Every finding on record at Ozanam Hall Of Queens Nursing Home Inc

Based on record review, and interviews conducted during survey the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards and practices. This was evident for one out of six residents (Resident #8). Specifically, Resident #8 reported to Assistant Director of Nursing #8 on 02/10/2025 that they were handled roughly on 02/07/2025 at approximately 10:15 AM by a Certified Nursing Assistant. The facility summary of investigation documented Resident #8 was assessed by Registered Nurse Supervisor #8 with no visible injuries and that Physician #8 was notified. The assessment was not documented in Resident #8's medical record. The findings are: The facility's policy titled 'Documentation in the Medical Record' dated 08/31/2023, documented licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in each resident's medical record in accordance with State laws and facility policy. Resident #1 was admitted to the facility with diagnoses including polyneuropathy (damage to the nerves in the body, causing muscle weakness and loss of balance), hypertension and major depressive disorder. The Minimum Data Set (a resident assessment tool) dated 02/11/2025 documented Resident #8 had intact cognition. A review of the Accident/ Incident Report dated 02/10/2025, revealed Resident #8 reported on 02/07/2025 at approximately 10:15 AM that Certified Nursing Assistant #8 walked into their room and said for them to hurry up they need to go to physical therapy, Certified Nursing Assistant #8 then grabbed them by their right wrist and yanked them out of bed. The facility's investigation dated 02/14/2025 revealed that the facility investigated the alleged allegation of abuse and concluded that abuse did not occur. According to the investigation Resident #8 was unable to identify Certified Nursing Assistant #8 and provided conflicting accounts of what happened. Resident #8 also reported that the abuse did not happen. According to the investigation, a head-to-toe assessment was done by Assistant Director of Nursing #8 and Resident #8 had no visible injuries. The police were called and arrived at the facility and interviewed Resident #8, Certified Nursing Assistant #8 and Resident #8 assigned Certified Nursing Assistant #10. After the interviews, no police report was filed, and no one was arrested. Certified Nursing Assistant #8 was suspended pending investigation outcome. An abuse care plan was initiated on 02/11/2025 with interventions for no male staff to be assigned to Resident #8. During an interview on 06/10/2026 at 4:00 PM, Social Worker #8 stated they visited Resident #8 on 02/10/2026 after receiving an allegation of abuse. Social Worker #8 stated that Resident #8 reported to them that a male rough handled them by squeezing and twisting their right wrist, then threw them into a chair and took them to a different floor (identified as rehab). Social Worker #8 stated they interviewed Resident #8 a second time on 02/14/2026 but Resident #8 appeared confused and stated that nothing happened. Social Worker #8 stated that they interviewed other residents on Resident #8's unit to determine if there were any other allegations of abuse and none was identified. Social Worker #8 stated they received in-service on abuse prior to the allegation and post allegation. Social Worker #8 stated they did not document their interview with Resident #8 because they had forgotten. However, they took notes and had their notes (on paper). During an interview on 06/10/2026 at 4:10 PM, the Director of Nursing stated that Resident #8 assigned Certified Nursing Assistant #10 asked Certified Nursing Assistant #8 to assist them with transferring Resident #8. They stated that Certified Nursing Assistant #10 and Certified Nursing Assistant #8 both stated they did not rough handled Resident #8. They stated Resident #8 had a head-to-toe assessment by Assistant Director of Nursing #8 and Resident #8 did not have any visible injuries. They stated that the physician and Resident #8's health care proxy was notified, and the police were called. They stated that the police did not file a report. They stated they suspended Certified Nursing Assistant #8 pending the investigation outcome. They stated the investigation concluded that abuse did not occur and Certified Nursing Assistant #8 had returned to work but later terminated for unrelated issues. They stated that Inservice was provided to all staff following the allegation of abuse. During a follow-up interview on 06/11/2026 at 2:30 PM, They stated that they checked Resident #8's medical record and there were no notes from nursing, social service or medical regarding the alleged allegation of abuse and assessment done. They stated that the assessment should have been documented in the resident's medical record. During an interview on 06/13/2026 at 3:30 PM the Medical Director stated if the medical provider assessed the resident after the allegation, they should have written a note in the resident's medical record. During an interview on 07/01/2026 at 4:00 PM, Resident #8 primary care physician stated they completed Resident #8's admission assessment on 02/07/2025 and that Resident #8 did not voice any complaints to them. They stated they do not recall any staff reporting to them that Resident #8 made an allegation and they do not recall conducting an assessment. They stated that an assessment and follow-ups would have been documented if they were notified. 10 New York Codes, Rules and Regulations 415.3.{e}{1}

Based on observations, and interviews conducted during the Recertification survey from 09/26/2024 to 10/03/2024, the facility did not ensure that residents are treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. This was evident for 6 (Residents #239, 106, 164, 160, 245 & 166) residents observed during the Dining Observation Task on Unit 6 and Unit 4. Specifically, 1). staff members were observed feeding residents (Residents #239, 106, 164, 160 & 245 ) while standing, and 2.) a resident (Resident #166) was observed in the dining room sitting at a table where another resident was served their lunch, and they were not served for an additional 30 minutes while the other resident ate at the table. The findings are: The facility policy titled Resident Rights-Promoting and Maintaining Resident Dignity During Mealtimes dated 03/16/2023, updated 03/21/2024 documented that it is the practice of this home to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. The policy also stated that all staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes; residents should be served one table at a time and all staff will be seated, if possible, while feeding a resident. 1.On 09/26/24 between 12:00 PM and 12:48 PM, on Unit 6, Resident #239 was observed seated in a Geri-chair in the hallway. Registered Nurse #3 was observed standing over Resident #239 while feeding them their lunch in the hallway. On 09/26/24 at 12:11 PM, Resident #106 was seated in a wheelchair in the Dining Room and Certified Nursing Assistant #1 was observed standing while feeding Resident #106. In addition, Certified Nursing Assistant #2 was also observed standing while feeding Residents #164 who was also seated in a wheelchair in the Dining Room. On 09/26/24 at 12:30 PM, Certified Nursing Assistant #3 was observed feeding Resident #160 while standing, and the Registered Nurse #3 was also observed standing and feeding Resident #245 in the Dining Room. On 09/26/24 at 12:35 PM, an interview was conducted with Certified Nursing Assistant #1 who stated that they always stand while feeding residents because the resident's chairs are too high. Certified Nursing Assistant #1 also stated that standing while feeding the residents will enable them to see the residents in case they are experiencing choking. On 09/26/24 12:43 PM, an interview conducted with Certified Nursing Assistant #2 who stated that they were aware that they have to sit to feed the residents, however they cannot sit because the resident's chairs are too high, and some of those chairs cannot be lowered. Certified Nursing Assistant #2 concluded by saying that maybe the facility needs to provide them higher chairs. Certified Nursing Assistant #2 could not recall if they had asked for another chair or complained to anyone at the facility about the chairs. On 09/26/24 at 12:48 PM, an interview was conducted with Registered Nurse #1 who stated that they have to elevate the resident's head and they supposed to sit down to feed residents. Registered Nurse #1 also stated that when elevating the head of the resident's chair they sometimes found it difficult to reach the residents. Registered Nurse #1 further stated that they did not see this as a concern as all the other staff was doing it. 40565 2. On 09/26/24 at 01:02 PM, Resident #166 was observed sitting at the table with another resident who had been served their lunch meal and was already eating, Resident #166 became angry after watching the other resident complete their meal while Resident #166 had still not been served their meal. Resident #166 stated that they had been waiting for their tray since 12 o'clock and had not yet been served so wanted to be taken out of the Dining Room. On 09/26/24 at 01:05 PM, Licensed Practical Nurse #2 was interviewed and stated that they were not aware that Resident #166 had not been served before they started feeding other residents in the dining room. On 09/26/24 at 01:10 PM, Registered Nurse #8 was interviewed and stated that they did not know what happened to Resident #166's ticket, but they will call for another ticket to ensure Resident #166 receives the correct meal. Registered Nurse #8 also stated that they did not observe that Resident #166 had not been served their meal while Registered Nurse #8 was monitoring the dining room. On 10/02/24 at 10:03 AM, the Director of Nursing was interviewed and stated that staff should not be standing up feeding residents and they have been trained that it is a matter of dignity to be at the same level with the resident to interact with them while feeding them. The Director of Nursing also stated that it is the responsibility of the nurses on the unit to ensure that staff are monitored to give appropriate care to the residents. There are also supervisors that make rounds to check them- The Director of Nursing stated that they were not sure why Resident #166's ticket was missing, but the staff could have removed Resident #166 from the dining room while their tray was being prepared. On 10/03/24 at 12:38 PM, the Administrator was interviewed and stated that they hold the dignity of the residents very high, and staff should not be standing when feeding the resident. The administrator stated that both agency staff and facility staff were given training when hired on how to respect the dignity of the resident. 10 NYCRR 415.5(a)

Based on observations, record review, and interviews conducted during the Recertification survey from 09/26/2024 to 10/03/2024, the facility did not ensure that residents were afforded the opportunity to participate in their care planning process This was evident for 1 (Resident #103) of 2 residents reviewed for Care Planning out of 38 total sampled residents. Specifically, Resident #103 or their representative were not invited to attend care planning meetings. The findings are: The facility policy titled Comprehensive Care Plan dated 02/09/2024, updated 03/21/2024 stated that the home will provide the resident and resident representative, when applicable, with advance notice of care planning conferences to enable resident/resident representative participation. Resident #103 was admitted with diagnoses that included Non-Alzheimer's Dementia, Malnutrition, and Psychotic disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented the resident had severe impairment in cognition and was dependent on staff for Activities of Daily Living. The Minimum Data Set assessment also documented that resident and family participated in assessment and goal setting. On 09/26/24 at 12:52 PM, Resident #103's representative was interviewed and stated that they had not been invited to any care plan meetings after the initial meeting in December 2023. On 10/02/24 at 09:37 AM, Registered Nurse #8 was interviewed and stated that the Social Worker is responsible for inviting residents and family members to the care plan meetings. On 10/02/24 at 11:42 AM, an interview was conducted with Social Worker #1who stated that they meet with residents and their family members only during initial, significant change and annual care plan meetings, and that residents and their family members are not invited to the quarterly meetings. Social Worker #1 also stated that they meet with the resident only during their quarterly review, and do not invite residents and their family for the quarterly care plan meeting. On 10/02/24 at 11:42 AM, the Director of Social Work was interviewed and stated that they invite resident and the family to initial, Significant change, annual, and discharge care plan meetings if it is separate from initial care plan meetings. The Director of Social Work stated that they only speak with the family over the phone for the quarterly review. On 10/03/24 at 12:10 PM, an interview was conducted with the Director of Nursing who stated that resident's care plan meetings are usually handled by Social Services, and when the resident's care plan meeting is due Social Services staff will notify the resident and the family members. The Director of Nursing stated that they do not know which care plan meetings the residents and their family members are invited to as it is the Social Services department that handles and organizes the meetings. The Director of Nursing further stated that they were of the impression that resident and resident family are invited to all care meetings, and they did not know that they were not being invited for the quarterly meetings. On 10/03/24 at 12:23 PM, the Administrator was interviewed and stated that resident and their families are invited for the initial, significant change and annual care plan meetings, but they have been having conversations with them for the quarterly assessment review since the COVID-19 pandemic. The Administrator also stated that they thought that family members would prefer this option, and they would meet with the residents and family if that is what they wanted. 10 NYCRR 415.3(f)(1)

Based on staff interview, observation and record review during the Recertification and Complaint Survey (NY00349107) conducted from 09/26/2024 to 10/03/2024, the facility did not ensure that injuries of unknown origin are reported immediately, but not later than 2 hours after the allegation is made to the New York State Department of Health. This was evident for 1 (Resident #148) of 5 residents reviewed for Falls out of a sample 38 residents. Specifically, Resident #148 was observed with discoloration of the chin and mouth of unknown origin which was not reported to New York State Department of Health. The finding is: Resident #148 was admitted to the facility with diagnoses which included Non-Alzheimer's' Dementia, Traumatic Brain Dysfunction, and Fracture of Nasal Bones. The Significant Change Minimum Data Set assessment dated [DATE] identified Resident #148 as severely cognitively impaired and able to make needs known, needed supervision of staff with Activities of Daily Living, including ambulation. The Nursing Progress note dated 08/18/2024 documented Resident #148 was visited by their child who noted discoloration of the resident's face. Resident #148 informed their child that they had had a fall. The note also documented that the Licensed Professional Nurse observed Resident #148 with discoloration to the lower lip measuring 2 centimeter by 1 centimeter and under the chin injury measuring 3 centimeter by 2.5 centimeter. The Quality Assurance Fall Investigation Statement Form dated 08/18/2024 documented that Resident #148's child reported that Resident #148 had fallen. The Summary of Investigation dated August 23, 2024, documented that Resident #148 was alert and oriented to person only, and had light reddish discoloration to the lower lip measuring 2cm x 1 cm and purplish discoloration under Resident #148's chin measuring 3 cm x 2.5 cm. The summary also documented that Resident #148, nor their child was able to state when and where a fall had occurred. The summary also documented that other nursing aides were interviewed and were unaware that Resident #148 had fallen. There was no documented evidence that the injury of unknown origin for Resident #148 was reported to the Department of Health as required. On 10/01/2024 at 4:24 PM, during an interview the Director of Nursing stated that the incident involving Resident #148 on 08/18/2024 was not called in because they did not consider that Resident #148 had experienced an injury. The Director of Nursing acknowledged that the Accident/Incident report documented that Resident #148 had discoloration to their lip and chin and could not explain how this had occurred, however the Director of Nursing did not think this incident needed to be reported as an injury of unknown origin. 10 NYCRR 415.4 (b)(2)

