there are call outs, they get assigned more residents. On 03/06/2025 at 2:40 PM, Certified Nursing Assistant #5 was interviewed and stated they work 7:00 AM to 3:00 PM on weekends and are assigned around 11 residents regularly. Certified Nursing Assistant #5 stated there are times when there is staffing shortage in the weekends at which time they will be assigned 14 residents. On 03/06/2025 at 3:10 PM, the Staffing Coordinator was interviewed and stated they were hired in September 2024 and at that time they were informed that there was a slight staffing shortage in the 11:00 - 7:00 PM shift for both weekdays and weekends. They stated staffing shortages occur on the weekends due to call outs. On 03/07/2025 at 10:57 AM, the Director of Nursing was interviewed and stated that they do the best they can to maintain staffing levels. They stated they were not aware of low weekend staffing between July to September 2024 or that the Payroll Based Journal was triggered for low weekend staffing for that quarter. Director of Nursing Services #1 further stated that the Administrator is primarily responsible for Payroll Based Journal Submission. On 03/07/2025 at 3:07 PM, the Administrator was interviewed and stated they were aware Payroll Based Journal was triggered for low staffing but is unsure as to why. Administrator #1 stated the staffing levels have not changed much and that in fact, it has improved compared to the previous years at which time the facility was not triggering this low. The Administrator further stated that since the Centers of Medicare Services updated the measures in the middle of 2024, the facility has been triggering worse even though staffing levels have not changed. They stated staffing for the weekends and weekdays is generally the same, however, there may be call outs during the weekend. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, record review, and interviews during Recertification Survey conducted from [DATE] to [DATE] the facility did not ensure safe food storage was practiced. This was evident during Kitchen Observation. Specifically, outdated food items were observed in the kitchen refrigerator. The findings are: The facility's policy titled Storage and Holding Timeframe for Food Items with a last reviewed date ,d+[DATE] documented to ensure safe food consumption, food items will be dated, placed in a container and if not consumed will be discarded. During the initial tour of the kitchen on [DATE] from 10:00 AM to 10:30 AM, the following expired items were observed stored in the kitchen refrigerator: 1. Dietary prepared snack of 20 plastic cups of 4 ounces cottage cheese with a labeled date of [DATE]. 2. 8 plastic cups of 4 ounces skim milk with a labeled date of [DATE]. 3. 4 plastic cups of 4 ounces cut pears with a labeled date of [DATE]. 4. 20 plastic cups of 4 ounces cranberry juice with a labeled date of [DATE]. On [DATE] at 11:08 AM, Dietary Aide #1 was interviewed and stated that outdated food items were overlooked and should have been discarded. On [DATE] at 12:13 PM, the Dietary Supervisor was interviewed and stated they had not worked for 2 days and had not realized they have outdated or expired residents' snacks in the refrigerator. They stated expired food are health hazard and should not be consumed. 10 NYCRR 415.14 (h)

Based on observation, record review, and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure the resident's right to be treated with respect and dignity was maintained. This was evident in 2 (Resident #32 and #40) of 23 total sampled residents. Specifically, 1.) Resident #32's urinary drainage bag was not placed in a dignity bag (a bag used to the cover and hold the catheter drainage/collection bag, so it is not visible) and was visible from the hallway, and 2.) Licensed Practical Nurse #2 remained standing while feeding Resident #40. The findings are: The facility's policy titled Promoting/Maintaining Resident Dignity with a revised date of 07/2024 documented it is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. The facility's policy titled Foley Catheter Management with a last revision date of 01/2024 documented that privacy bags should be always provided. 1. Resident #32 was admitted to the facility with diagnoses of Cerebrovascular Accident and Seizure Disorder. The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #32 had intact cognition and had an indwelling catheter, Resident was dependent for bed mobility. A Comprehensive Care Plan for urinary incontinence and indwelling catheter was initiated on 03/30/2022 and was last reviewed on 06/01/2025. The facility interventions include to observe for changes in continence status. During observation on 03/02/2025 at 1:59 PM, 03/03/2025 at 8:57AM, and on 03/04/2025 at 8:46 AM, Resident #32 was observed in bed in their room with their urinary catheter drainage bag uncovered and hanging on the bed frame. The urinary drainage bag was visible to people passing in the hallway. On 03/04/2025 at 8:46 AM, Certified Nursing Assistant #1 was interviewed and stated Resident #32 was in their assignment. They stated they thought the urinary dignity bag is only used when resident is out of bed. On 03/04/2025 at 8:51AM, Registered Nurse #1 was interviewed and stated Resident #32 should always have the urinary drainage bag must be inside a dignity bag and that the staff are aware of this. On 03/07/2025 at 12:19 PM, the Director of Nursing was interviewed and stated that dignity bags must always be used for residents with urinary catheters, whether resident is in bed or on the chair. Surveyor: [NAME], [NAME] 2. Resident #40 was admitted with diagnoses that include Dysphagia following Cerebral Infarction, Major Depressive Disorder, and Non-Alzheimer's Dementia. The quarterly Minimum Data Set assessment dated [DATE] documented that Resident #40 had moderately impaired cognition required total assistance of one-person for eating. The physician orders dated 02/09/2025 documented Resident #40 was on comfort care and needs total assistance in eating to prevent food aspiration secondary to diagnosis of Dysphagia. During observation on 03/02/2025 at 11:32 AM, Licensed Practical Nurse #2 was observed standing next to Resident #40 while spoon feeding the Resident. Resident #40 had their head raised to catch the food. On 03/06/2025 at 10:54 AM, Licensed Practical Nurse # 2 was interviewed and stated Resident #40 needs total assist with meals and is spoon fed. They stated they were standing while they spoon fed Resident #40 and knew this was inappropriate. On 03/07/2025 at 11:01 AM, the Director of Nursing was interviewed and stated staff should be seated next to the resident while spoon feeding them to ensure appropriate precaution is observed and dignity is preserved. 10 NYCRR 415.3(a) 44472