Based on observation, record review, and interviews conducted during the recertification survey from 09/26/24 to 10/03/24 the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain grooming, and personal hygiene. This was evident for 1 (Resident #43) of 6 residents reviewed for Activities of Daily Living out of 38 sampled residents. Specifically, Resident #43 was observed unkempt with brown, dirty looking clothing and also noted with a strong urine odor. The finding is: The facility policy and procedure titled Completing the Activity of Daily Living Support created 5/6/2022 stated that residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. The policy also stated that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. Resident #43 had diagnoses which included Dementia, Anxiety Disorder and Depression. The Minimum Data Set assessment dated [DATE] documented Resident #43 had impaired cognition and required partial or moderate assistance during shower/bathe, and also required supervision assistance during toileting. The Minimum Data Set assessment further documented that Resident #43 was incontinent of bowel and bladder. The Comprehensive Care Plan related to self-care performance deficit(s) limited mobility, communication deficits, Dementia with impaired cognition last updated on 08/06/2024, documented that the resident required partial and moderate assistance with bathing/showering, personal hygiene, and toileting. Interventions included bathing/showering and as necessary. The Registered Nurse progress note dated 07/20/24 documented that Resident #43 was alert and verbally responsive, assisted with some activity of daily living, refused shower this morning despite some encouragement from staff. The Registered Nurse Plan of Care progress note dated 08/06/24 documented that Resident #43 was confused, had activity of daily living functional deficit(s) related to limited mobility and unsteady gait. The progress notes also documented that Resident #43 refused showers. The Certified Nursing Assistant Task dated 09/01/24 to 10/02/24 documented that showers were provided two times a week. The Certified Nursing Assistant Task also documented Showering/Bathing prefers shower; Tuesday and Friday on 7-3 shift including fingernail care and shaving as needed. There was no documentation on the Certified Nursing Assistant Task that Resident #43 had refused shower. On 09/26/24 at 11:21 AM, during the initial tour of Unit 6, Resident #43 was observed in the room, unkempt with brown, dirty looking clothing and also noted with a strong urine odor. Resident #43's room was also noted with strong, stale smelling urine odor. Resident #43 was confused and unable to answer questions. On 09/26/24 at 12:08 PM, Resident #43 was also observed in a wheelchair in the hallway, and a strong urine odor was detected as Resident #43 passed by. The assigned Certified Nursing Assistant #5 was also passing by and was asked about Resident #43's strong odor. Certified Nursing Assistant #5 stated that Resident #43 always refused shower and would not let anyone enter their room. Certified Nursing Assistant #5 also stated that Resident #43 was last showered on Friday 09/20/24, and that the family member is aware of this behavior. Certified Nursing Assistant #5 further stated and there is nothing they can do about it when Resident #43 refuses to shower. On 09/27/24 at 09:53 AM, Resident #43 was observed in their room. The room was clean, and Resident #43 was observed to be wearing clean clothes. There was no urine odor detected. On 09/27/24 at 10:00 AM, a follow-up interview was conducted with Certified Nursing Assistant #5 and stated Resident #43 received shower this morning after they encouraged them to shower. Certified Nursing Assistant #5 also stated that they brought Resident #43 out of the room and had housekeeping staff clean the room. Certified Nursing Assistant #5 further stated that Resident #43 is scheduled to shower twice per week during the day shift, however Resident #43 had not been receiving shower due to Resident #43 refusing to shower. On 09/27/24 at 10:01 AM, an interview was conducted with Certified Nursing Assistant #9 who stated that they had been assigned to care for Resident #43 in the past and Resident #43 always refused care, especially showers. Certified Nursing Assistant #9 also stated that when Resident #43 was showered and given clean clothes, Resident #43 would remove clothing and put back on dirty clothing. The Certified Nursing Assistant #9 further stated that Resident #43 is very aggressive and always does not want people in their room. On 09/27/24 at 11:45 AM, an interview was conducted with Registered Nurse #2 who stated that Resident #43 refused care, and their child was aware of this behavior. Registered Nurse #2 also stated that Resident #43 will not let anyone in the room, has some psychiatric issues and is being followed up by the psychiatrist. Registered Nurse #2 further stated that Resident #43 will not cooperate with staff attempts to shower them despite all efforts. On 09/30/24 at 10:20 AM, Resident #43 was again observed in their room; the room was clean, and Resident #43 was also observed wearing clean clothes. On 10/01/24 at 12:23 PM, an interview was conducted with the Director of Nursing who stated that they were not aware that Resident #43 was not receiving showers as scheduled. The Director of Nursing also stated that Certified Nursing Assistants need to communicate and notify nursing supervisor if activity of daily living care cannot be provided. The Director of Nursing further stated that it is the unit nursing supervisor's responsibility to ensure that care is provided in accordance with the plan of care. 10 NYCRR 415.12(a)(3)

Based on observation, record review and staff interview conducted during the Recertification survey from 09/26/2024 to 10/03/2024, the facility did not provide an ongoing program to support residents in their choice of activities based on the comprehensive assessment and care plan and the preferences of each resident, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident. This was evident for 2 (Resident #347 and Resident #408) reviewed for Activities out of a sample of 38 residents. Specifically, Resident #347 and Resident #408 were observed on multiple occasions not engaged in any activity programs. The findings are: The facility policy and procedure titled Recreational Activities with a revision date of November 2022 stated that it is the policy of the facility to provide a comprehensive recreational program as part of the multidisciplinary care approach. The policy also stated that the programming, both facility-sponsored group and individual activities and independent activities is geared for the enhancement of the social, emotional, intellectual, physical, creative, and spiritual well-being of the resident population, in accordance with the psychosocial assessment of the resident. The policy further stated that activities are individualized and customized based on the resident's previous lifestyle. 1. Resident #347 was admitted to the facility with diagnoses that included Non-Alzheimer's Dementia and Cataracts. The Significant Change Minimum Data Set assessment dated [DATE] documented that Resident #347 had moderately impaired cognition and was dependent on staff for most activities of daily living and used a wheelchair for mobility. Section F Preferences for Customary Routine and Activities documented that it was very important for Resident #347 to listen to music they like and be around pets, and not very important to participate in religious services or practices. On 09/27/2024 at 10:15 AM, Resident # 347 was observed seated in a wheel chair asleep, positioned against the wall facing the Nursing station in on open hallway along with four other residents. A television on the wall on was playing a Catholic mass service. On 09/30/2024 at 2:30 PM, Resident #347 was observed in the Activity room seated on a wheel chair positioned against the wall facing the Nurses station, with no clear view of the program playing on the television. On 10/01/24 at 11:47 AM, Resident #347 was observed in the Activity Room seated in a wheel chair with several other residents watching news on the television. Resident #347 was positioned behind a wall which blocked the view of the television. In addition, the television volume was lowered making it difficult for anyone to hear or understand what was being said in the program. The Activities Admission assessment dated [DATE] documented that Resident #347 was interested in music, television movies and does not participate in spiritual activities. The Comprehensive Care Plan with focus resident is independent on staff for meeting emotional, intellectual, and social needs initiated 7/15/2024 included a goal of Resident will attend and participate in activities of choice when not in therapy. Interventions included invite the resident to scheduled activities and provide a program of activities that is of interest and empowers the resident by encouraging, allowing choice, self-expression, and responsibility. There was no documented evidence that Resident #347 had been engaged in any activities on the unit or provided with 1:1 visits from Recreation staff. 2. Resident #409 was admitted to the facility with diagnoses that include Atrial Fibrillation, Renal Insufficiency and Non -Alzheimer's Dementia. The Admission Minimum Data Set assessment dated [DATE] identified Resident #409 with moderately impaired cognition and required supervision and assistance from staff for Activities of Daily Living. The Admission Minimum Data Set assessment also documented in Section F Preferences for Customary Routine and Activities that it was very important for Resident #409 to have books, newspapers, and magazines to read, to listen to music they like, to do things with groups of people and do their favorite activities. On 09/27/2024 at 12:01 PM, Resident #409 was observed on Contact Isolation in a single bedded room. Resident #409 was observed seated in a Geri chair facing a television set on the wall that was not turned on. There was no radio available in the room. On 09/30/2024 at 01:37 PM, Resident #409 was interviewed and stated that they would like to receive newspapers, magazines, or books to read. Resident #409 also stated that no one had visited them or offered them newspapers or books to read. The television in the room was observed to be turned on at this time. The Activity Admission assessment initiated on 08/28/2024 documented that Resident #409 wishes to participate in activities in the facility, including group and independent activities. The Comprehensive Care Plan related to resident is independent for meeting emotional, intellectual, and social needs but dependent on staff for physical needs dated 09/02/2024 included a goal of resident will attend/participate in activities of choice when not in therapy. Interventions included introduce to other residents with similar background, interest and encourage and facilitate interaction, invite the resident to scheduled activities, provide a program of activities that is of interest and empowers the resident by encouraging, allowing choice, self-expression, and responsibility. There was no documented evidence that Resident #409 had been engaged in any activities on the unit or provided with 1:1 visits from Recreation staff. The Activity Calendars dated July 2024, August 2024, September 2024, and October 2024 included no activity program scheduled to occur on the 10th floor. On 10/01/2024 at 12:18PM, the Activity Director was interviewed and stated that the unit has no activity leader because this is a Rehabilitation unit, and residents are independent and can go to other units, stay in their rooms, or go to in the activity room on the unit where there is a television on. The Activity Director also stated that residents on this unit are asked if they want to attend any ongoing activities on other units. The Activity Director was asked for and was not able to provide any documentation that Resident #347 and Resident #409 had attended or participated in any activity programs. On 10/01/2024 at 12:40 PM, Registered Nurse #9 was interviewed and stated that there were no structure activities on Unit 10 and no recreational leader comes to the unit. Registered Nurse #9 also stated that this is a rehabilitation unit, and residents go to therapy and when they return they either stay in the Activity room and watch television, go to their rooms, or family members may visit, and they may bring them downstairs to the garden. On 10/02/2024 at 02:10 PM, Certified Nursing Assistant #13 was interviewed and stated that there are no activities on this floor; residents go to therapy in the morning and stay in the activity room when they come back to the unit. Certified Nursing Assistant #13 also stated that there is a television on all day for residents to watch if they so desire and there is a radio, but it is not always on. 10 NYCRR 415.5(f)(1)

Based on observations, record reviews and interviews conducted during the Recertification Survey-09/26/2024 to 10/03/2024 facility did not ensure that residents received proper treatment and assistive devices to maintain hearing abilities. This was evident for 1 (Resident #287) of 1 resident reviewed for Communication/Sensory out of a sample of 38 residents. Specifically, Resident #287 with a hearing impairment did not receive an audiology consultation or assistive devices to improve hearing ability. The finding is: Upon request, the Director of Nursing stated that the facility does not have a policy and procedure related to consultation, and that resident care is based on an individual plan of care. Resident #287 was admitted to the facility with diagnoses that included End Stage Renal Disease, Hypertension, benign prostatic hyperplasia. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #287 was moderately cognitively impaired, does not have hearing problems and no hearing aid or other hearing appliance was used. On 09/26/24 at 11:17 AM, Resident #287 was met in the room, alert and awake. Resident #287 was greeted repeatedly but was not able to hear the surveyor's questions and asked the surveyor to repeat self. Resident #287 stated they were not able to hear because they had an impairment to their left ear. Resident #287 was unable to recall if they had a hearing aid and asked the surveyor to speak to their child. The Comprehensive Care Plan titled Communication Problem dated 11/11/22, last updated 11/03/23 documented that the resident had a communication problem related to being hard of hearing. Interventions included staff need to increase speaking volume when talking to the resident, anticipate and meet resident's needs, speak on an adult level, speaking clearly and slower than normal, and validate resident's message by repeating aloud. The Physician orders since Resident #287's admission contained no documented evidence that an audiology consult was provided, or that Resident #287 had been seen by an audiologist. On 10/02/24 at 10:56 AM, an interview was conducted with the assigned Certified Nursing Assistant #5 who stated they have been taking care of the resident for over 5 months. Certified Nursing Assistant #5 also stated that Resident #287 is hard of hearing, and they need to speak louder when talking to them. Certified Nursing Assistant #5 further stated that Resident #287 has never had a hearing aide. On 10/02/24 at 11:28 AM, an interview was conducted with Resident #287's child who stated that Resident #287 used to have hearing problems when they were at home before being admitted into the nursing home. Resident #287's child also stated that they could not recall if anyone at the facility had ever discussed any hearing concerns of their parent or whether their parent had been seen by an audiologist. On 10/02/24 at 11:55 AM, an interview conducted with the Director of Minimum Data Set assessments who stated that they reviewed the previous Minimum Data Set assessments and found that the hearing problem of Resident #287 was not identified however it was identified on the upcoming assessment dated [DATE] that was not yet submitted. On 10/02/24 at 12:42 PM, an interview was conducted with the Attending Physician who stated that all resident care needs should be followed up during their visits. The Attending Physician also stated that a resident with a hearing impairment should be accommodated to ensure that assistive devices, such as hearing aids are provided if required. The Attending Physician further stated that Resident #287 should have been seen since the audiologist comes regularly to the facility and as needed. On 10/02/24 at 02:18 PM, an interview was conducted with the Director of Nursing who stated that residents with hearing problems will first have their ears cleaned of any wax. If the hearing problem persists, then they will be referred to the audiologist who comes to the facility frequently. The Director of Nursing also stated that they were not aware that Resident #287 was hard of hearing. The Director of Nursing further stated that the audiologist comes a couple of times a month, and the nurses are supposed to identify a problem and get an order for the resident to be seen by the audiologist if needed. 10 NYCRR 415.12(3)(b)(1-3)

Based on observations, record review and interviews conducted during the Recertification Survey from 9/26/2024 to 10/03/2024, the facility did not ensure that residents who needed respiratory care was provided such care consistent with professional standards of practice. This was identified for 2 of 4 Residents (Resident #58 and Resident #127) reviewed for Respiratory Care out of a sample of 36 total sampled residents. Specifically, Resident #58 and Resident #127 who received continuous oxygen did not have pulse oxygen saturations appropriately monitored and there was no date on their nasal cannula/ tubing date indicating when the tubing was last changed. The findings are: The facility policy titled Oxygen Administration dated 02/27/2024 states that it is the policy to change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated, date tubing when changed. The policy also stated that staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. 1. Resident #127 was admitted to the facility with diagnoses that included Heart Failure, Hypertension, and Shortness of breath. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #127 was cognitively intact and was receiving oxygen therapy. The Physician orders dated 01/08/2024 stated Oxygen inhalation per nasal cannula at 2 liters per minute every shift every day. On 09/30/2024 at 10:17 AM, Resident #127 was interviewed and stated that it had been more than a week since oxygen tubing was last changed. On 09/30/2024 at 10:17 AM, Resident #127 was observed receiving 2 liters of oxygen via nasal cannula. There was no date observed on the tubing. On 09/30/2024 at 12:03 PM and on 10/01/24 at 10:05 AM, Resident #127 was observed receiving 2 liters of oxygen via nasal cannula. There was no date observed on the tubing. The Vitals Summary documented that an Oxygen saturation of 97% was last recorded on 06/11/2024. A Nursing progress note dated 07/15/2024 documented that Resident #127 had an Oxygen saturation of 96%. A Nursing Progress Note dated 08/02/2024 documented that Resident #127 refused to have their oxygen saturation assessed. Review of the Electronic Medical Record contained no documented evidence that Resident #127's oxygen saturation had been recorded after 08/02/2024. There was no documented evidence of when oxygen tubing was last changed for Resident #127. 2. Resident #58 was admitted with diagnoses that included Pneumonia and Chronic Obstructive Pulmonary Disease. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #58 was cognitively intact, was admitted with oxygen therapy and was receiving oxygen currently. The Physician orders dated 07/01/2024 stated oxygen inhalation per nasal cannula at 2-3 liters per minute every shift for shortness of breath. On 09/27/2024 at 10:50 AM, Resident #58 was interviewed and stated that oxygen tubing was last changed weeks ago. On 09/27/2024 at 10:50 AM, Resident #58 was observed receiving oxygen 2 liters via nasal cannula. There was no date on the oxygen tubing. On 09/30/2024 at 12:03 PM, Resident #58 was observed resting in bed with nasal cannula in place, oxygen running at 2 liters per minute. There was no date on the oxygen tubing. On 10/01/2024 at 10:40 AM, Resident #58 was observed with Registered Nurse #8 receiving 2 liters of oxygen. There was no date on the nasal cannula tubing. The Vital Signs Summary last documented an oxygen saturation of 97% was recorded for Resident #58 on 07/26/2024. Review of the Electronic Medical Record contained no documented evidence that Resident #58's oxygen saturation had been recorded after 07/26/2024. There was no documented evidence of when oxygen tubing was last changed for Resident #58. On 10/02/2024 at 10:58 AM, Licensed Practical Nurse #5 was interviewed and stated that Licensed Practical Nurses on the units usually change the oxygen tubing twice a week, if it is dirty or noted to be on the floor. Licensed Practical Nurse #5 also stated that the tubing must have a label with a date to indicate when it was last changed. If there is no date on the tubing, then it poses a risk of infection control. Licensed Practical Nurse #5 stated that Oxygen saturation level should be recorded under vital signs and while the nurses check the oxygen saturation for residents on oxygen, it is not being recorded appropriately. Licensed Practical Nurse #5 also stated that they could not locate any documentation for the past couple of weeks regarding oxygen saturation levels for Resident #58 and Resident #127, and there was no other oxygen monitoring system in place for them. Licensed Practical Nurse #5 further stated that if oxygen levels are not monitored continuously there is risk of residents going into respiratory distress. On 10/01/2024 at 10:12 AM, Registered Nurse #8 was interviewed and stated that oxygen tubing is supposed to be changed weekly, is done mostly on the overnight shift, and staff are supposed to place a piece of tape on the tubing with the date that the tubing was changed. Registered Nurse #8 also stated that if the tubing is not changed it creates an infection control risk and the tubing also gets harder and is not as patent. Registered Nurse #8 was unable to locate a date on the tubing indicating when it was last changed and stated that there are no notes documenting when it was last changed either. Registered Nurse #8 stated that the charge nurses are responsible for monitoring oxygen saturation adequately as residents can go into respiratory distress if it is not properly monitored. On 10/02/2024 at 02:32 PM, the Registered Nurse #1 was interviewed and stated that if a resident is on continuous oxygen the pulse oxygen saturation should be monitored every shift. Registered Nurse #1 also stated that oxygen saturation levels had not been checked today for Resident #127 and Resident #58, both Licensed Practical and Registered nurses are responsible for checking the pulse oxygen saturation of residents. Registered Nurse #1 stated that they were not sure why this had not been or documented for several weeks. Registered Nurse #1 also stated that they are not sure how often nasal cannula tubing should be changed and did not know why there were no dates on the tubing. On 10/02/2024 at 03:05 PM, the Director of Nursing Service was interviewed and stated that there should be an order for oxygen saturation to be checked once a shift and typically it should be checked once ever shift. Monitoring needs to be done for resident on continuous oxygen to ensure that they are on the right concentration of oxygen and licensed staff should be monitoring oxygen use. The Director of Nursing Service also stated that the nasal cannula tubing should be changed weekly as per protocol as this creates an infection control issue if not changed appropriately. The protocol is that night shift nurses are supposed to change tubing every Tuesday night and label it with the date it was changed. The Director of Nursing Services stated that there are supervisors on each floor who are supposed to oversee staff and identify issues that required correction or education, however, these two issues were not noted to be a concern and is something that should have been followed by all staff as it is normal protocol. The Director of Nursing also stated that all nursing staff on been inserviced on the protocol regarding oxygen use. 10 NYCRR 415.12(K)(6)