Based on observation, record review, and interview during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services, including provision of equipment, to prevent further decline in range of motion. This was evident in 1 (Resident #41) of 2 residents reviewed for positioning / mobility out of 21 total sampled residents. Specifically, Resident #41 was observed multiple times without a left-hand roll in place as per physician's order. The findings are: The facility's policy titled Adaptive Devices with a last reviewed date of 10/2023 stated it was the policy of the facility to provide adaptive devices to its residents. All adaptive devices with current orders with physician and nursing staff will be picked up by nursing staff and entered to the Certified Nursing Assistant Accountability with correct don/on/off devices with appropriate wearing schedule. Resident #41 had diagnoses of Huntington Disease, Dementia, and Depression. The Minimum Data Set assessment dated [DATE] documented that Resident #41 had moderately impaired cognition and was dependent in all areas of activities of daily living. The assessment also documented that Resident #41 had and an impairment on one side of the upper extremity. A care plan with focus on restorative nursing rehabilitation was initiated for Resident #41 on 04/24/2024 and was last reviewed on 3/02/2025. The facility interventions included left hand roll to be worn at all times except for skin check and hygiene. A physician's order dated 10/31/2024 and was last renewed on 03/01/2025 documented orders for left hand roll to be worn at all times except for skin check and hygiene. During multiple observations on 03/03/2025 at 1:09 PM, on 03/03/2025 at 3:00 PM, on 03/04/2025 at 12:03 PM, and on 03/04/2025 at 1:45 PM, Resident #41 was observed without a left-hand roll in place. On 03/04/2025 at 1:46 PM, an interview was conducted with Certified Nursing Assistant #8 who was assigned to Resident #41. Certified Nursing Assistant #8 stated they started working with Resident #41 about one month ago and that Resident #41 is totally dependent for care. Certified Nursing Assistant #8 stated they did not apply the left-hand roll and does not know where it was. On 03/04/2025 at 1:54 PM, Registered Nurse #1 was interviewed and stated Resident #41 is fully dependent on activities of daily living and requires extensive assistance. Registered Nurse #1 stated Resident #41 was prescribed a left hand roll due to left hand stiffness. They stated staff are to document and sign off when they place the device on the hand of the Resident. On 03/04/2025 at 2:40 PM, the Director for Rehabilitation was interviewed and stated that Resident #41 had tightness in their left hand and was prescribed a hand roll. They stated they observed Resident #41 earlier in the day without a left-hand roll applied, and they placed a new hand roll on the left hand. They further stated Certified Nursing Assistants are responsible for putting the hand roll on. On 03/07/2025 at 11:09 AM, the Director of Nursing was interviewed and stated if the left-hand roll is not in place for Resident #41, Resident #41 may develop contractures which can worsen over time. The Certified Nursing Assistants are responsible for applying the left-hand roll. The Registered Nurses and Licensed Practical Nurses on the unit are responsible for ensuring that the Certified Nursing Assistants are applying the device. 10 NYCRR 415.12 (e)(2)

Based on observation, record review, and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that a therapeutic diet was provided when there is a nutritional problem, and the health care provider orders a therapeutic diet. This was evident in 1 (Resident #3) of 2 residents reviewed for Activities of Daily Living out of 23 total sampled residents. Specifically, Resident #3, who had a physician's order for thickened liquid, was observed drinking juice without a thickener. The findings are: The facility's policy titled Thicken Up with a last revised date of 12/2024 documented that there are Thicken Up Instant Food Thickener on the trays based on Physician's, Dietician's, Nursing, and Speech Therapist evaluations of swallowing ability related to fluids. Thicken Up is ordered for those with swallowing issues for fluids. The facility's policy titled Activities of Daily Living with a last revised date of 11/2024, documented that nursing staff are in serviced upon new hire and as needed on following the plan of care. Resident #3 was admitted to the facility with diagnoses that include Anemia, Bipolar Disorder, Dysphagia, and Muscle Wasting. The Minimum Data Set assessment dated [DATE] documented Resident #3's cognition as intact, required moderate assistance for eating, and complained of difficulty or pain with swallowing. A Speech Therapist's progress note dated 01/28/2025 documented Resident #3 presented with anterior spillage when eating / drinking and coughing episodes with thin liquids. Recommended puree, honey thick liquids, skilled speech therapy services for dysphagia, and consistency modification. A Comprehensive Care Plan for dysphagia (impaired swallowing) was initiated for Resident #3 on 01/30/2025. The facility interventions include ongoing dysphagia assessment and treatment, and diet as ordered by the physician. A care plan notes dated 01/30/2025 by Registered Dietitian #1 documented Resident #3's diet was downgraded to pureed with moderately thick liquids as resident having difficulty time coordinating respiration and swallowing function. A physician's order dated 02/24/2025 documented the following dietary orders: Regular with pureed consistency and thickened liquids, mildly Thick 2 (Nectar). During dining observation on 03/02/2025 at 11:40PM, Resident#3's meal tray ticket documented nectar thick liquids, regular-puree. A packet of thickener and 3 cups of juice were observed on the tray. There was no staff observed putting thickener on Resident #3's juice. Resident #3 was observed on 2 occasions drinking juice without a thickener and started coughing. On 03/07/2025 at 12:53 PM, the Speech Language Pathologist was interviewed and stated that Resident #3 had orders for nectar thick liquid because Resident has dysphagia and is high risk for aspiration. On 03/07/2025 at 2:38 PM, Certified Nursing Assistant #2 was interviewed and stated it is the nurses' responsibility to put thickener on residents' drink. They stated thickener packets would usually be on the residents' tray, and they would notify the nurse who would put it in the residents' drinks. On 03/07/2025 at 2:45 PM, Licensed Practical Nurse #1 was interviewed and stated that nurses are responsible for thickening the liquids for residents on thickened liquids. On 03/07/2025 at 11:54 AM, the Director of Nursing was interviewed and stated that Certified Nursing Assistants are responsible for adding the thickener on the residents' drink when they serve the resident's meal tray. They stated all Certified Nursing Assistants received an in-service education and were trained that if there was a thickener on the tray, then it was supposed to be given. 10 NYCRR 415.12(i)(2)

Based on record review and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services Data System within 14 days after assessments were completed. This was evident in 5 (Residents #6, #41, #48, #88, #92) of 5 residents reviewed for Resident Assessment. Specifically, Minimum Data Set assessments were not transmitted within 14 days after the assessments were completed. The findings are: The facility's policy titled Minimum Data Set 3.0 Completion with a revised date of 05/2024 documented that submissions should be done according to the Resident Assessment Instrument manual and federal and state guidance. The Quarterly Minimum Data Set Assessment for Resident #6 was completed on 02/09/2025 and was transmitted to the Centers for Medicare and Medicaid Services Data System on 03/02/2025. The Quarterly Minimum Data Set Assessment for Resident #41 was completed on 02/06/2025 and was transmitted to the Centers for Medicare and Medicaid Services Data System on 03/02/2025. The Quarterly Minimum Data Set Assessment for Resident #48 was completed on 02/06/2025 and was transmitted to the Centers for Medicare and Medicaid Services Data System on 03/02/2025. The Quarterly Minimum Data Set Assessment for Resident #88 was completed on 02/06/2025 and was transmitted to the Centers for Medicare and Medicaid Services Data System on 03/02/2025. The Quarterly Minimum Data Set Assessment for Resident #92 was completed on 02/06/25 and was transmitted to the Centers for Medicare and Medicaid Services Data System on 03/02/2025. The facility's validation report dated 3/5/2025 documented that all 5 submissions were transmitted late. On 03/07/2025 at 12:14 PM the Director of Nursing was interviewed and stated they are currently the Minimum Data Set Coordinator and is responsible for submitting the Minimum Data Set assessments to the Centers for Medicare and Medicaid Services Data System. The Director of Nursing stated they are aware that the submissions were late, and that it was an oversight. 10 NYCRR 415.11

Based on observation, record review, and interviews during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure the daily nurse staffing information included all the required information. This was evident during review of the Staffing Task. Specifically, the daily posting of nurse staffing information did not include the total number of licensed and unlicensed nursing staff directly responsible for resident care. The findings are: The facility policy titled Staffing Guidelines with a last reviewed date of 09/2024 documented that the facility will post the nursing staff information including the census on a daily basis at the beginning of each shift. During multiple observations from 03/02/2025 through 03/03/2025, the nurse staffing information was posted on a door in the front lobby near the security desk. The information that was documented on the form included the facility name, date, resident census, and actual number of hours worked by licensed and unlicensed nursing staff. There was no documentation of the total number of licensed and unlicensed nursing staff directly responsible for resident care. 03/07/2025 10:22 AM, Staffing Coordinator #1 was interviewed and stated they are aware that the staff posting should include the total number of hours worked by Licensed Practical Nurses, Certified Nursing Assistant and Registered Nurses, in addition, to the actual hours worked by staff and the resident census. However, the Staffing Coordinator #1 stated that they never paid attention to the information on the staff posting as they are not primarily responsible for it. On 03/07/2025 at 12:00 PM, Registered Nurse #2 was interviewed and stated they were not aware that the total number of Registered Nurse, Licensed Practical Nurses and Certified Nursing Assistants that worked each shift should be included in the staff posting. On 03/07/2025 at 10:57 AM, the Director of Nursing was interviewed and stated they and Registered Nurse #2 are primarily responsible for the staff posting. the Director of Nursing stated they were not aware that the total number of Certified Nursing Assistants, Registered Nurses and Licensed Practical Nurses giving direct care should also be included on the staff posting. They stated they did not realize the guidelines had been changed and the total number of staff giving direct care was required to be posted. On 03/07/2025 at 03:07 PM, the Administrator was interviewed and stated that while they were aware the total number of hours worked by nursing staff should be listed on the staff posting, they were not aware that the total number of staff giving direct care should be included. 10 NYCRR 415.13

Based on record review and interview during the Recertification Survey conducted from 03/02/2025 to 03/07/2025, the facility did not ensure that the Medical Director consistently participated or attended the Quality Assurance & Performance Improvement (QAPI) meetings. Specifically, the Medical Director had not participated in 2 of the Quality Assurance & Performance Improvement (QAPI) and Quality Assessment & Assurance (QAA) meetings. The findings are: The facility policy titled Quality Assurance and Performance Improvement (QAPI) and Quality Assurance (QAA)with a last revision date of 12/04/2024 stated the purpose of Quality Assurance and Performance Improvement is to study, plan, analyze and validate specific areas of improvement for positive resident care outcomes. The committee members include Members of the Governing Board, Administrator, Medical Director, Director of Nursing Services, Infection Preventionist, Director of Rehabilitation, Director of Environmental Services, Director of Food Services/Dietary, Director of Social Services and Direct Care Staff. A review of the quarterly Quality Assurance & Performance Improvement meeting attendance Sheets showed no documented evidence that the Medical Director attended the meetings held on 08/21/2024 and 01/07/2025. On 03/07/25 at 02:17 PM, the Director of Nursing was interviewed and stated that the Medical Director would have signed the attendance sheet if they were present at the Quality Assurance and Performance Improvement meetings. On 03/07/2025 at 03:43 PM, the Administrator was interviewed and stated they invited the Medical Director on every Quality Assurance and Performance Improvement meetings. They stated the last time the Medical Director attended the meeting was on May 2024. The Administrator stated that the Medical Director could not attend one of the quarterly meetings due to scheduled cataract surgery. 10 NYCRR 415.15(a-c)