Based on observation, record review, and interviews conducted during a Recertification and Complaint (#NY 552) survey, the facility did not ensure that there was sufficient staff available to meet the residents' needs in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care. This was evident for 2 (Resident #42 and Resident #238) of 5 residents reviewed for Activities of Daily Living (ADLs) out of a total sample of 38 residents, the Resident Council facility task, and the Sufficient and Competent Nurse Staffing facility task. Specifically, (1) Residents #42 and #238 did not receive showers for a 3-week period from 6/27/22 to 7/14/22. (2) The facility nurse staffing assignments were consistently less than the projected staffing needs specified in the Facility Assessment. The findings include but are not limited to: 1) Resident #42 was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #42 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS further documented Resident #42 required the total assist of two or more persons for transfers and bathing. During an interview on 07/12/22 at 09:43 AM, Resident #42 stated they did not have a shower in the past three weeks. Resident #42 stated the staff uses a cloth, soap, and water to clean him/her daily, but this was not enough. Resident #42 stated he/she feels dirty when he/she cannot take shower. Resident #42 stated he/she is supposed to have shower on the evening shift twice per week on Tuesdays and Fridays, but when Resident #42 asks for the shower, the staff always say they are short staffed. Resident #42 stated they do not want to get anyone in trouble; they just need a shower. Resident #42 stated it is just two showers per week, and they cannot get that. The Certified Nursing Assistant Accountability Records (CNAARs) from 6/1/22 to 7/18/22 documented Resident #42 was scheduled to receive showers on Tuesday and Friday evenings. The CNAAR documented Resident #42's last shower was provided on 6/24/22. There was no documented evidence Resident #42 received a shower or bed bath from 6/25/22 to 07/14/22. During an interview on 07/15/22 at 03:05 PM, CNA#7 stated he/she is assigned to Resident #42 on a regular basis, and Resident #42's shower days are Tuesdays and Fridays. CNA#7 stated he/she gave Resident #42 a bed bath on 7/1/22, but it was not documented. CNA #7 stated there were 3 CNAs on the floor, and they were assigned 17 residents, including 6 who required a lift for transfer, making it hard to have time for documentation. CNA #7 stated he/she is affected physically from working multiple doubles, and the facility needs more staff. During an interview on 07/15/22 at 03:34 PM, the Registered Nurse (RN#3) stated they worked the day and evening shifts in the last month. RN #3 stated Resident #42 was alert and oriented but confused at times. RN #3 stated Resident #42 did not report any shower concerns, and the assigned CNA did not report that they were unable to provide a shower. RN #3 stated the CNAs must document care provided even when they ware working with less staff. RN #3 stated staff have stayed as late as 3 and 4am to complete documentation. RN #3 stated they see the CNAs giving showers, but they were unable to recall the last time they saw Resident #42 receive a shower. During an interview on 07/15/22 at 10:30 AM, the day shift Registered Nurse Supervisor (RN #4) stated this is the worst staffing they have ever seen. RN #4 stated they start calling staff from home to get shifts covered before reporting to work. He/she checks in with the night shift nursing supervisor in an attempt to replace staff. RN #4 stated they need at least 4 CNAs on the unit. RN #4 is the only supervisor on the day shift, and the evening shift has two supervisors. The night shift has one to two supervisors. The staff are diligent and work very hard and she often signs off for CNAs to get paid when they do not get a break. RN #4 stated when there are 3 CNAs, the staff get the work done, and he/she encourages them to do the best they can. RN #4 stated the nurses stay late to complete documentation and care plans. RN #4 was not aware staff were not giving showers or documenting what is required in the CNAAR. RN #4 stated he/she spoke with CNA #7 and CNA #8, and they reported Resident #42 received a shower on 7/5/22. RN #4 stated all showers and bed baths should be documented in the CNAAR despite the short staffing. 2) Resident #283 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Quarterly MDS dated [DATE] documented Resident #238 was cognitively intact and required the extensive assist of two persons for bed mobility, transfer, and bathing. During interviews on 7/14/22 at 9:43 AM and 7/18/22 at 09:46 AM, Resident #283 stated he/she had not received a shower for the past two weeks. Resident #283 stated the staff work hard, but they do not always have time to provide showers due to short staffing. The CNAARs from 6/1/22 to 7/18/22 documented Resident #238 was scheduled to receive showers on Monday and Thursday evenings. The CNAAR documented Resident #238's last shower was provided on 6/23/22. There was no documented evidence Resident #238 received a shower or bed bath from 6/27/22 to 07/14/22. During an interview on 07/18/22 at 03:00 PM, CNA #3, assigned to Resident #238's unit, stated that there are usually three to four CNAs on the unit, and he/she can be assigned up to 17 residents. If there are only three CNAs on the unit, we are not able to give showers to all the residents scheduled for showers. CNA#3 stated that he/she usually explains the reason to the residents if they are not able to get their scheduled showers. CNA #3 stated the CNAs document if a shower was given in the CNAAR, and the CNAAR is not filled out if the shower was not given. 3) During an interview on 07/14/22 at 12:56 PM, an anonymous complainant stated the facility is severely understaffed. They visited the facility two weeks ago on a Sunday, and there were 2 CNAs assigned to care for 50 residents. The complainant stated this facility is clearly understaffed and needs more CNAs. 4) The facility did not have a policy for Staffing, and the Facility Assessment was provided as the document that addressed staffing in lieu of a policy and procedure. The Facility Assessment, last updated 7/1/2021, documented unpredictable events may influence the staff available, but the facility strives to ensure necessary staffing based on the following model for direct care staff: 11-7 shift =10 nurses and 25 CNAs, 7-3 shift =19 nurses and 41 CNAs, and 3-11 shift = 18 nurses and 34 CNAs. The Facility Assessment further documented Unit 3 was closed, and Units 4 and 5 are offered dementia programs. Units 5, 6, and 8 have residents with impaired cognition, behaviors and elopement risk; these are locked units with wander guards. Unit 10 is a short term rehab unit. The facility currently has seven (7) active units. The Facility Staffing Sheets from 6/24/2022 to 7/14/2022 documented the CNA staffing levels were consistently below the par levels with resident census ranging from 295 to 320 residents. The facility staffing sheets documented the following regarding the Assigned, Facility Required, and Actual CNAs who worked: 6/24/2022: Census 305 Day shift = CNA Total Assigned: 30, Total Required: 39, Actual worked: 26 Evening shift = CNA Total Assigned: 28, Total Required: 32, Actual worked: 28. 6/25/2022: Census: 307 Day Shift = CNA Total Assigned: 30, Total Required: 40, Actual worked: 28 Evening shift = CNA Total Assigned: 28, Total Required: 32, Actual worked: 27 Night shift = CNA Total Assigned: 20, Total Required: 24, Actual worked: 21 6/26/2022: Census: 309 Day Shift = CNA Total Assigned: 28, Total Required: 40, Actual worked: 25 Evening shift = CNA Total Assigned 27, Total Required: 32, Actual worked:2 Night shift = CNA Total Assigned: 16, Total Required: 24, Actual worked: 17 6/27/2022: Census: 309 Day Shift = CNA Total Assigned: 30, Total Required: 39, Actual worked: 29 Evening shift = CNA Total Assigned: 25, Total Required: 32, Actual worked: 25 Night shift = CNA Total Assigned: 20, Total Required: 24, Actual worked: 19 6/28/2022: Census: 307 Day Shift = CNA Total assigned: 36, Total Required: 41, Actual worked: 28 Evening shift = CNA Total assigned: 27, Total required: 32, Actual worked: 27 Night shift = CNA Total Assigned: 21, Total Required: 21, Actual worked: 21 6/29/2022: Census: 311 Day Shift = CNA Total assigned: 28, Total Required: 40, Actual worked: 24 Evening shift = CNA Total assigned: 21, Total Required: 32, Actual worked: 21 Night shift = CNA Total assigned: 20, Total Required: 23, Actual worked: 19 6/30/2022: Census: 312 Day Shift = CNA Total assigned: 31, Total Required: 41, Actual worked: 26 Evening shift = CNA Total assigned: 25, Total Required: 32, Actual worked: 24 Night shift = CNA Total assigned: 23, Total Required: 14, Actual worked: 26 7/1/2022: Census: 314 Day Shift = CNA Total Assigned: 29, Total Required: 39, Actual worked: 26 Evening shift = CNA Total Assigned: 24, Total Required: 32, Actual worked: 25 Night shift = CNA Total Assigned: 19, Total Required: 24, Actual worked:20 7/2/2022: Census: 313 Day Shift = CNA Total Assigned: 25, Total Required: 39, Actual worked: 23 Evening = CNA Total Assigned: 25, Total Required: 32, Actual worked: 25 Night shift = CNA Total Assigned: 19, Total Required: 24, Actual worked: 17 7/3/2022: Census: 315 Day Shift = CNA Total Assigned: 22, Total Required: 39, Actual worked: 21 Evening shift = CNA Total Assigned: 20, Total Required: 32, Actual worked: 23 Night shift = CNA Total Assigned: 16, Total Required: 24, Actual worked: 15 7/4/2022: Census: 314 Day Shift = CNA Total Assigned: 31, Total Required: 40, Actual worked: 27 Evening shift = CNA Total Assigned: 21, Total Required: 32, Actual worked: 21 Night shift = CNA Total Assigned: 18, Total Required: 24, Actual worked: 17 7/5/2022: Census: 313 Day Shift = CNA Total Assigned: 33, Total Required: 41, Actual worked: 29 Evening shift = CNA Total Assigned: 26, Total Required: 32, Actual worked: 26 Night shift = CNA Total Assigned: 16, Total Required: 24, Actual worked: 17 7/6/2022: Census: 314 Day Shift = CNA Total Assigned: 33, Total Required: 39, Actual worked: 31 Evening shift = CNA Total Assigned: 30, Total Required: 32, Actual worked: 30 Night shift = CNA Total Assigned: 27, Total Required: 40, Actual worked:19 7/7/2022: Census: 320 Day Shift = CNA Total Assigned: 31, Total Required: 38, Actual worked: 28 Evening shift = CNA Total Assigned: 24, Total Required: 32, Actual worked: 25 Night shift = CNA Total Assigned: 19, Total Required: 24, Actual worked: 18 7/8/2022: Census: 318 Day Shift = CNA Total Assigned: 29, Total Required: 40, Actual worked: 26 Evening shift = CNA Total Assigned: 26, Total Required: 32, Actual worked: 24 Night shift = CNA Total Assigned: 22, Total Required: 24, Actual worked: 20 7/9/2022: Census: 318 Day Shift = CNA Total Assigned: 27, Total Required: 40, Actual worked: 22 Evening shift = CNA Total Assigned: 25, Total Required: 32, Actual worked: 26 Night shift = CNA Total Assigned: 19, Total Required: 24, Actual worked: 20 7/10/2022: Census: 316 Day Shift = CNA Total Assigned: 24, Total Required: 40, Actual worked: 23 Evening shift = CNA Total Assigned: 22, Total Required: 32, Actual worked: 25 7/11/2022: Census: 315 Day Shift = CNA Total Assigned: 31, Total Required: 40, Actual worked: 25 Evening shift = CNA Total Assigned: 19, Total Required: 32, Actual worked: 21 Night shift = CNA Total Assigned: 16, Total Required: 24, Actual worked: 13 7/12/2022: Census: 314 Day Shift = CNA Total Assigned: 34, Total Required: 38, Actual worked: 33. Evening shift = CNA Total Assigned: 23, Total Required: 32, Actual worked: 21 Night shift = CNA Total Assigned: 19, Total Required:24, Actual worked:16 7/13/2022 Census: 311 Day Shift = CNA Total Assigned: 33, Total Required: 40, Actual worked: 27. Evening shift = CNA Total Assigned: 28, Total Required: 32, Actual worked: 28 Night shift = CNA Total Assigned: 19, Total Required: 24, Actual worked: 20. Review of the actual staffing sheet compared with the facility Assessment have no documented evidence that any unit in the facility from the period of 6/14/2022 to 7/14/2022 met staffing require for the units. During an interview on 07/18/22 at 12:05 PM, CNA #2 stated they can be assigned to as many as 17 residents. CNA # 2 the unit has a capacity of 50, and there used to be 6 CNAs assigned to the unit. Now, there are usually three CNAs, sometimes less, assigned to the unit most of the time. CNA #2 stated that it is impossible to shower all residents scheduled to receive one each day due to the extreme short staffing. Some residents require two-person assist for showers, which adds to the issue. The staff ensure bed baths are provided if showers cannot be given, but bed baths are not documented in the CNAAR. During an interview on 07/18/22 at 11:19 AM, CNA #10 stated this is the worst staffing they have seen at the facility. On Monday, they were assigned 16 residents and could not take a break. On Saturday and Sunday, CNA #10 worked on the 6th floor, and there were three CNAs to care for 50 residents. CNA #10 stated at times they have had to care for 17 to 20 residents, and they do the best they can. CNA #10 stated they do not give showers, but they give bed baths. Many of the residents require a lift to get out of bed. CNA #10 stated they do not have time to document care given in the CNAAR due to the heavy workload, and they rush to get everything done, sometimes skipping lunch and breaks. CNA #10 reported they have spoken to the DNS and Administrator, but nothing has changed. During an interview on 07/15/22 at 03:52 PM, CNA#11 stated they work the 3-11 and 11-7 shifts. CNA #11 stated every weekend there are 2 CNAs assigned to care for 50 residents. CNA #11 stated there is no time to give residents attention or stay and talk like you normally would, but they give the best care they can. CNA #11 stated sometimes they are very tired, but they come to work no matter what. Staff call out sick when they are overtired. CNA #11 stated it used to be a pleasure to come to work. When CNA #11 has 17 residents assigned, they go room to room providing care and may give a bed bath instead of a shower. CNA #11 stated they give the shower another day when there is adequate staffing. CNA #11 stated staff rush to get everyone out of bed and clean, and it is hard work. During an interview on 07/14/22 at 04:52 PM, LPN#2 stated, at times there are 2 CNAs on the unit, and they are they only nurse. LPN #2 stated they will assist the CNAs by delaying medications for one hour to get residents into bed. LPN #2 is sometimes mandated to work an extra shift after working alone. LPN #2 is aware the facility is trying to recruit people. LPN #2 stated staff do their jobs well, but the facility needs more staff. During an interview on 07/14/22 at 04:37 PM, RN #5 stated the facility is understaffed. RN #5 stated the staffing is 1 Nurse and 3 CNAs for 49 to 50 residents, and the workload is incredible. CNAs also work late, sometimes past midnight, to complete their work. RN#5 stated staff are tired and they feel rushed. During an interview on 07/18/22 at 12:10 PM, the Staffing Coordinator for Nurses (SCN) stated they is responsible for scheduling the nurses in the facility. If there is an increase in census on the 10th floor, they increase staff to two nurses at night. With the current staffing, the facility is not able to meet the projected staffing requirement, but the staffing for the nurses has improved. The SCN stated it is hard to cover the nurses' vacation leave. The SCN stated the facility has four per diem nurses from the agency, who work when available. The SCN stated they makes the schedule one month in advance and calls the Per Diem nurses to check availability. The SCN stated the scheduled staff does not meet the required number because the facility does not have the number of staff needed. The Administrator and DNS have been aware of the staffing issues since last year, and they are trying to hire more nurses. The facility is contacting agencies, but is is very difficult to get staff. During an interview on 07/18/22 at 12:49 PM, the Director of Nursing Services (DNS) stated they did receive any specific complaints about residents not receiving showers. The DNS stated they heard some complaints about showers in general that were caused by unit changes. Each unit has a different shower schedule. During survey, the DNS has become aware that CNAs forgot to document showers and/or bed baths, and they will do a Quality Assessment investigation to close the gaps and ensure residents get showers. The DNS stated the lack of shower documentation should be picked up during the monthly CNAAR review done by the supervisors, nurse managers, and DNS. The DNS stated the facility is short staffed re: supervisors and nurse managers, but nursing staff try their best to complete the review. The DNS stated staffing the facility is an issue. Sometimes, up to four CNAs will call out on one unit, and it is impossible to replace them. They do not believe resident care is compromised by the inadequate staffing. Staff have been mandated to work extra time in order to maintain minimum staffing. The DNS contacted multiple agencies, but the agencies do not provide the staff they promised. Administrative staff assist with feeding and serving trays during lunch, especially on the units with 3 CNAs. Families have emailed, called, and complained to the DNS and the families are informed of the staffing issues and facility efforts to obtain staff. The DNS has responded to all concerns. Management meets weekly to discuss the staffing issues, and staff have been offered money as an incentive. During an interview on 07/18/22 at 12:49 PM, the Administrator stated the facility is looking to secure a new contract with another staffing agency outside of New York. The facility is exploring every avenue to assist with the staffing issue. The Administrator stated the facility never relied on agencies for staffing before the COVID-19 pandemic because the facility was well staffed. The facility identified a critical staffing issue in late 2021 that continued to present day. The residents are receiving adequate care. The Administrator stated the staff in other department cannot be used to assist with resident care because they are part of a union. Families of long-term residents who have resided in the facility a long time are aware of the staffing change and miss the extra staff, but newer residents from other facilities and their families report the care at the facility is better. The Administrator stated all staff answer call lights and understands some residents are anxious. All management meets weekly to discuss the staffing concerns and any progress. Administrator stated two units are closed, and the facility is trying their best. 415.13(a)(1)(i-iii)

Based on observation, record review, interviews conducted during the recertification survey, the facility did not ensure infection control practices were maintained during meals. This was evident for 1 (Unit 4) of 7 Units observed during dining. Specifically, Certified Nursing Assistants (CNA) did not perform hand hygiene in between sanitizing residents' hands prior to meal service. The findings are: The facility policy titled Infection Control: Handwashing: revised 4/1/2022 documented hand hygiene prevents the spread of infections and personnel follow the handwashing/hand hygiene procedures. On 07/15/2022 at 12:06 PM, CNA #2 was observed in the Unit 4 dining room donning gloves and using sanitizer wipes to assist residents with hand hygiene prior to meal service. CNA #4 used a wipe to sanitize the hand of Resident #273, took a new wipe and sanitized the hands of Resident #261, took a new wipe and sanitized Resident #463's hands, and took another wipe and sanitized Resident #243's hands. CNA #4 was not observed performing hand hygiene in between sanitizing each residents' hands. On 07/15/2022 at 01:05PM, CNA #2 was interviewed and stated they sanitize residents' hands prior to meal service and CNA #2 did perform hand hygiene in between each resident. On 07/15/2022 at 01:01 PM, Registered Nurse #5 was interviewed and stated residents are provided with baby wipes to wash their hands prior to meal services. Staff are required to perform hand hygiene in between residents as part of infection control. On 07/18/2022 at 12:57PM, the Infection Preventionist was interviewed and stated they do rounds to observe staff during meal service. Hand hygiene is performed in between each resident when sanitizing the resident's hands. 415.19 (a)(1)(b)(4)

Based on observations, interviews, and record review conducted during the Recertification Survey, the facility did not ensure residents were provided with care and interventions to carry out Activities of Daily Living (ADL) in accordance with their needs and preferences. This was evident for 2 (Resident #283 and #42) of 5 residents reviewed for ADLs out of a sample of 38 total residents. Specifically, 1) Resident #283 and 2) Resident #42 were not provided with the ADL assistance to receive showers or bed baths in accordance with their needs and preferences. The findings are: The facility policy titled Certified Nursing Assistant Accountability Record (CNAAR) last revised January 2018, documented the Certified Nursing Assistant (CNA) will initial in the appropriate column, date, and shift at the completion of care each day, signifying that care listed on the CNAAR has been performed and will inform the nurse if unable to perform care. 1) Resident # 283 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #283 was cognitively intact and required the physical assistance of 2 people for bathing. On 7/18/22 at 09:46 am, Resident # 283 was interviewed and stated they wanted to be showered but have not received a shower or bed bath within the past 2 weeks. CNAAR from 6/01/22 through 7/18/22 documented Resident #283 was scheduled to receive showers on Monday and Thursday evenings. There were no CNA initials or signatures documented in the shower section of the CNAAR from 6/27/22 through 7/18/22. There was no documented evidence Resident #283 refused to have showers or bed baths. There was no documented evidence Resident #283 received showers or bed baths from 6/27/22 through 7/18/22. On 07/18/22 at 09:59 AM, CNA #1 was interviewed and stated they are assigned up to 16 residents making it difficult to care for the residents. There are 3 to 6 residents who require a shower each day and, at times, CNA #1 can only assist with 1 shower. CNA #1 ensures their assigned residents are washed daily. The CNAs provide bed baths when they are unable to provide showers. Bed baths are not documented on the CNAAR. On 07/18/22 at 12:05 PM, CNA #2 was interviewed and stated they are assigned up to 17 residents daily and it is impossible to assist in showering residents according to their shower schedules. There is a shortage in staff and residents receive bed baths when they are not showers. Bed baths are not documented on the CNAAR. On 07/18/22 at 03:00 PM, CNA #3 was interviewed and stated if residents do not receive a shower, the CNAs do not document on the CNAAR and the CNAAR does not get filled out. On 07/18/22 at 03:05PM, Registered Nurse (RN) #1 was interviewed and residents are scheduled for showers twice a week. Residents'' showers are rescheduled when the facility is short of staff and showers cannot be given. CNAs do not document in the CNAAR when showers are not given to a resident. 2) Resident # 42 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #42 was cognitively intact and was totally dependent on 1 person for assistance with bathing. On 07/12/22 at 09:43 AM, Resident #42 was interviewed and stated they have not received a shower within the past 3 weeks. Staff report they are unable to provide Resident #42 with a shower because they are short of staff. Resident #42 stated their Certified Nursing Assistant (CNA) uses a washcloth to clean them daily, but this is not enough, and they still feel dirty. Resident #42 s scheduled to have a shower twice a week on the evening shift. The CNA Accountability Record (CNAAR) from 6/01/22 through 7/18/22 documented Resident #42 is scheduled to have showers every Tuesday and Friday on the evening shift. There were no CNA initials or signatures documented in the shower section of the CNAAR from 6/27/22 through 7/18/22. There was no documented evidence Resident #42 refused to have showers or bed baths. There was no documented evidence Resident #42 received showers or bed baths from 6/27/22 through 7/18/22. On 07/15/22 at 03:05 PM, CNA #7 was interviewed and stated they are assigned to Resident #42 and provides Resident #42 with bed baths. Resident #42 last received a bed bath on 7/1/22 and CNA #7 does not have time to complete their documentation because they were assigned 17 residents and the unit needed more CNAs. CNA #7 stated they balance their work when scheduled to provide multiple showers to residents that require the assistance of 2 people to take showers. On 07/15/22 at 03:00 PM, CNA #8 was interviewed and stated they were assigned to care for Resident #42 on the evening shift. CNA #8 provided Resident #42 with showers, but the unit was short of staff and CNA #8 did not have time to document giving Resident #42 showers in their CNAAR. On 07/15/22 at 03:34 PM, Registered Nurse (RN) #3 was interviewed and stated Resident #42 was confused and did not report to RN #3 that they were not receiving showers. The CNAs did not report to RN #3 that they were unable to complete their documentation because they were short of staff. RN #3 could not recall when Resident #42 last received a shower and could not provide documented evidence a shower was given to the resident. an interview was conducted with Registered Nurse (RN#3). On 07/15/22 at 10:40 AM, the RN Supervisor (RNS) was interviewed and stated they were not aware Resident #42 was not receiving showers according to their shower schedule. CNAs document in the CNAAR when they provide residents with showers and/or bed baths. CNAs are expected to complete the CNAAR despite being short of staff. The RNS stated Resident #42 received a shower on 7/5/22 and 7/08/22 but was unable to provide documented evidence that showers were given to the resident. On 07/19/22 at 10:50 AM, the Assistant Director of Nursing (ADON) was interviewed and stated staff are required to document in the resident's medical record when residents are provided with a shower. Staff document when a resident refuses to shower or prefers bed baths. The ADON stated the CNAs must have forgotten to document giving showers to residents. If there is no documentation that showers were given, then it was not done. On 07/18/22 at 12:49 PM and 7/19/22 at 01:48 PM, the Director of Nursing was interviewed and stated they have not received complaints from residents that they were not receiving showers. Each unit has a different shower schedule and residents may not receive a shower because they changed units. CNAs forgot to document giving showers and/or bed baths and a quality assurance assessment will be done to ensure that residents receive showers. The CNAs are required to report to the nurse when they are unable to complete their assignment and the staff must work together to ensure residents receive showers. The nursing department is short of staff and CNAAR monthly documentation has not been checked for completion as it should have. 415.12(a)(3)

Based on record review, and interview during the recertification survey, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment accurately reflected a resident's status. This was evident for 1 (Resident #314) of 38 sampled residents (Resident #314). Specifically, the MDS assessment for Resident #314 did not accurately reflect the resident's discharge to the community. The findings are: The facility policy titled MDS Process and Coding Integrity last revised October 2019 documented accurate MDS coding is based on documentation in the medical record. Resident #314 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Discharge Care Plan dated 4/14/022 documented resident planned to be discharged home. The Nursing note dated 4/29/2022 documented resident was discharged to the community. The MDS assessment dated [DATE] documented Resident #314 was discharged to the hospital. On 07/15/2022 at 12:37PM, an interview was conducted with MDS Coordinator #2 who stated Resident #314 was discharged to the community, but the discharge MDS documents the resident went to the hospital. On 07/15/2022 at 12:41PM, an interview was conducted with the MDS Coordinator #1 who stated Resident #314 was discharged to the community and it was an oversite that the MDS documented the resident went to the hospital. The MDS Coordinator #1 will correct the mistake in the MDS. 415.11(b)

Based on record review and staff interview, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessment(s) were electronically transmitted to the Centers of Medicare/Medicaid Services Data System (CMSDS) within 14 days of completion. This was evident for 1 (Resident #4) out of 1 residents reviewed for Resident Assessment. Specifically, the MDS for Resident # 4 was scheduled for submission on [DATE] and was not submitted. The findings are: The policy titled MDS & Coding Integrity dated ,d+[DATE] documented discharge assessment for deaths in the facility will be transmitted within 7 days of death. The Death Certificate for Resident # 4 documented the resident expired in the facility on [DATE]. There was no documented evidence a MDS assessment for Resident #4's death in the facility was submitted to the CMSDS. On [DATE] at 10:48 AM, the MDS Coordinator was interviewed and stated Resident #4's MDS reporting the resident's death in the facility was not submitted on [DATE] as scheduled. The facility has a computer program that tracks the submission of MDS assessments. The computer program did not alert the MDS Coordinator that Resident #4's MDS assessment was scheduled for submission and did not alert them when the MDS was not submitted. 415.11

Based on record review and interviews conducted during the Recertification and Abbreviated survey (NY 081), the facility did not ensure all alleged violations of abuse with serious bodily injury, including injuries of unknown origin were reported immediately, but no later than 2 hours after the allegation was made to the New York State Department of Health (NYSDOH) for 1 (Resident #412) of 2 residents reviewed for Abuse. Specifically, the facility did not report Resident #412's left [CONDITION(S)] of unknown origin to NYSDOH. The findings are: The facility policy titled Prevention, Identification, Investigation and Reporting of Mistreatment, Neglect and Reporting of Abuse, Neglect, Mistreatment or Exploitation of a Resident or Misappropriation of Resident Policy last revised 7/12/22 documented the facility reports alleged violation of mistreatment, neglect, and abuse, including injuries of unknown origin, and misappropriation of resident property, immediately to the administrator of the facility. Incidents involving abuse or resulting in serious bodily injury, or suspicion of abuse must be reported within two (2) hours after forming the suspicion. All other incidents (do not involve Abuse and do not result in serious bodily injury must be reported within twenty-four (24) hours. Resident #412 was admitted to the facility on [DATE] with diagnosis [CONDITION(S)] and dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #412 was severely cognitively impaired. The Facility Accident/Incident (A/I) Report dated 12/26/2020 at 9:00 PM documented that on 12/26/2020 at 9:00 PM staff was placing the canvas under the resident to transfer back to bed, when staff observed the resident having pain on the left hip. Resident #412 was unable to verbalized what happened. The A/I documented location of occurrence as unknown. Nursing progress notes dated 12/27/2020 documented x-ray of Resident's #412's hip showed an acute femur fracture with moderate angulation. Resident #412 was transferred to the hospital. X-ray results dated 12/27/2020 documented acute intertrochanteric fracture of the femur with moderate angulation. The facility A/I conclusion dated 12/27/2020 documented resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/15/22 at 04:22 PM an interview was conducted with resident Medical Doctor (MD) who stated Resident #412 had an x-ray that revealed a fracture and the MD determined it was spontaneous in nature due to the resident's comorbidities. The fracture was no one's fault. On 07/15/22 at 10:48 AM, the Director of Nursing (DNS) was interviewed and stated Resident #412 did not have a fall at the time of the incident. The A/I investigation included obtaining statements from staff for the three shifts prior to discovery of the injury. All the statements were reviewed and there were no discrepancies. Abuse was ruled out after review of the A/I and the resident's medical record. The DNS did not report the fracture to the NYSDOH because they reviewed the facility's findings of the investigation and ruled out abuse. origin but did not report. 415.4(b)(1)(i)