Based on observation, record review and interviews during an abbreviated survey (Case #NY00318543), the facility did not ensure a resident's rights to be free from involuntary seclusion. This was evident for one resident (Resident #1) of three residents reviewed. Specifically, on 07/06/23 at 12:45 AM, the Facility's Administrator observed Resident #1's room door was closed, and a plastic garbage bag was tied from the doorknob to the handrail in the hallway. Resident #1 was in the lock room. The Administrator initiated an investigation and reviewed the Facility's surveillance camera. The camera revealed that starting from 06/23/23, staff members used plastic garbage bags to keep Resident #1's room door locked. The staff members seen on the video were terminated. All staff were re-in-serviced on abuse, neglect, and mistreatment. The Findings are: The Facility's Policy & Procedure titled, Prohibition of Resident Abuse/Neglect, last reviewed 07/2023, defines Involuntary Seclusion as separation of a resident from other residents or from their roommate, or confinement to their room against the resident's will or the will of the resident's legal representative. The Facility's Incident Accident/ Report dated 07/06/23, documented that several staff members including housekeepers, nurses, and nursing assistants on the night shift from 06/23/23 to 07/05/23, were involved with using plastic garbage bags to lock Resident #1's room door. The plastic garbage bags were tied form Resident #1 s doorknob to the handrail in the hallway. Resident #1 was admitted to the facility with diagnoses of Dementia, Cerebrovascular Accident (CVA) and Schizophrenia. The Minimum Data Set (MDS-an assessment tool used to determine level of care) dated 06/22/23, documented Resident #1 was cognitively intact, required extensive assistance with most activities of daily living (ADL), and was ambulatory with unsteady gait. A surveillance camera footage without audio sound, reviewed on 09/12/23 at 02:39 PM, showed that from 06/23/23 to 07/05/23, two Housekeepers (HK), six Certified Nursing Assistances (CNA), and three Licensed Practical Nurses (LPN) were identified using plastic bags or observed others using plastic bags to tie Resident #1's doorknob to the handrail in the hallway. Resident #1 was locked in the room. A Post New Admission Progress Note dated 06/19/23, written by LPN #1 documented Resident #1 was alert, verbally responsive with confusion, noncompliant with safety measures, wandering on and off the unit without the wheelchair and spits on self. A Behavior Care Plan Activity Report effective 06/22/23, documented Resident #1's behaviors as restlessness, wandering on unit, spitting into hand, and wiping all over surfaces including nurse's desks, tables medication cart or any uncovered surfaces including walls, floors, and doors. The Behavior notes for the evening shift on 06/23/23, documented Resident #1wandering, verbally and physically abusive, socially inappropriate behaviors, spitting on hand wiping surfaces and resisting care. The Attending Physician's Orders June-July 2023 reveals no documented evidence of specific orders for monitoring Resident #1. During an interview on 09/13/23 at 05:00 PM, The Administrator stated during night observations on 07/06/23 at 12:45 AM, Resident #1's doorknob was tied with a plastic bag and attached to the handrail in the hallway. CNA #1 admitted to using the plastic bag to lock Resident #1's door. The decision was made to check the surveillance camera footage and it was observed that the use of plastic bag to lock Resident #1's room door occurred prior to 07/06/23. During a telephone interview on 10/18/23 at 10:18 AM, CNA #1 stated that the Administrator asked who was responsible for placing the plastic bag to Resident #1's room doorknob and the handrail, to keep the door shut on night of 07/05/23- 07/06/23, and CNA #1 responded yes they did. CNA #1 stated that, the facility does not believe in one-to-one monitoring of residents. The former Nurse Supervisor (RNS #1) was aware. CNA #1 stated that locking of Resident #1's door occurred prior to 07/05/23 - 07/06/23. Some residents wander at night and can be redirected or sit at the nurses' station and will be monitored. Resident #1 was not easily redirected and was verbally and physically abusive. Resident #1 was alone in the room and the staff check on the resident hourly to determine safety and whether the resident needed to be changed. CNA #1 was in-serviced on abuse and neglect and the actions needed to maintain the resident's safety. During a telephone interview on 10/15/23 at 03:45 PM, CNA #6 who worked on the day shift stated that they saw the plastic bag on Resident #1's door for the first time on that morning (does not recall exact day or date). CNA #6 stated they checked on the resident during observations although the resident was not assigned to them and they removed the bag, then listened to the request of another staff member (does not recall name) to replace the bag. Later heard that a night staff person was sent home for placing the bag on the door. During a telephone interview on 10/15/23 at 3:55 PM, LPN #3, stated they work on both east and west wings of the facility on the day shift. Stated, I did not see a plastic bag on the door when I went in the room with the CNA #6, the only thing I noticed that morning was that Resident #1 was not walking up and down the hallway as usual, I did not see when the bag was placed on the door. Stated also that plastic bags have been used to tie doorknobs of bathrooms when they are clogged to prevent the residents using it. Stated also that not allowing a resident to leave their room freely can be considered abusive. During an interview on 09/22/23 at 01:42 PM, HK #2 stated that housekeepers strip and wax the floor on the evening of 06/23/23. Stated that before the date and time for stripping and waxing the floors the housekeeping supervisor speaks with the Director of Nursing (DON) and the Administrator and the decision is made. The floor staff was notified in writing as to date and time the waxing and stripping will be done. Stated that they (HKs) were on the west wing from about 06:00 PM (evening shift). Resident #1 was sitting near the nurse's station and was told that that the floor was going to be stripped and waxed. The resident understood, got up and went to their room while calling us derogatory words. Does not recall seeing the night nurse supervisor while on the unit. Stated they both decided to tie the bag on the door as we knew the Resident #1 to be unpredictable and very difficult to redirect and we knew the resident would fall if the resident tried to leave the room into the hallway. Stated we completed the job and was leaving the floor about 12:30 AM or 01:00 AM. Stated we returned and saw LPN #1 and the LPN #1, said leave it, they would remove the bag. Stated that they were in-serviced on abuse and neglect but was never told or realized that closing the door and trying to protect the resident would be considered abuse or mistreatment. During a telephone interview on 10/24/23 at 12:12 PM, CNA #5 stated that they were seen on camera pulling Resident #1's chair into their room on the 11:00 PM- 07:00 AM shift. Stated they removed the resident from the hallway using their chair to the room because prior to that Resident #1 was seen licking everything and they decided the resident may be safer in their room. Denied placing a plastic bag on the resident's doorknob at any time, recalls removing the bag in the morning during their final observations. During an interview on 9/13/23 at 04:29 PM, the DON stated on 07/06/23 at 01:00 AM they were informed by the Administrator that CNA #1 admitted to tying the plastic bag on Resident #1's door and was immediately sent home. Resident #1 was assessed later that day, and there was no injury. Sibling was called and stated, as long as the person responsible was removed, they are ok. Also stated there were no other residents affected and a formal investigation was started. The new RNS (#2) stated they knew nothing about it and made a round at 11:45 and there no bag was seen. The investigation expanded and 11 staff members were suspended and later terminated. A facility wide re-in-service on abuse/neglect/mistreatment with competency questions and direct questioning of staff was done. A quality (QAPI) meeting was held 07/11/23, and determination made that RNS on all shifts are now required to sign a log for each round and minimum of three rounds required each shift. Stated unit staff have always been required to do hourly rounding, half hourly if a resident is at risk for elopement. Also determine that plastic bags will not be used to tie anything in the facility. A Plan of Correction was not required for this citation. The facility took corrective actions and was found to be in substantial compliance on 07/13/23, prior to the onsite visit on 09/12/23. Resident #1 was immediately assessed by the Director of Nursing (DON) on 07/06/23 and there were no injuries. Resident #1continued to receive psychiatric services. Medications were reviewed with recommendations made for adjustment of administration time to aid sleep. The Policy and Procedure on Abuse Prevention was reviewed on 07/11/23 and no changes was made. All Staff involved were suspended during investigation or moved to other unit or shifts during the investigation. They staff that involved were later terminated on 07/11/23. Facility wide re-education on Abuse/Neglect/Mistreatment/Behavior and seclusion policy was completed on 07/13/23. A quality QAPI meeting was held on 07/11/23 and Plan of Correction was discussed. Systemic changes in effect included the decision to have a minimum of three observations rounds to be done by RNS each shift, and documentation on rounds sheet to be completed after each observation round. No plastic bags to be used to tie anything in the facility. Staff competency testing was completed post in-services on Abuse/Neglect/Mistreatment. During interviews on 09/13/2023 to 10/02/2023, two LPNs, two RNS, four CNAs, and one Housekeeper stated understanding of the abuse policy and the definition of seclusion. 10 NYCRR 415.4

Based on observation, record review, and interview conducted during the recertification survey the facility did not ensure an effective infection prevention and control program. This was evident during review of the Legionella Plan and the [NAME] Unit during Medication Administration. Specifically, 1) there were no remediation plan put in place after greater than 30 percent samples tested for legionella were positive, and 2) blood pressure (BP) cuffs were not disinfected after use between Resident #81, #69, and #87. The findings are: The facility policy titled Infection Control Policy: Multipurpose Equipment Cleaning dated last reviewed October 2023 documented all multipurpose equipment must be cleaned and disinfected between resident use. The policy further stated cleanse multipurpose equipment with germicidal/antimicrobial disinfectant disposable wipe. 1) On October 6 2023, during the Annual Recertification survey of the facility, legionella testing results were reviewed from June 29 2023, and it was noted that thirty percent or more of the samples tested were positive. On October 6, 2023 at approximately 1:30 pm, in an interview with the Administrator, stated that contractor is due to come in on Monday (10/9) for further sampling and no further remediation was conducted up to present time. Surveyor: [NAME]-[NAME], Lyd 2)On 10/04/23 at 09:18 AM, Licensed Practical Nurse (LPN) #4 was observed using the BP machine on Resident #81 without sanitizing the BP cuff prior to placement on the resident's right arm. LPN#4 did not sanitize the BP cuff after use with Resident #81 and rolled the machine to Resident #69. LPN #4 placed the BP cuff on Resident #69's left arm, took their BP, did not sanitize the BP cuff, and moved on to Resident #87. LPN #4 did not sanitize the BP cuff and placed the cuff on Resident #87's left arm. On 10/04/23 at 10:00 AM, an interview was conducted with LPN #4 who stated they are supposed to clean the BP cuff in between each resident use. They have no excuse for not cleaning the BP cuff in between use with Resident #81, #69, and #87. On 10/05/23 at 03:10 PM, an interview was conducted with the Director of Nursing Services (DNS) who stated all medical reusable equipment such as BP cuffs are supposed to be cleaned after each resident use. The staff are all in-serviced on Infection Control Protocols and the need to clean the reusable equipment between use. 415.19(a)(1-3) 41709

Based on observation, interviews, and record review conducted during the Recertification survey of 10/2/23 through 10/11/23, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during the Kitchen observation. Specifically, items were observed stored undated and with opened packaging, observation of staff not washing hands or changing gloves before handling food after entering and exiting the walk-in refrigerator, and staff were observed not wearing facial hair coverings. The findings are: The facility's policy titled Labeling and Dating Stored Food, effective date 11/2008, review date 8/2023, states the procedure of How to Properly Store, Label and Date Foods in Various Areas of the Kitchen: keep all foods on shelves, off the floor, opened packages should be wrapped or otherwise sealed; refrigerators: always remove any leftovers of canned foods from the original container, transfer to a sealed container and label and date the container for storage; indicate the date on which a container, jar, etc. was opened; freezers: label (if packaging doesn't identify the contents clearly) and date all items. An undated document titled Dress Code, documents kitchen personnel must wear protective hair covering. An undated document titled Personal Hygiene How to Wash your Hands, documents when to wash your hands, including a handwritten notation immediately before on gloves, and after touching unclean equipment or work surfaces. A brief tour of the kitchen was conducted on 10/2/23 at 9:06AM with [NAME] #1. During the tour, the walk-in freezer was observed with a box of Morning Star bacon without a date, and an open box of Morning Star Veggie Sausage links in an open plastic bag, links exposed, and without a date. On 10/2/23 at 9:16AM, Dietary Aide (DA) #1 was observed exiting the walk-in refrigerator, wearing a pair of gloves, and observed returning to their workstation and started preparing cheese sandwiches. DA #1 was asked when they are supposed to wash their hands. DA #1 responded (via staff translator DA # 4, that they are supposed to wash their hands and then use gloves to touch everything. The State Agency (SA) told DA #1 that they were observed leaving the walk-in refrigerator and going back to their workstation, picked up a 6 paper plate, then 2 slices American cheese, without having replaced the gloves/or washing hands. A second tour of the kitchen was conducted on 10/5/23 at 11:29AM. [NAME] #2 was observed serving the lunch meal without covering their facial hair (beard and mustache). [NAME] #2 was asked at that time about the use of hair restraints to cover facial hair. [NAME] #2 responded that they were not aware of beard nets. DA #3 was also observed with facial hair without a cover. DA #3 was also asked about the use of hair restraints/rules for to cover hair, specifically facial hair (DA #3 was noted with a beard and mustache) DA #3 stated that they were told if it was trimmed, it is okay and does not need to wear a covering. An interview was conducted with the Food Service Director (FSD) on 10/5/23 at 11:33AM, who stated that it is policy and procedure to cover hair by using a net to cover hair; if they have beard and it is long, they have to cover it. The FSD further stated that when it is low cut then they do not need to cover it. 415.14(h)

Based on interview and record review, during the recertification survey 10/2/23 through 10/11/23, the facility did not ensure the individual financial record was made available to the resident and/or resident representative through quarterly statements. This was evident for 1 (Resident #61) of 2 residents reviewed for Personal Funds out of a sample of 25 residents. Specifically, there was no evidence quarterly statements were provided to a resident or their representative. The findings are: A facility policy and procedure titled Conveyance of Funds revision date 4/23 documented statements are prepared quarterly and provided to residents and/or their responsible parties. A Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #61 had moderately impaired cognition and was diagnosed with Non-Alzheimer's Dementia and Depression. On 10/02/23 at 9:34AM, an interview was conducted with Resident #61's next of kin (NOK) who stated that they do not receive a quarterly bank statement unless they ask for one. A Personal Needs Account (PNA) Ledger as of 10/2/23, documented resident #61 had a balance of $12,857.98. There was no documented evidence that the resident and/or their representative had been provided with a quarterly statement. An interview was conducted with the Director of Recreation (DR) on 10/4/23 at 3:08PM. The DR stated the business office provides a ledger with patient fund account information, including balances. The DR stated that they track withdrawals and send the information to the business office for updating. The statements are given quarterly or when asked for. The DR further stated that if the resident is not oriented, it goes to the representative on file. If they go to the representative, they will put the statement in an envelope and bring it to the business office to mail; the ledger comes preprinted with the address and it goes into a window envelope. An interview was conducted with the Comptroller on 10/4/23 at 3:57PM, who stated they get the statements from the Director of Recreation, already in the envelope, all they do is stamp it and mail it out. This is done every quarter. The Comptroller stated they do not have proof of mailing, as it is not sent out certified mail and no copies of the envelope are made. The Comptroller stated some are sent by email. They checked their computer records and did not find that a copy of an email documenting same for Resident #61. The Comptroller stated that the NOK sends in receipts for items that they have purchased, and the business office sends a check. The Social Worker is the one who is responsible or should be verifying the address. The Director of Recreation verified that the mailing address was correct. An interview was conducted with the Administrator on 10/4/23 at 4:40PM, who stated that personal funds quarterly statements, are sent to them by the outside billing company quarterly. They further state that the Comptroller gives the statements to the Director of Recreation who, along with the Social Worker, will distribute to the residents who can get it. If the resident is not competent/not oriented, it is mailed to the family. The Director of Recreation will give the statements to the business office in an envelope to mail. The Administrator further stated that if someone is telling us that they are not getting their statements, they would make sure that they got it. 415.26(h)(5)(i)