Based on observations, record review, and interviews conducted during an abbreviated survey (NY 784), the facility failed to ensure that residents were free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the residents' medical symptoms. This was evident in 1 out of 3 residents (Resident #1) sampled for the use of restraints. Specifically, on 5/11/2022 at around 9:45 AM, Wound Nurse/ Registered Nurse #2 (RN #2) observed Resident #1, who has severe cognitive impairment, was in bed with a nightgown tied around his/her thighs. The findings are: The facility's Policy and Procedure entitled: Prevention, Identification, Investigation, and Reporting of Abuse Neglect and Mistreatment revised on 4/2022, documented that the facility's employees, Consultants, contractors, volunteers, and other caregivers, will provide an environment for residents that are safe and free from abuse, neglect, exploitation, and misappropriation, treating each resident with respect, dignity, and the provision of privacy. The facility's Policy and Procedure entitled Resident Rights with revised date 04/2022, documented that the facility will protect and promote the rights of the resident, and afford each resident his/her basic right to be treated with dignity and respect. This document also documented that the resident retains the right to be free from verbal, sexual, mental, or physical abuse, corporal punishment, and involuntary seclusion, and free from chemical and physical restraints except those restraints authorized in accordance with state and federal laws. A review of the facility's investigation dated 5/18/2022, documented that on 5/11/2022 at around 9:40 AM, the Wound Nurse/RN #2 observed Resident #1 in the bed with his/her nightgown tied around his/her thighs, restricting the resident #1's movement. Resident #1 was not able to give an account due to cognitive impairment. The Wound Nurse/RN #2 immediately untied the knot with the assistance of a 7-3 shift assigned Certified Nurse Assistant #2 (CNA #2). Upon assessment, there were marks on Resident #1's thighs where the gown had been tied. There were no changes in the range of motion from the Resident #1's baseline, and no signs or complaints of pain. The 7-3 shift, CNA #2 denied knotting Resident #1's grown around his/her thighs and stated that he/she got knowledge of the knot when assisting the Wound Nurse/ RN #2. The 11-7 shift Charge Nurse (RN #1) denied tying Resident #1's gown around his/her thighs. The 11-7 shift CNA #1 also denied tying Resident #1's grown around his/her thighs. CNA #2 observed that Resident #1 was in the bed at 1:00 AM, 3:00 AM, and 5:45 AM. He/she checked and changed the resident's disposable brief, tied the strings of his/her gown together, and smoothed the gown under Resident #1. Statements were obtained also from staff who worked on the 5/10/2022, 3-11 shift and nobody saw that Resident #1 was tied. The Police were called, came to the facility, and declined to investigate the allegation because there was no injury to Resident #1. After completing the investigation, the facility determined that it is inconclusive as to who was responsible for tying Resident #1's nightgown. Resident #1 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS, an assessment tool) dated 4/7/2022, identified that Resident #1 had short and long-term memory problems and was severely cognitive impaired for daily decision making. Resident #1 required extensive assistance of two persons with bed mobility and was totally dependent for transfers and toilet use. Restrain was not ordered. A Comprehensive Care Plan (CCP): Potential for Abused initiated on 2/4/2022, documented that the interventions are to allow Resident #1 to express feelings and concerns, involve designated representatives in care plan, and monitors interactions with others. The CCP was updated on 5/11/2022, and documented that Resident #1 was observed in bed with his/her gown tied around his/her thighs A CCP for Behaviors during care, related to Dementia was initiated on 7/21/2021, documented Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included explaining all procedures to the Resident #1 and allowing the Resident #1 time to adjust to changes. If care is rejected, stop and re-approach after 5 minutes. The care plan does not have interventions to monitor, document, and report to MD any changes with Resident #1's behavior. A review of Resident #1's Physician Orders, there was no documentations or orders to use a restraint. A Health Status Note, written by RN #3 dated 5/11/2022 at 08:44 AM, Late Entry, documented that a report was received from RN#1 that Resident #1 was found in bed with his/her nightgown tied around their thighs. The nurse examined Resident #1 and noted a slight redness around the area on the upper thighs. Resident #1 was examined during the 3-11 shift and no redness were observed. A Physician/Nurse Practitioner/Physician Assistant Note dated 5/12/2022 at 4: 07 PM, documented a report from the Wound Nurse/RN#1 that Resident #1 was found in bed with the nightgown tied around him/her thighs during rounds. Resident #1 was assessed, and the right knee and leg are contracted. There were no redness, bruising, injuries, or skin breaks to thighs or groin areas. A Point of Care Audit Report dated 5/10/2022-5/11/2022 documented that CNA #1 turned and positioned Resident #1 at 12:00 AM, 2:00 AM, 4:00 AM, and 6:00 AM. Bed mobility and toileting were signed by CNA #1 at 6:59 AM. During an interview on 6/6/2022 at 2:13 PM, CNA #1 who worked on the 5/11/2022, 11 PM-7 AM shift stated that he/she was working with Resident #1 since admission. CNA #1 stated that he/she provided care to Resident #1 at around 1:00 AM, 3:00 AM, and 5:45 AM. When CNA #1 was changing Resident #1 he/she noted that Resident #1 was making knots on the feeding Tube, on the night gown and on the bedsheet. CNA #1 also stated that he/she saw that Resident #1 knots a sheet to the feed tubing. CNA #1 stated that he/she did not tell the nurse because the Resident #1 always does that. The nurses were aware of it. CNA #1 stated that to prevent Resident #1 from touching the feeding tube he/she took the right part of the gown and placed it over Resident #1's left leg and the left part of the gown he/she placed over the right leg. CNA #1 stated that he/she did not tie the ends of the gown. Nothing was knotted or tied. CNA #1 stated that his/her intent was not to restrain Resident #1. CNA #1 was suspended for 2 weeks and received in-service on abuse. After the incident, the facility did not re-assign CNA #1 and he/she continued to be assigned to Resident #1 after suspension. CNA #1 was re-assigned to the 7th floor. During an interview on 6/6/2022 at 2:30 PM, CNA #2 who worked on the 5/11/2022, 7-3 shift stated that he/she was assigned to Resident #1 on 5/11/22. CNA #2 started the round at 7:05 AM, he/she went into Resident #1's room and Resident #1 was awake in the bed, covered with the sheet and blanket up to the waist area. CNA #1 did not see a gown tied around Resident #1 thighs because he/she was covered. Resident #1's hands were visible, and he/she was playing with the sheet. Resident #1 was smiling, not saying anything. Resident #1 had made no attempts to get up, no behavior issues were noted. CNA #2 went back to feed the roommate breakfast. Resident #1 was still in bed. He/she had a feeding tube. It was after 8:00 AM and Resident #1 was still covered. Next time CNA #2 saw Resident #1 was when the Wound Care team came. CNA #2 did not change Resident #1 because he/she had three residents for the wound care round. CNA #2 came from another room and saw the wound team coming to Resident #1. CNA # 2 said to the team that he/she did not get a chance to change Resident #1. CNA #2 and the Wound Nurse went to Resident #1 together. CNA #2 went to wet the towel and heard the Wound Nurse say that look how they tied the resident. CNA #1 glanced but did not see to the full extent how Resident #1 was tied. CNA #2 did not see what was used or where Resident #1 was tied. Resident #1 had a night gown on the top of his/her body. After the nurse untied Resident #1, CNA #2 cleaned Resident #1 and did not see any redness or marks. Resident #1 was smiling with no distress. RN #1 prepared Resident #1 for the wound doctor. Days later CNA #2 was called to write a statement. CNA #2 received in-service on abuse prevention prior to the incident and after. CNA #2 stated that he/she did not tie Resident #1 and never observed that the Resident #1 was tied. During an interview on 6/7/2022 at 1:30 PM, Wound Nurse/ RN #2 stated that on 5/11/2022 at around 9:45 AM, they were doing wound rounds on the unit. The Wound Nurse goes early to check if the residents are clean and ready to be seen by the doctor. The Wound Nurse went to Resident #1's room and tried to pull up the night gown and was unable. He/she turned Resident #1 on the side and still could not pull up the night gown. He/she was attempting to turn Resident #1 again. The morning CNA #2 walked in and said that he/she was sorry because he/she did not change Resident #1 yet and the resident is probably dirty. CNA #2 helped to check Resident #1 and then the Wound Nurse and saw that the night gown was tied between Resident #1' s legs. It looked like Resident #1 was wearing a jumpsuit Resident #1 was not able to make the knot. Resident #1 liked to pull and touch things but was not able to make a knot. The Wound Nurse turned to CNA #2 and ask who tied him/her like this. CNA #2 replied that it was the night shift. The diaper was wet and had BM. It looks like CNA #2 did not get a chance to change Resident #1. Usually, CNA #2 cleans and washes residents for wound round. Resident #1 was untied. The body assessment was done and observed indentations (red marks) with no skin opening, and no bruising, Resident #1 was smiling. No grimacing of pain. The Director of Nursing #1(DNS #1) was notified. During an interview on 6/8/2022 at 12:07 PM, RN #1 stated that he/she worked on 5/11/2022 at 11-7 AM shift. RN #1 stated that he/she has seen Resident #1 playing with the feed tubing and the feeding machine was alerting. RN#1 unwrapped the feed tubing and the feed was run freely. RN #1 observed Resident #1 making knots on the end of the gown. There was a towel on the abdomen to prevent leakage. Resident #1 was attempting to remove and roll the towel. RN #1 did not document it because he/she assumed that Resident #1 does that all the time. It was endorsed by the evening nurse that the Resident#1 had a habit of kinking the tubing and making knots. RN #1 did not physically see CNA #1 taking care of Resident #1. RN #1 knew that CNA #1 made the round and saw CNA #1 going into the Resident #1's room. RN #1 did not give any medication on the night shift. RN #1 changed the dressing to the Resident #1's feeding tube after 1:00 AM. There were no knots on the Resident#1 's nightgown, nothing was restricted to the Resident #1's movements. CNA #1 did not say that Resident #1 was touching the tubing. RN #1 did a round at the end of the shift and saw Resident #1 at approximately 10 min to 7:00 AM to check if the feeding was finished. RN #1 did not disconnect the feeding tube. RN #1 did not see anything unusual, and nothing was reported. During an interview on 6/6/2022 at 5:49 PM, DNS #1 stated that they were responsible for investigating incidents. DNS #1 stated that the facility does not use any form of restraints. DNS #1 was notified of the incident, and the staff was suspended pending the investigation. DNS #1 stated that the incident was reported to the police, who responded but did not take any report because Resident #1 was not injured. DNS #1 interviewed the night shift and RN #1 who denied seeing any restrains. CNA #1 denied restraining Resident #1. The morning shift RN #2 denied any knowledge of restraint. RN #3 did morning rounds to make sure Resident #1's feeding tube was intact and did not see anything. The Wound Nurse came to prepare Resident #1 for Wound Doctor's round and discover Resident #1 's gown was tied around his/her thighs. According to the Wound Nurse, it was tied in the knot that restricted Resident #1 movement. During the investigation, DNS #1 determined that abuse happen but was not able to determine which staff did that. According to the morning CNA #1, he/she did not provide care to Resident #1. The 11-7 CNA #1 and RN #1 were suspended. It was an inconclusive investigation, and they were called back to work. CNA #1 came back to work and was assigned to Resident #1 because there were no witness and staff denied restraining Resident #1. The staff received an in-service on Abuse and Resident Rights to be free from restraint. During a telephone interview on 6/29/2022 at 11:00 AM, DNS #1 stated that if a CNA observed any resident's behavior that included playing, touching, knotting the tubing, or the night gown during care, he/she should notify the nurse. The nurse should document the behavior in the resident's medical record and update the CCP with interventions and the outcome of the interventions. There was no documented behavior in Resident # 1's chart that he/she was making knots on the feed tube or on the night gown. 10 NYCRR: 415.4(a) (2-7)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY 496), the facility failed to protect resident's rights to be free from physical abuse. The facility did not ensure each resident was free from abuse for 1 out of 3 residents (Resident #1). Specifically, on 4/15/2022, two staff members, the Assistant Director of Nursing #1 (ADNS #1) and Certified Nursing Assistant #1 (CNA #1) witnessed the Activity Leader #1 using his/her left foot to repeatedly kick Resident #1's right foot. The findings are: The facility's Policy and Procedure entitled Prevention, Identification, Investigation, and Reporting of Abuse Neglect and Mistreatment revised on 4/2022, documented that the facility's employees' consultants, contractors, volunteers, and other caregivers, will provide an environment for residents that are safe and free from abuse, neglect, exploitation, and misappropriation, treating each resident with respect, dignity, and the provision of privacy. A review of the facility's investigation dated 4/15/2022, documented that on 4/15/2022 at 2:20 PM, ADNS #1 and CNA #1 observed Activity Leader #1 repeatedly kicking Resident #1's right foot with his/her left foot. Resident #1 was sitting in the chair in the Activity Room. When Activity Leader #1 realized that ADNS #1 saw him/her, he/she approached ADNS #1 and said that Resident #1 kicked him/her. Activity Leader #1 was separated from the residential area and was escorted out of the facility. Activity Leader #1 denied hitting Resident #1. The facility concluded that abuse occurred based on 2 witnesses. Activity Leader #1 was terminated. Resident #1 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 2/16/2022, documented that Resident #1 had short-term and long-term memory problems. A Comprehensive Care Plan (CCP) for the potential to be abused was initiated on 2/1/2022, documented that the interventions were to allow Resident #1 to express feelings and concerns. Staff to be alert of Resident #1 signs of distress or fear and to monitor Resident #1 for safety. The CCP was updated on 4/15/2022 after Resident #1 was observed being hit by an Activity Leader #1 on his/her leg. A CCP for Resident #1: The potential to be physically aggressive related to Dementia, and poor impulse control, initiated on 3/12/2022, documented the interventions that included that Resident #1 must be monitored and have one to one supervision. A Health Status Note dated 4/15/2022 at 3:35 PM, written by the Assistant Director of Nursing #1 (ADNS #1) documented that ADNS #1 was at the nursing station and observed that the Activity Leader #1 who was assigned to the unit was standing very close to Resident #1, who was sitting in a chair in the Day Room. The Activity Leader #1 used his/her left foot to repeatedly hit the right foot of Resident #1. Resident #1 was assessed and had no visible injuries. Resident #1 verbalized no pain and proceeded to ambulate on the unit. Activity Leader #1 was escorted off the unit and out of the facility immediately. Medical Doctor #1 (MD #1) was notified and ordered to monitor Resident #1 for any change in condition. Resident #1's family was notified. A Physician Note dated 4/20/2022 at 8:21 PM, documented that Resident #1 was examined due to an altercation with a staff member. There was no visible injury noted. Resident #1 has severe Dementia and did not remember the incident. No pain, no swelling, or difficulty walking. No need for psych medication. No need for hospital transfer. Continue to monitor activity. The findings were discussed with the family. During a telephone interview on 6/6/2022 at 5:00 PM accused Activity Leader #1 who is no longer working in the facility, stated that he/she worked in the facility 9 AM-5 PM shift for [AGE] years. On 4/15/2022, Activity Leader #1 was doing an activity with the residents on the fifth unit. Resident #1 was got up and went to the garbage pail and started to eat from the garbage. Activity Leader #1 told Resident #1 not to eat the garbage because it was dirty. Resident #1 refused to listen and took his/her shoe and hit Activity Leader #1's arm in the wrist area and started kicking using both feet. Resident #1 hit Activity Leader #1's knee. Activity Leader #1 got away from Resident #1. Activity Leader #1 saw ADNS #1 at the nursing station and said look what the resident did. It was a black mark on the pants from the resident #1's shoe. Activity Leader #1 went back to do what he/she was doing. After a few minutes, ADNS #1 approached Activity Leader #1 and ordered them to take their belongings and leave the facility. Someone said that I kicked Resident #1. I did not kick or hit Resident # 1. I never hit anybody in my life. The facility suspended Activity Leader #1 for 2 weeks to 5/6/2022 and then terminated their services. During an interview on 6/6/2022 at 5:41 PM, CNA #1 stated that the incident happens on 4/15/2022, at around 2:00 PM. CNA #1 stated that he/she was not assigned to Resident #1. They were monitoring residents in the common area near the nursing station. CNA #1 heard some screaming and turned to see what happen. He/she observed Resident #1 was sitting on the chair and Activity Leader #1 was kicking Resident #1 with his/her left foot in Resident #1 foot. CNA #1 saw Activity Leader #1 kick Resident #1 three or four times. When CNA #1 was approaching Resident #1, Activity Leader #1 moved away pretending nothing happen. Resident #1 was screaming. CNA #1 asked Resident #1 if he/she was in pain and the Resident #1 said yes. Resident #1 was able to tell his/her needs. At that time ADNS #1 came to the unit and CNA #1 reported what he/she observed. During an interview on 6/6/2022 at 5:49 PM, the Director of Nursing #1 (DNS #1) stated that he/she did not report the incident to police because it was obvious abuse with 2 witnesses. Activity Leader #1 was suspended immediately and terminated. All staff receives ongoing in-service on abuse prevention. DNS #1 stated that if there was injury or suspicion of abuse, they report the incident within 2 hours to the Administrator and NYDOH. DNS stated that he/she investigated and reported the incident to NYDOH on 4/15/2022. On 4/18/2022 he/she realized that the report did not go through DNS look-up and realized that he/she saved the report in HERDS but forgot to submit it on 4/15/2022. The incident was submitted to NYDOH on 4/18/2022. During a Telephone interview on 7/1/2022 at 1:24 PM, ADNS #1 stated that on 4/15/2022, while at the nursing station ADNS heard two other residents screaming and turned around to see that the Activity Leader #1 hit Resident #1 a few times on the right foot using his/her left foot. When Activity Leader #1 saw ADNS #1 he/she started approaching him/her and show some marks on their pants saying that Resident #1 hit Activity Leader #1 with a shoe. There was no witness that Resident #1 hit the Activity Leader #1. Activity Leader #1 was separated from all the other residents and DNS #1 was notified. Activity Leader #1 was sent home pending investigation. Activity Leader #1 received an in-service on abuse prevention and how to deal with aggressive residents prior to the incident. ADNS #1 stated that he/she assessed Resident #1 and no visible injuries or pain were identified. The MD and family were notified. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY 96), the facility failed to report immediately, but not later than 2 hours after forming a reasonable suspicion of a crime, if the events that cause the suspicion resulted in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. This was evident for 1 out of 3 residents reviewed (Resident #1). Specifically, on 4/15/2022, two staff members: the Assistant Director of Nursing #1 (ADNS #1) and Certified Nursing Assistant #1 (CNA #1) witnessed the Activity Leader #1 repeatedly use his/her left foot to kick Resident #1's right foot. The facility did not report the incident to law enforcement. The findings are: The facility's Policy and Procedure entitled Prevention, Identification, Investigation, and Reporting of Abuse Neglect and Mistreatment revised on 4/2022, documented that upon receipt of a report, the Administrator, or his/her designee, must report to state or federal agencies, as applicable, any suspected or alleged abuse, mistreatment, neglect, misappropriation, or injury of unknown source within twenty-four hours of receipt of the report. In case of serious bodily injury, the notification must be made no later than two hours after discovery or forming the suspicion. The Administrator, or his/her designee, shall also report to the local police if such allegation meets the requirements of the Elder Justice Act. A review of the facility's investigation dated 4/15/2022, documented that on 4/15/2022 at 2:20 PM, ADNS #1 and CNA #1 observed Activity Leader #1 repeatedly using his/her left foot to kick Resident #1's right foot. Resident #1 was sitting in the chair in the Activity Room. When the Activity Leader #1 realized that ADNS #1 saw him/her, he/she approached ADNS #1 and said that Resident #1 kicked him/her. Activity Leader #1 was separated from the residential area and was escorted out of the facility. Activity Leader #1 denied hitting Resident #1. The facility concluded that abuse occurred based on two witnesses. Activity Leader #1 was terminated. Resident #1 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 2/16/2022 documented that Resident #1 had short-term and long-term memory problems. A Health Status Note dated 4/15/2022 at 3:35 PM, written by the Assistant Director of Nursing #1 (ADNS #1) documented that ADNS #1 was on the unit and observed Activity Leader #1 standing very close in front of Resident #1, who was sitting in a chair in the day room. Activity Leader #1 used his/her left foot to repeatedly hit the right foot of Resident #1. Resident #1 was assessed, and no visible injury was seen. Resident #1 did not have any pain and continued to walk on the unit. The Activity Leader #1 was escorted off the facility immediately. The Medical Doctor #1, (MD #1) was notified and ordered to monitor Resident #1 for any change in medical condition. The family was notified. A Physician Note 4/20/2022 at 8:21 PM, documented that Resident #1 was examined due to an altercation with a staff member with no visible injury noted. Resident #1 has severe Dementia and does not remember the incident. No pain, no swelling, or difficulty walking. No need for psych medication. No need for hospital transfer. Continue to monitor activity. The findings were discussed with family, Psychiatrist, and nursing. During a telephone interview on 6/6/2022 at 5:00 PM, the accused Activity Leader #1 who is no longer working in the facility, stated that he/she worked in the facility 9 AM-5 PM shift. On 4/15/2022, Activity Leader #1 was doing an activity with the residents on the fifth unit when somebody said that I kicked Resident #1. Activity Leader #1 stated that he/she did not kick or hit Resident #1 and never hit anybody in their life. The facility suspended Activity Leader #1 for 2 weeks to 5/6/2022 and then terminated Activity Leader #1. During an interview on 6/6/2022 at 5:41 PM, CNA #1 stated that the incident happens on 4/15/2022, at around 2:00 PM. He/she observed Resident #1 sitting on the chair and Activity Leader #1 was kicking Resident #1's foot. CNA #1 saw Activity Leader #1 kick Resident #1 three or four times. At that time ADNS came to the unit and CNA #1 reported what was seen. During an interview on 6/6/2022 at 5:49 PM, Director of Nursing #1 (DNS #1) stated that he/she did not report the incident to police because it was obvious abuse with 2 witnesses. Activity Leader #1 was suspended immediately and terminated. During a telephone interview on 7/1/2022 at 1:24 PM, ADNS #1 stated that on 4/15/2022, while at the nursing station saw Activity Leader #1 using his/her left foot to hit Resident #1's right foot. When Activity Leader #1 saw ADNS #1 he/she started approaching him/her and show some marks on their pants saying that Resident #1 hit Activity Leader #1 with a shoe. There was no witness that Resident #1 hit the Activity Leader and staff cannot retaliate. ADNS #1 notified DNA #1 immediately. 10 NYCRR: 415.4(b)(1)(i)