Based on observations, record review, and interviews during the Recertification survey conducted from 10/02/23 to 10/11/23, the facility did not ensure that a clean, comfortable, and homelike environment was provided to residents. Specifically, rusty brown color, dirty shower wall tiles, build up dirt in the bathroom tiles, were observed in resident's rooms, hallways, a urine odor in the common areas, debris on the floor, and a garbage bin overflowing. This was evident in multiple areas on the [NAME] Side unit. The findings are The facility policy and procedure titled, Daily General Cleaning -All Residents Areas last dated 11/2022 documented sweep all flooring using chemical treated mop, empty and clean all waste basket receptacles, damp dust daily. The policy further stated, after daily through cleaning, all residents areas will be polished periodically throughout the day. All floors will be mopped daily using a germicidal solution. During observations of the environment conducted on the [NAME] Side unit from 10/02/2023 at 10:17 AM to 10/10/23 at 10:14 AM, the following was observed : Room [NAME] 7 - bathroom floor was noted with build up dirt in between the tiles. Room [NAME] 19 - bathroom floor was noted with build up dirt in between the tiles. Room on the [NAME] side labeled Resident Shower Room in the hallway noted with rustic brown color in between the floor tiles. Left side of the shower wall noted very dirty. Shower wall tiles across the entrance door are filled with rustic brown dirt. Rustic marks seen where the water is turning off. Room located in hallway near the bathroom are [NAME] 5 and [NAME] 6 Residents bathroom in the hallway labeled Resident Rest Room, the bathroom floor was noted with build up black dirt between tiles and large rustic brown color area. Tiles noted with black residue on entrance to rest room and black dirt behind the door. 41709 Room [NAME] 5, observed the floor in room appeared dull with multiple blacken linear marks on the floor. Resident stated it could be cleaner. Strong urine odor noted in room especially the bathroom. An empty uncovered urinal observed on floor in bathroom. Open urinal observed on the handrail in the bathroom. room [ROOM NUMBER] on [NAME] Unit bathroom smell of urine open urinal hung on bathroom rail. Bathroom Floor with badge tiles in between the titles black built up dirt in all corners of bathroom and in-between tiles. The floor in room with multiple black scratch marks in all directions built up black dirt behind door with visible rat glue trap. Broken tile at the entrance of bathroom at the right corner. The [NAME] Side Unit with strong odor of urine despite surveyor wearing KN95 Mask. No specific resident observed smelling urine. All residents are out of bed and dressed in own clothing. Resident who remained in the room choose to stay in room watching TV. West Nurses station floor with rust color built up dirt under tables, computers keyboard with white built-up dirt visible between keys on keyboard, the floor with built up stuck on black dirt along all equipment edges resting on the floor and built-up dirt in all corners of nurses' station. room [ROOM NUMBER] [NAME] observed. The room floor contains black linear marks all over the floor. The small garbage bin under the sink was overflowing with plastic materials, blue gloves. One blue glove was observed on the floor in room next to the garbage bin. On 10/05/23 at 02:10PM, an interview was conducted with Housekeeper #1 (HK#1), for the [NAME] Side Unit. HK #1 stated they use green spray which is a 3 M disinfectant cleaner and disinfectant wipes to clean the unit. They clean the toilet with a brush and was trained to use the disinfectant cleaner with a mop to clean the floors. HK #1 is new to the facility and the floor has black multiple marks, was mopped, but the floor cannot be cleaned. HK #1 stated the mop was not able to clean the black dirt built in between tiles and stated they are not able to remove the dirt. They are not sure where the urine smell is coming from, but always clean the rooms every day at work. On 10/05/2023 at 2:14 PM, Housekeeper #2 was interviewed and stated, that during the day, the facility has four housekeepers. Two housekeepers on the East side and two housekeepers on the [NAME] side. As per HK #2, the cleaning supplies are not doing the job properly. Housekeeper #2 further stated that a meeting is already settle with the Director of Housekeeping and the housekeeping staff to come up with better cleaning supplies. On 10/05/2023 at 3:54 PM, the Director of Nursing (DON) was interviewed and stated that they are aware of the urine smell. They have a new housekeeping Director who started last August. The Director's plan is to strip and wax all the rooms to take away the smell. On 10/06/2023 at 10:45AM, the Director of Housekeeping was interviewed and stated that the housekeeping staff is aware of the smell and that we will be updating the cleaning materials. Housekeeping staff will also be updating through in-service, training, stripping and waxing the rooms. On 10/10/23 at 12:31 PM, an interview was conducted with The Administrator who stated the Director of Housekeeping is new and is making progress. . 415.5 (h) (2)

Based on observation, record review and interviews conducted during the Recertification survey conducted from 10/02/23 to 10/11/23,and complaint (NY00306641 ) survey, the facility did not ensure that a resident was free from financial abuse. This was evident for 1 of 3 residents reviewed for abuse in a sample of 25 (Resident # 155). Specifically, a resident complained that a staff borrowed money and has not paid back the loan. The finding is: The facility Policy and Procedure titled, Prohibition of Residents Abuse/Neglect and Misappropriation of Property with a revised date of 07/2023 documents, Residents have the right to be free from exploitation and misappropriation of property and neglect. The procedure documents, To comply with New York State and Federal regulations, provide patients/residents with considerate and respectful care which promotes independence and dignity in an environment free from abuse, mistreatment, neglect, exploitation and misappropriation of property. The policy defines Exploitation as The illegal or improper use of an adult funds, property assets or resources by another individual including but not limited to fraud, social media, false pretences, embezzlement, conspiracy, forgery, falsifying records, coerced property transfer of denial access of assets. Resident # 155 was admitted to the facility on [DATE] with diagnoses including: Anemia, Atrial Fibrillation, Hypertension, Schizophrenia, Malignant Neoplasm of the Stomach and Diabetes Mellitus. Resident was discharged from the facility to the community on 01/06/2023. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] identified the resident with a score of 12 on the Brief Interview for Mental Status (BIMS),with short and long term impairment. On activities of daily living (ADLs) needing assistance in most area of care like bathing, ambulation, transfer, mobility and dressing. Review of the Comprehensive Care Plan (CCP) dated 10/14/2022 on Victimization related to resident at risk for victimization due to congregate living. The goal set was resident will not experience any form of abuse or mistreatment and will report concerns to staff. For intervention: address resident concerns as they occur, encourage resident to voice any concerns to staff, observe for changes in mood, manner, behavior and observe resident during routine care and daily activities. Review of the Nurses notes from 10/01/2022 to 01/30/2023 reveals no documentation of resident's complaint of staff borrowing money. Review of the Social Worker (SW) notes from 10/01/2022 to 01/30/2023 reveals no documentation of resident's complaint of staff borrowing money. Review of the Accident/Incident report Summary of Investigation documented on 12/2/2022 at approximately 3:55 PM, the SW was informed by Resident #155 that a Certified Nursing Assistant (CNA) had borrowed money from her about a week ago and to this date the money had not been returned. During the SW interview Resident #155 stated, I was sitting in the hallway and CNA #3 asked for the money which I had on hand as I just got the money from my brother who came visiting. The SW asked why they gave the money and was told, I was trying to be nice. On 12/5/2022, CNA #3 was interviewed by the Director of Nursing (DNS) and stated, I did not take the money and I don't not know what the resident was talking about. A statement was written to the effect that CNA# 3 did not borrow or take any money from the resident. CNA #3 was sent home and told not to report for duty pending an investigation. On 12/06/2022, CNA # 3 rescinded their previous statement and rewrote a new statement in which they stated, I borrowed money from Resident #155. I was out with COVID for a week and when I returned, I gave the money back. CNA # 3 was terminated from service on 12/14/2022. On 10/06/2023 at 2:45 PM the Director of Nursing Services (DNS) was interviewed and stated, The 101st Police Precinct, covering the facility's area was called to report the incident. Police officers came and upon learning the complainant had some Psychiatric diagnoses, did not interview the resident. There was no report taken as the Police stated, This is an internal investigation. The CNA did not have a history of borrowing money and they have no knowledge of previous incidents of the CNA borrowing from residents. 415.4 ( b)

Based on record review and interview during the Recertification and Complaint survey (NY 00306641) ,the facility did not ensure all alleged violations involving abuse, neglect , including misappropriation of property were reported in a timely manner to the Department of Health. This was evidenced in 1 of 5 residents reviewed for abuse in a sample of 25. (Resident #155) . Specifically, a resident complained that a staff member borrowed money and has not paid back the loan. The finding is : The facility Policy and Procedure titled Prohibition of residents Abuse/Neglect and Misappropriation of property with a revised date of 07/2023 documented it is illegal to improperly use adult funds, property assets or resources by another individual including but not limited to fraud , social media , false pretences, embezzlement, conspiracy, forgery, falsifying records, coerced property transfer of denial access of assets . Resident # 155 was admitted to the facility on [DATE] with diagnoses : Anemia, Atrial Fibrillation, Hypertension, Schizophrenia, Malignant Neoplasm of the Stomach and Diabetes Mellitus amongst other . The Minimum Data Set (MDS) 3.0 assessment dated [DATE] identified the resident with a score of 12 on the Brief Interview for Mental Status(BIMS),with short and long term impairment. On activities of daily living(ADLs) needing assistance in most area of care like bathing, ambulation, transfer, mobility and dressing. Review of the Comprehensive Care Plan (CCP) dated 10/14/2022 on Victimization related to resident at risk for victimization due to congregate living. The goal set was resident will not experience any form of abuse or mistreatment and will report concerns to staff. For intervention: address resident concerns as they occur, encourage resident to voice any concerns to staff, observe for changes in mood, manner, behavior and observe resident during routine care and daily activities. Review of the Accident/Incident report Summary of Investigation documented, On 12/2/2022 at approximately 3:55 PM , the SW was informed by Resident #155 that a Certified Nursing Assistant (CNA) had borrowed money from her about a week ago and to this date. The money had not been returned. During the SW interview, Resident #155 related the incident as, I was sitting in the hallway and CNA #3 asked for the money which I had on hand as I just got the money from my brother who came visiting. The SW asked why she gave the money and stated, I was trying to be nice . On 12/5/2022 CNA #3 was interviewed by the Director of Nursing (DNS) and stated, They did not take the money and does not know what the resident was talking about. A statement was written to the effect that CNA# 3 did not borrow or take any money from the resident. CNA # 3 was sent home and told not to report for duty pending the investigation. On 12/06/2022 , CNA # 3 rescinded his previous statement and rewrote a new statement in which was stated I borrowed the money from Resident #155. I was out with COVID for a week and when I returned , I gave the money back. CNA # 3 was terminated from employment at the facility on 12/14/2022. On 10/06/2023 at 2:45 PM , the Director of Nursing (DNS) was interviewed and stated the incident was reported to the NYSDOH on 12/07/2022 and was not reported immediately because the DNS was still doing interviews and investigations. 415.4 (b)

Based on record review, observation, and staff interviews conducted during the Recertification survey of 10/2/23 through 10/11/23, the facility did not ensure that person-centered care plans (CCP) with measurable goals, time frames and interventions were developed to address a resident's concerns. This was evident for 1 of 4 residents (Resident #304) reviewed for Nutrition and 1 of 5 residents (Resident #36) reviewed for unnecessary medications, out of a sample of 25 total residents. Specifically, 1) a CCP was not developed for Resident #304 with liver cancer and hepatitis C, and 2) a CCP was not developed to address the care needs of Resident #36 with a Foley catheter. The findings are: The facility policy and procedure titled Comprehensive Care Plan (CCP) dated 5/23 documented all residents will have a CCP completed in accordance with federal and state requirements. The CCP will include measurable goals with time frames to meet the resident's medical, nursing, and psychosocial needs. 1. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #304 was cognitively intact and diagnosed with Liver cancer, Viral Hepatitis C, and Diabetes mellitus. Physicians' orders include megestrol 400 mg/10 mL oral suspension give 10 milliliters (400 mg) by oral route once daily dated 9/23/23 for malignant neoplasm of liver and Lenvima 4 mg capsule give 1 capsule by oral route every other day at the same time each day, dated 9/24/23 for Liver Cell Carcinoma. Based on record review, there was no evidence that a CCP was developed and implemented for the Resident #304's diagnosis of Liver Cancer and Viral Hepatitis C. An interview was conducted on 10/10/23 at 10:11AM with Registered Nurse (RN) #1, who stated that the night nurse starts the care plans and then they will go over it or the Director of Nursing (DNS) will go over it. RN #1 stated they check to make sure there are interventions and look at the resident's diagnosis and make sure there is a corresponding CCP. RN #1 was unable to produce a CCP related to Resident #304's liver cancer or hepatitis C diagnosis. An interview was conducted on 10/10/23 at 12:21 pm with the DNS who stated the 11-7 shift is responsible for initiating CCPs. The DNS makes sure that all the necessary care plans are in place. Resident #304 did not have a CCP for liver cancer and hepatitis in place and it was an oversight. 18881 2. Resident # 36 was admitted to the facility with diagnoses Anemia and Peripheral Vascular Disease. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented Resident #36 was moderately cognitively impaired and had a Suprapubic catheter. Review of the Physician order dated 09/18/2023 documented an order of Suprapubic catheter french 22 with 30 centimeter (cc) of normal saline (NSS) balloon for neuromuscular bladder dysfunction. Catheter care daily as per facility protocol . There was no documented evidence a CCP related to Suprapubic catheter was developed and implemented for Resident #36. The Director of Nursing (DNS) was interviewed on 10/05/2023 at 4:09 PM and stated CCPs are initiated by Registered Nurse (RN) in the unit. The DNS confirmed there is no catheter CCP for Resident #36 and there should be. 415.11 (c)(1)