Based on interviews and records review conducted during an Abbreviated Survey (NY 315), the facility did not ensure that an alleged violation involving abuse was reported to the New York State Department of Health (NYSDOH) within two hours after the allegation was made. This was evident for 1 out of 3 residents reviewed (Resident #1). Specifically, on 4/15/2022 at 2:20 PM, two staff members: the Assistant Director of Nursing #1 (ADNS #1) and Certified Nursing Assistant #1 (CNA #1) witnessed Activity Leader #1 using his/her left foot to kick Resident #1's right foot. The facility reported the incident to NYDOH on 4/18/2022 at 10:49 PM. The findings are: The facility's Policy and Procedure entitled Prevention, Identification, Investigation, and Reporting of Abuse Neglect and Mistreatment revised on 4/2022, documented that upon receipt of a report, the Administrator, or his/her designee, must report to state or federal agencies, as applicable, any suspected or alleged abuse, mistreatment, neglect, misappropriation, or injury of unknown source within twenty-four hours of receipt of the report. In case of serious bodily injury, the notification must be made no later than 2 hours after discovery or forming the suspicion. A review of the facility's investigation dated 4/15/2022, documented that on 4/15/2022 at 2:20 PM, ADNS #1 and CNA #1 observed Activity Leader #1 used his/her left foot to repeatedly kick Resident #1's right foot. Resident #1 was sitting in the chair in the Activity Room. When Activity Leader #1 realized that ADNS #1 saw him/her, he/she approached ADNS #1 and said that Resident #1 kicked him/her. Activity Leader #1 was separated from the residential area and was escorted out of the facility. Activity Leader #1 denied hitting Resident #1. The facility concluded that abuse occurred based on 2 witnesses. Activity Leader #1 was terminated. A Health Status Note dated 4/15/2022 at 3:35 PM, written by the Assistant Director of Nursing #1 (ADNS #1), documented that ADNS #1 was standing on the unit and observed Activity Leader #1 standing close to Resident #1, who was sitting in a chair in the Day Room. Activity Leader #1 used his/her left foot to repeatedly hit the right foot of Resident #1. Resident #1 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Activity Leader #1 was escorted off the unit and the out of the facility immediately. The Medical Doctor #1 (MD #1) was notified and ordered to monitor Resident #1 for any changes. The family was notified. Resident #1 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 2/16/2022, documented that Resident #1 has short-term and long-term memory problems. A Physician Note on 4/20/2022 at 8:21 PM, documented that Resident #1 was examined due to an altercation with a staff member and no visible injuries were noted. Resident #1 has severe Dementia and does not remember the incident. No pain, no swelling, or difficulty walking. There was no need for hospital transfer. Continue to monitor activity. Discussed with family, Psychiatrist, and nursing. During an interview on 6/6/2022 at 5:49 PM, the Director of Nursing #1 (DNS #1) stated that if there were injuries or suspicion of abuse, the incident will be reported within 2 hours to the Administrator and NYDOH. DNS #1 stated that he/she investigated and reported the incident to NYDOH on 4/15/2022. On 4/18/2022 he/she realized that the report did not go through DNS look-up and realized that he/she saved the report in HERDS but forgot to submit it on 4/15/2022. The incident was submitted to NYDOH on 4/18/2022. During an interview on 7/1/2022 at 1:24 PM, ADNS #1 stated that on 4/15/2022, while at the nursing station ADNS #1 observed Activity Leader #1 hit Resident #1 a few times on the right foot. When Activity Leader #1 saw ADNS #1 he/she started approaching him/her and demonstrated some marks on their pants saying that Resident #1 hit Activity Leader #1 with a shoe. There was no witness that Resident #1 hit Activity Leader #1 and staff cannot retaliate, it is abuse. Activity Leader #1 was separated from all residents and DNS #1 was notified immediately. 10 NYCRR: 415.4(b)(1)(i)

Based on observation, record review, and interview conducted during the COVID-19 Focused Infection Control Survey (Event ID OAQN11) completed on 11/10/2020, the facility failed to establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, isolation gowns were not being used for residents on isolation related to COVID-19 exposure or new admission status. In addition, there were no signs posted to indicate residents on isolation were on contact and droplet precautions. This was evident for 3 out of 6 resident floors observed for infection control concerns (Floors 5, 9, and 10). The findings are: The Centers for Disease Control and Prevention (CDC) guidance titled Preparing for COVID-19 in Nursing Homes, updated 6/25/2020, documents the facility should create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (Healthcare Personnel) should wear an N95 or higher-level respirator (or facemask if respirator not available), eye protection, gloves, and gowns when caring for the resident. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP is newly identified in the facility. The CDC guidance titled Responding to Coronavirus (COVID-19) in Nursing Homes, dated 4/30/20, documented that in the 48 hours prior to symptom onset of a newly identified [DIAGNOSES REDACTED]-CoV-2-infected Health Care Provider (HCP), the residents who were cared for by the HCP should be restricted to their room and be cared for using all recommended COVID-19 PPE (in accordance with CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated November 4, 2020) until the HCP's COVID-19 test results are known. If the HCP is diagnosed with [REDACTED]. CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated November 4, 2020 provides: HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. The NYSDOH Health Advisory titled COVID-19 Cases in Nursing Homes (NH) and Adult Care Facilities dated 3/13/20 revised 7/10/20, documented that if there are confirmed cases of COVID-19 in a NH, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. HCP and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e. do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed and hand hygiene must be performed. The policy and procedure for COVID-19 Admissions and Readmissions, effective March 2020, documented that the facility will follow CDC and CMS guidance to place all new admissions and readmissions on a dedicated unit in order to reduce the risk of spread of COVID-19. Whenever possible, long term residents returning from hospital and new admissions will be assigned to a room on a designated isolation unit where the resident will remain for a minimum of 14 days. All staff will follow contact precautions when caring for the resident if supplies are available. The admissions policy did include droplet and airborne precautions. The policy and procedure on COVID-19, revised 08/14/2020, documented the facility will post signs on the door or wall outside the resident room that clearly describes the type of precautions needed. The Staff Testing List of COVID-19 positive staff members documented that a staff member of the 9th floor tested COVID-19 Positive on 10/30/2020 and another staff member of the 5th floor tested COVID-19 Positive on 11/03/2020. 1) The 9th floor quarantined unit was observed on 11/10/2020 at 10:27AM. All staff observed were wearing surgical masks and face shields while on the unit. One sign for Contact Precaution was noted for a resident with a Non-COVID-19 infection. There were no signs for Contact and Droplet Precautions by the entrance, on other residents' doors, or on walls outside the rooms on the unit. 2) The 5th floor quarantined unit was observed on 11/10/2020 at 12:25PM. There were no signs at the unit entrance or on the resident rooms to indicate the residents were on contact and droplet precautions. Staff were wearing surgical masks and face shields while on the unit. CNAs were entering residents' rooms without donning gowns prior to entering. On 11/10/2020 at 2:45PM, CNA #2 was observed wheeling Resident #2 out of the main bathroom on the 5th floor. CNA #2 was observed wearing a surgical mask and face shield. Registered Nurse Manager #1 (RNM #1) of the 5th floor was interviewed on 11/10/2020 at 12:30PM. She stated that the residents on the unit are on quarantine and are on contact and droplet precautions. She further stated that staff were given instructions for contact and droplet precautions during reports at the beginning of the shifts. She verbalized that staff were instructed to wear surgical masks, eye shields, and gloves at the beginning of the shift. She added that gowns were used for resident care. CNA #2 was interviewed on 11/10/2020 at 2:45PM. She stated that she took Resident #2 to the bathroom and washed the resident's hands. She stated that she did not wear a gown while washing the resident's hands. CNA #2 verbalized that the resident did not use the toilet. In addition, she stated that she did not wear gowns to provide care for Resident #2 or any other residents on her assignment during the shift. She stated that she was not told that she had to wear gowns prior to entering residents' rooms or for resident care. 3) On 11/10/2020 at 9:45AM, the 10th floor new admission unit was observed. There were no signs for contact/droplet precautions signs posted outside residents' rooms. Staff were wearing an eye cover/face shield and surgical mask while on the unit and when entering resident rooms. During an observation on the 10th floor, on 11/10/2020 at 10:35AM, a Certified Nursing Assistant (CNA #1) was observed making Resident #1's bed. CNA #1 was observed fluffing Resident #1's pillow then she straightened the cover sheet. CNA #1 was wearing an eye shield, surgical mask, and gloves; CNA #1 was not wearing a gown. On 11/10/2020 at 2:05PM, the 10th floor unit admission unit was observed. There were no signs posted on or near resident rooms to indicate residents were on contact and droplet precautions. Staff were wearing surgical masks and face shields on unit. CNA #3 entered Resident #3's room without a gown and stated that she was going to take Resident #3 to the bathroom. CNA #1 was interviewed on 11/10/2020 at 10:40AM and stated that they are required to use an eye covering/face shield and a surgical mask while on the unit. In addition, gloves are worn when providing care to residents. CNA #1 further stated that staff on the unit were not informed to use gowns while on the unit, going into resident rooms, and while providing care. CNA #3 was interviewed on 11/10/2020 at 2:20PM. She was assigned to Resident #3. She stated that she only used gowns when caring for residents who had precautions signs placed on their rooms. She stated that Resident #3 had no precautions sign on the door, and she was not told that she should wear a gown when caring for Resident #3. Registered Nurse Manager #2 (RNM#2) was interviewed on 11/10/2020 at 10:15AM. She stated that the 10th floor holds new admissions/readmissions (short-term care and long-term care residents). The facility ensures all residents have a negative COVID-19 test result prior to admission. Residents are put on quarantine status for 14 days for observation, put on standard precautions, monitored for any signs and symptoms of COVID-19 and are tested for COVID-19 on admission day and weekly thereafter. RNM #2 reported that the facility required staff to use eye covering/face shields and surgical masks while working on the floor. She further reported that the unit staff were not informed by leadership to wear gowns on the unit or when providing care to residents on 14-day quarantine. CNA #4 was interviewed on 11/10/2020 at 2:30PM and stated that she was regularly assigned to the admission/readmission unit on the 10th floor. She uses masks, face shields, and gloves when caring for the residents on the unit. She stated she wears gowns to care for residents when there are signs on their rooms for precautions. She verbalized that her assigned new admissions and readmission residents were not on contact and droplet precautions. She added that the unit is COVID-19 free. The Infection Control Preventionist was interviewed on 11/10/2020 at 12:38PM. She stated that the residents on the 5th floor and new admissions and readmissions on 10th floor were placed on contact and droplet precautions. She further stated that no signs were placed on the units or on the residents' rooms to indicate what precautions the staff should follow. She verbalized that the facility's residents are COVID-19 Negative. She in-serviced staff and sent emails and memos to the managers regarding the quarantined units and the required PPE. The charge nurses instruct the staff regarding the precautions at the beginning of the shifts. She stated NYS DOH Epidemiology recommended gowns should be used for residents on quarantine and new admissions on 11/06/2020. She also stated gowns were added to the required PPE worn for the residents on quarantine on 11/06/2020. A follow-up interview was conducted with the Infection Control Preventionist on 11/10/2020 at 4:55PM. She stated that residents on the 5th and 9th floors are on quarantine with contact and droplet precautions due to exposure to two COVID-19 positive staff members who are currently out on quarantine. She further stated that the facility placed signs on the elevators, on the two units and on residents' rooms. Signs for Contact and Droplet Precautions were placed on the resident rooms on the 5th and 9th floor quarantine units and 10th floor admission/readmission unit. In addition, 5th and 9th floors quarantine signs were placed on the elevators. She further added that the staff were instructed to use full PPE for resident care on these units. The Director of Nursing was interviewed on 11/10/2020 at 5:20PM. She stated that admissions and readmissions were placed on the 10th floor. The residents are admitted with negative COVID-19 test results. Residents are tested for COVID-19 upon admission or on the following day and kept in their rooms. The residents are monitored for any signs and symptoms of COVID-19 during the 14 days period. She stated that staff wore masks, face shields and gloves when attending to the residents, but staff did not wear gowns. She further stated that no signages were placed on the residents' rooms for contact and droplet precautions. In addition, no Physician's orders are written for admitted residents for contact and droplet precautions. On inquiry about the facility's policy indicating that residents are placed on contact precautions; she stated that the facility will review their policy and update as needed. She also stated that no signs were posted on the 5th and 9th floors units where residents are quarantined due to exposure to positive staff. She stated that due to the concerns of the surveyors, signs indicating quarantine were posted in the elevators, and contact and droplet precautions signs were posted on the two quarantined units. 415.19(a)(1),(b)(1)

Based on record review and staff interviews conducted during the re-certification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 non-comprehensive assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, a quarterly assessment was not transmitted within 14 days after the completion date. This was evident for 1 of 5 residents reviewed for the Resident Assessment task out of a sample size of 38 residents. (Resident # 6) The finding is: The facility policy and procedure titled MDS/RAI Process and Coding Integrity revised in (MONTH) 2019 documented it is the policy of this facility to provide an interdisciplinary approach in conducting and completing the Resident Assessment Instrument (RAI), including both OBRA and Prospective Payment System Assessments. All MDS activities are conducted in accordance with RAI Manual and Center for Medicare and Medicaid (CMS) guidelines. The policy also documented MDS completion timing-the MDS is to be completed within maximum 14 days of the Assessment Reference Date (ARD). Resident # 6 was admitted to the facility on [DATE]. The quarterly MDS assessment dated [DATE] was completed and transmitted on 10/15/2019. The assessment should have been completed and transmitted on 08/30/2019 meeting the 14 days requirement as per CMS guidelines. On 10/17/2019 at 3:00 PM, an interview was conducted with the Director of MDS. The Director of MDS stated there is an MDS calendar that will list all residents due for renewal between 60 days to 90 days. Notification is then sent out to all the different disciplines involved with the resident care to complete their respective sections. Once the MDS is completed, it is then signed off by the MDS coordinator and or by the Director and transmitted to CMS. The Director of MDS further stated the MDS was missed and she was not sure how this occurred. 415.11

Based on recordsreview and interviews conducted during re-certification and abbreviated survey the facility did receive adequate supervision to prevent accidents. Specifically: A CNA (Certified Nurses Assistant) did not follow the resident's plan of care when assisting the resident in transfering from bed to wheel chair. As a result the resident fell from the bed, and obtained a laceration to the face. This was evident for 1 resident reviewed for accidents out of a sample of 35 sampled residents Complaint #NY 908 1) Resident #475 is a [AGE] year-old admitted to the facility for short term rehab on 12/27/17, with [DIAGNOSES REDACTED]. The Minimum Date Set (MDS) 3.0 assessment dated [DATE] documented the resident's cognition is intact with a Brief Interview of Mental Status (BIMS) of 13. Alert and oriented, confusion and some trouble with recall. The resident was totally dependent on staff with chair to bed/bed to chair transfers and required substantial/maximum assistance sit to laying, lying to sitting, sitting to standing. The Comprehensive Care Plan (CCP) dated 12/27/17 for Resident #475 documented all care and goals for the resident. Specifically, the CCP for Falls/stated: The resident is at risk for falls related to confusion, gait/balance problems and unaware of safety needs. The Certified Nursing Assistant Assignment Record(CNAAR) for the resident documented the resident required extensive assistance by 2 people for showers, bed mobility, turning and repositioning, dressing, transfers, to move between surfaces as necessary, and for toileting. Occupation/Physical Therapy Plan of Care/ Initial assessment dated [DATE] documented treatment for [REDACTED]. It also revealed she was alert and oriented to person and place only. Moderate cognitive impaired status with cognition/following commands at 51-70 percent ability and required frequent direction in occasional situations. Recall, safety/judgement were marked at 31-50 percent ability. Resident was at maximum assistance required for all Activities of Daily Living (ADL), self-care with hygiene, dressing, grooming, toileting, functional transfers, shower/tub/wheel chair/toilet, bed mobility: sit/stand, wheel chair/wheel chair assist. The facility's forms titled Quality Assurance Fall Investigation documented that the resident had various falls while at the facility. The resident had two documented falls on on 12/29/17. The first fall was at 4:40 AM where resident was observed by staff sitting on the floor by the foot of her bed and resident indicated she was trying to get out of bed to get an emery board for her nails and attempted to get herself out of the bed. No injury. The second fall was at 8:30 AM and caused by a CNA who attempted to transfer the resident without the assist of another person,which resulted in the resident falling face down and sustaining a laceration between the eyebrows size 1.4cm x 0.2cm, treated with Steri Strip per doctor's orders, with neurological checks performed every 4 hours for 48 hours. The facility summary of investigation report dated 01/03/2018 revealed resident with a history of subdural hematoma status [REDACTED]. The resident required two-person assistance for transfers and ambulation, close supervision and anticipation of needs to prevent further falls. The Employee file/records of CNA#1 revealed date of hire to be 05/08/2017. It contained all pertinent paperwork including job description, trainings and competencies. The Policy on Incident/Accident dated 2/2017 documents that all incidents shall be reported, describing the procedure and protocol required by regulations and facility guidelines. It also describes how to identify falls, their occurrence, assessments and care plan with immediate and new interventions required, including falls risk assessment and falls reduction with family/representative to participate in the planning. On 01/22/18 at 4:26 PM a telephone interview with CNA#1 was conducted. CNA #1 said she was a floater for that day (temporarily assigned to different units). She said that she was asked to assist another resident first and had given someone a shower. A staff member called her asking her to go in to the room, saying resident's spouse wanted her to get up to use the bathroom. CNA#1 stated she went into the resident room and spouse was in there talking to resident and told her the resident had just come in the night before. CNA#1 said he began telling her about an incident the resident suffered at home and the hours before the shift change. The spouse then stepped out the room while she began assisting resident. The resident was sitting at the edge of bed and the CNA let her go to get the wheel chair, turned for a split second and the resident fell face down. The CNA immediately called for assistance, the resident was picked up off the floor with two staff members, evaluated and treated, according to policies and procedures of the facility. The CNA admitted she did not look at the CNAAR Care plan book at her start of shift which is her guide on resident care and their needs. The CNA stated she did not work on a specific floor in the facility saying she was a floater/temp staff member and was not familiar with the residents. She stated that the wait for a second person can be cumbersome and she was trying to get ahead of her work. On 01/23/18 at 09:59 AM an Interview was conducted with RN #1 (Registered Nurse) a supervisor. RN#1 stated CNA #1 immediately notified staff about the accident and followed policies and procedures. RN stated that when she entered the resident's room she saw the resident lying face down and there was blood visible on the resident. They picked up the resident from the floor, and provided immediate care and treatment to the resident. The spouse returned to the room as well and was upset but staff tried to maintain calm with appropriate interventions initiated for resident and spouse. RN #1 stated it was learned during the investigation, that CNA#1 did not look at the CNAAR assignment book concerning resident care and began transferring this resident without knowing the resident's care plan; which specified two-person assist on those written orders. This omission contributed to the accident. The RN and Director of Nursing DON immediately investigated the incident and had CNA#1 perform role play to understand what happened. CNA#1 was removed off the unit and terminated immediately after the incident and investigation. The RN said the CNA was usually excellent in all care rendered prior to this incident and it was her only incident. RN#1 stated she was the person who completed her two-month evaluation/competencies and the CNA#1was aware of all her job responsibilities and duties including looking at the assignment book first before performing any resident care. On 1/23/18 at 10:36 AM, an interview with the DOn Director of Nursing was conducted. She was in the facility on that day and was called to the unit concerning the fall. She conducted the investigation with the RN Supervisor asking CNA for role play to understand what happened and the aide said the resident was at edge of bed she went to get wheel chair and the resident fell forward on to floor, cutting her head. Everyone was notified immediately by CNA according to protocol and the resident was picked up and assessed by RN. DON reports the CNA was a temporary CNA/floater and the role play done during investigation with supervisor RN present corroborated with RNs account. The resident asked to go to bathroom and her spouse said she can do it by herself, and he left the room, the CNA assisted the resident to sitting position at the bedside, left her dangling while she reached for the wheel chair, but the resident went down immediately. The CNA failed to get report before going to perform duties on the unit. She did not follow the resident's plan of care. After the immediate intervention and investigation, the CNA was terminated and relieved from her duties at the facility. On 01/23/18 10:43 AM an interview was conducted with the spouse. He said the resident was sleeping and was unable to come to the phone. He stated the second day she was there she was in the room on 10th floor and the CNA went to provide help in dressing resident, He said he told the CNA that she cannot stand alone, at hospital was on a 1:1. He said he left the room to give privacy and walked 10 feet away into the hallway and when he returned he saw the resident lying face down in a pool of blood. He stated he did not witness the fall but that she hit the foot rest from the wheel chair that was on the floor. He reporeds she has a scar between the eye brows from one fall and above the eye brow from a second fall on a different floor. Resident had numerous falls. He said the first one was at home before admission and the others while at the facility. The first one at the facility on the 10th Floor at 4:40am then 8:30 AM on the same day and another serious one was on the 3rd floor 8:30 PM or 9:00 PM unsure of the dates, but was sutured at 5:30 AM the next day at the hospital. The resident was discharged to her home from the facility on 01/14/15. After speaking to the spouse, a brief interview was conducted with the DON (Director of Nursing) on 01/23/18 at 11:13 AM. The DON provided a copy of all incidents/occurrence and investigation for this resident and the information conferred with the information concerning falls that the spouse referred to during the telephone interview but the DON stated that the Resident had multiple falls that was related to cognitive impairment sustained after her initial fall at home and with resident becoming restless and with poor impulse control. The Resident was not exhibiting the understanding that she required assistance. Her BIMS was 13 with some impaired cognition that was undetermined and being reassessed. New interventions were put into place and the spouse was included in the care planning to avoid further falls. 415.12(h)(1)

Based on staff interviews and record review conducted during an abbreviated survey, the facility did not ensure that a resident received the necessary care and services to attain the highest practicable level of physical well- being. Specifically, the facility did not implement a recommendation of an assistive drinking equipment for 1 of 3 residents sampled for quality of care issues (Resident #1). The Occupational Therapy Assistant (OTA) evaluated Resident # 1 on 10/21/2015 at which time a covered mug was recommended due to the resident's incoordination and spilling of liquids, when attempting to hold a mug with both hands. On 11/4/2015, Resident #1 spilled a cup of hot tea sustaining a 6x8cm burn to the left mid-thigh. The recommendation was not implemented and the resident did not receive the covered mug. Complaint # NY 755 The Findings include: Resident #1 is an [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented Resident #1 has intact cognition. The Facility's Investigation Summary dated 11/4/2015 documented that the OTA evaluated Resident #1 on 10/21/2015. It was noted that Resident #1 was having difficulty holding a glass to drink juice. The OTA reportedly recommended a covered mug to allow Resident #1 to safely drink through a straw. The OTA reportedly delivered the covered mug to a member of the dietary staff, however the use of a covered mug was not added to the resident meal ticket and the covered mug was not provided for use at mealtime. The investigation further revealed on 11/4/2015, Resident #1 missed-held a cup of hot tea and it spilled on her left mid-thigh. She sustained a reddened area measured 6x8cm. Diagnosis: [REDACTED]. Review of the OTA note dated 10/21/2015 documented Resident #1 has incoordination and spills beverages. The resolution documented please provide a covered mug. The Rehabilitation Nursing Recommendations Form dated 10/21/2015 documented Resident #1 requires a covered mug to promote safe feeding and eating. The FDR Feeding Equipment list dated 10/16/2015 revealed that Resident #1's name was not on the list. There were no other FDR Feeding Equipment list for the month of October 2015. The Certified Nursing Assistant Assignment Record (CNAAR) for the month of 10/2015 has no documentation for Resident #1 to be provided with a covered mug. The Nursing Progress Note dated 11/4/2015 at 1:30PM documented that Resident #1 is status [REDACTED]. Icepack applied, and order given for polymen to be applied to the affected area. The Medical Doctor Progress Note dated 11/05/2015 documented Resident #1 was assessed for second degree burn measured 8x6cm. The OTA was interviewed on 12/7/2015 at 12:56PM. She stated, on 10/21/2015, she observed Resident #1 with incoordination of her left hand. The Resident was struggling to hold a cup of juice with both hands. The OTA also stated that a recommendation for a covered mug was ordered and she entered the recommendation into the computer. In addition, she stated that she provided the dietary supervisor with the covered mug. The OTA was asked for the name of the dietary supervisor she gave the covered mug to, and she stated that she does not remember. She further stated that the recommendation was also given to the Occupational Therapy Secretary to be added to the feeding list. The Occupational Therapy Secretary was interviewed on 7/5/2016 at 9:50 AM. She stated that she added Resident #1's name and the recommendation for a covered mug to the FDR Feeding Equipment list and placed a copy in the mail box. When the Secretary was asked for the date that she added Resident #1's name and recommendation to the FDR Feeding Equipment list, she stated that she does not remember and that she does not have a copy of the old list. Review of the only FDR Equipment Feeding list dated 10/16/2015 revealed that Resident #1's name was not on the list. The Manager of Food Service was interviewed on 12/7/2015 at 1:18PM. She stated that she does not recall being given a ticket with recommendation for a covered mug for Resident #1. She further stated, if she had been given the recommendation, it would have been entered into the computer. The Registered Nurse that was assigned to Resident #1 was interviewed on 5/2/2016 at 10:00AM. She denied receiving a referral for an assistive device for Resident #1. The Director of Rehabilitation Department was interviewed on 5/9/2016 at 12:30PM. She was asked if any of the Occupational Therapy staff had conducted an observation of the recommended adaptive device for Resident #1 and she stated, Occupational Therapy staff would only observe the resident if they were specifically working with the resident for feeding purposes. The facility revised policy and procedure for adaptive equipment dated 8/2012 documented Nursing, Dieticians and Occupational Therapists will periodically monitor the status of residents using adaptive feeding equipment by observation and report findings to the Quality assurance Committee. 483.25