Based on record review and interviews conducted during the Recertification and abbreviated survey of 10/2/23 through 10/11/23, the facility did not ensure that the comprehensive care plans (CCP) were reviewed and/or revised after each assessment and as needed. Specifically, a resident with a new order for a positioning device did not have their CCP updated for that intervention. This was evident for 1 of 1 (Resident #44) reviewed for limited range of motion (ROM). The findings are: The facility policy and procedure titled Comprehensive Care Plan (CCP), issue date 5/2015, review date 5/23, states all residents will have a CCP completed in accordance with federal and state requirements. The CCP will include measurable goals with time frames to meet the resident's medical, nursing, and psychosocial needs as identified in the Minimum Data Set (MDS). The CCP will be developed, reviewed, and revised by the interdisciplinary team as follows: initial admission, re-admission from hospital, quarterly after completion of MDS core elements, whenever a significant change occurs, special reviews, episodically, as plan of care changes and annually. Resident #44 was observed sitting in their room, in the wheelchair or in bed on 10/4/23 at 10:40AM, 10/5/23 at 10:10AM, and 10/6/23 at 10:01AM with a contracture on the left hand and no hand roll in place. The quarterly Minimum Data Set 3.0 (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 7/15 (severely impaired cognition), functional status requiring extensive assistance of 2 for bed mobility, transfer, and toilet use; extensive assistance of 1 for dressing, eating, and personal hygiene. The diagnoses include cancer, hypertension, cerebral vascular accident, and non-Alzheimer's dementia. A Physician's Order dated 9/15/2023 at 10:47AM indicates small gauze roll to be worn in left hand at all times except for hygiene and skin check. A CCP titled Contractures, last updated 8/31/23 documents resident has contractures. The goal is contractures will not increase in severity x 90 day. Interventions are to monitor for changes. There is no evidence that the CCP was reviewed and revised for the gauze roll order dated 9/15/23. On 10/10/2023 at 10:11 AM, Registered Nurse (RN) Supervisor #2 was interviewed and stated that the care plans are started by the night nurses then the day shift RN supervisor or the Director of Nursing will go over them. The RN supervisor further stated that for each diagnosis there is a corresponding care plan and the care plans are updated as needed. On 9/15/2023, a Physician order for hand roll was given for left hand contracture. The Resident's care plan on contracture was not updated to include the order for th left hand. 415.11(c)(2) (i-iii)

Based on observation, record review and staff interview, during the Recertification survey , the facility did not ensure that residents who need respiratory care, including tracheostomy care and suctioning are provided such care including supplies, as consistent with current professional standards of practice, the comprehensive care plan and resident's goal and preferences. It was observed there was no extra tracheal cannula on the resident's bedside. Furthermore, available supplies had an expiration dated of 2005, 2018 and ,d+[DATE] . This was evidenced in 1 of 1 resident investigated for respiratory care in a sample of 25. Resident #56. The finding is : The facility Policy and Procedure titled tracheostomy Care with a revision date of ,d+[DATE] on the purpose documented, Oceanview Nursing and Rehabilitation Center provides appropriate care for any resident presented with tracheostomy as prescribed by the physician, to maintain airway patency, maintain Infection Control standards and prevent skin breakdown at stoma site. Suction machine and suction equipment with appropriate size disposable inner cannula must be readily available at bedside. Resident # 56 was admitted to the facility with diagnoses including: Malignant neoplasm of the larynx, Cancer, Malnutrition, Depression, Asthma and Atrial Fibrillation. The Minimum data Set (MDS) 3.0 assessment dated [DATE] on activities of daily living documents- needing assistance and supervision, able to propel self with use of wheelchair and able to communicate with lip reading and nodding the head. On [DATE] at 4:00PM , resident was observed and spoken too in the room. A suction machine and suction kit was observed on the bed side table. On [DATE] at 3:24PM , the resident was observed again in their room. It was noted that there was no extra inner cannula kit available at bedside in case of an emergency. Review of the Physician orders dated [DATE] documented, Tracheostomy care, suction as needed, change ties as needed and tracheal care every shift and as needed (PRN) . Review of the Comprehensive Care Plan (CCP) on Respiratory care dated [DATE] documented, Resident requires tracheostomy due to inability to maintain airway due to Cancer. Goal set is that resident will remain free of signs and symptoms of infection and the interventions were: allay fear, answer call light promptly and ensure that emergency kit with secondary airway, ambu bag and suction machine present in the room, Evaluate and monitor lung sounds, signs and symptoms of respiratory distress, provide and monitor oxygen saturation and treatments as per physician's order. Pulmonologist consult as needed and use of aseptic technique when re-inserting tracheostomy tube . On [DATE] at 3;27 PM , Unit Registered Nurse Supervisor # 1 was interviewed and stated There has to be an extra shiley there on the bedside. The State Agent (SA), went back to the room and observed there was none available. RNS#1 stated, We have them available in my closet and in the nurses station. Observation of the supplies available reveals that the facility 5 tracheal cannula are all expired dated 2005 / 2018 and ,d+[DATE] . RNS #1 was further asked what is the size of the tracheal tube used and stated honestly speaking I don't know . RNS#1 further stated, We normally don't admit residents with tracheal care. I come in the morning and I suction the resident. If needed in the evening or night the licensed nurses will do it. 415.12 (k) (6)