Every finding on record at Spring Creek Rehabilitation & Nursing Care Center

Based on observation, record review, and interviews during a survey, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice. This was evident for one (1) out of three (3) sample residents (Resident #1) reviewed for nutrition and hydration. Specifically, Resident #1 with history of poor oral intake had no documented oral intake from 03/14/2026 at 8:00 AM through 03/16/2026 at 1:00 PM was not assessed by Registered Nurse to prevent complication. Additionally, the medical doctor was not notified until 03/16/2026 at 3:44 PM after Registered Nurse Supervisor #2's assessment due to Resident #1 change in mental status and was rapidly declining. The findings are: The facility policy titled Meal Consumption with a reviewed date 08/2025 documented the facility will ensure that each resident receives adequate nutrition to maintain health, prevent weight loss, and support overall well-being. Staff will monitor, assist, accurately document meal consumption and promptly intervene when intake is inadequate. Certified Nursing Assistant will document intake percentage for each meal, record refusals and resident behaviors and report poor intake promptly. If a resident consumes less than 50 percent of meals, staff must report to nurse immediately. The nurse's responsibilities will review intake documentation daily, assess resident with poor intake, document interventions and outcomes, notify medical doctor/provider as indicated and ensure care plan reflects nutritional needs. The Medical Doctor /Provider will be notified when meal intake is consistently less than 50 percent, significant decline in intake is observed, weight loss occurs, and residents refuse meals repeatedly. Resident #1 was admitted to the facility with diagnoses including dementia with declining mental and functional status, and pulmonary venous congestion (abnormal accumulation of fluid in the lungs' blood vessels).The Minimum Data Set (a resident assessment tool) dated 03/08/2026, documented Resident #1 had severely impaired cognition and required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating. A dietary care plan for hydration/fluid maintenance dated 02/13/2026 documented Resident #1 was at risk for dehydration due to dementia and varied oral intake. Interventions included will observe for signs and symptoms of dehydration and explore potential reasons for decreased oral intake such as swallowing problems, mouth pain and depression.A review of the physician's order dated 02/13/2026 documented Resident #1 was on no added salt mechanical soft diet with thin liquids and diet was downgraded to puree solids on 03/12/2026 per speech therapist recommendation.A review of the Resident Certified Nursing Assistant Documentation History Detail revealed Resident #1 had no oral intake from 03/14/26 8:00 AM-9:00 AM through 03/16/2026 12:00 PM-1:00 PM. A total of 8 meals were missed.There was no care plan documented for Resident #1 regarding refusal of meals or poor appetite.There was no documentation that the Medical Doctor or Registered Nurse were notified until 03/16/2026 at 3:44 PM when Registered Nurse Supervisor #2 documented Resident #1 was assessed and had a change in mental status and was rapidly declining. A review of nursing notes dated 03/16/2026 at 3:44 PM by Registered Nurse Supervisor #2 documented Resident #1 with change in mental status. Resident #1 has been rapidly declining. Resident #1 was assessed noted weak, lethargic (feeling very tired, sluggish or lacking energy), and only responsive to tactile stimuli. Resident #1 has not been eating and spitting up brown secretions from mouth. Medical Doctor #1 was notified and ordered to start intravenous fluids for three (3) days, complete blood count, comprehensive metabolic panel, urine analysis and culture and sensitivity tests. Resident #1 was seen later by Medical Doctor #1 at bedside and ordered to send Resident #1 to emergency room.A review of medical notes dated 03/16/2026 at 7:34 PM by Medical Doctor #1 documented Resident #1 was weak, lethargic, shaky with heavy breathing, not alert but obtunded (diminished responsiveness to stimuli) , pale color. Ordered laboratory work ups, started intravenous fluids, 1-gram Rocephin given but was not improving. Ordered to send to emergency room as they became unstable due to altered mental status.During an interview on 03/23/2026 at 11:46 AM, Certified Nursing Assistant #1 stated they were the regular staff assigned to Resident #1. Certified Nursing Assistant #1 stated Resident #1 had history of not eating well. Certified Nursing Assistant #1 stated Resident #1 had behavior of being combative during care and when feeding them they would take two (2) spoonful and take a few sips of fluids and then Resident #1 would push away the tray. Certified Nursing Assistant #1 stated not all the time Resident #1 refuses to eat or drink but there were times when they would eat 25 percent to 75 percent of their meals. Certified Nursing Assistant #1 stated they worked on 03/14/2026 to 03/15/2026 from 7:00 AM to 3:00 PM shift and they documented zero 0 percent in eating because Resident #1 did not eat their meals. Certified Nursing Assistant #1 stated they offered fluids to Resident #1 but did not document. Certified Nursing Assistant #1 stated they did not report to Licensed Practical Nurse #1 because they knew that Resident #1 had not been eating and refused to eat.During an interview on 03/24/2026 at 4:45 PM, Certified Nursing Assistant #2 stated they were assigned to Resident #1 on 03/14/2026 and 03/15/2026 from 3:00 PM to 11:00 PM shift. Certified Nursing Assistant #2 stated they were aware that Resident #1 had poor appetite, and the family comes to visit and brings food for Resident #1 to encourage them to eat. Certified Nursing Assistant #2 stated on 03/14/2026 and 03/15/2026 in the evening shift they documented zero (0) percent for food consumption because Resident #1 refuses to eat. Certified Nursing Assistant #2 stated they offered juice to Resident #1 and took it but did not document the fluid consumption. Certified Nursing Assistant #2 stated they were supposed to report to Licensed Practical Nurse #1 when Resident #1 did not eat.During an interview on 03/24/2026 at 5:10 PM, Licensed Practical Nurse #1 stated they worked on 03/14/2026 from 7:00 AM to 11:00 PM and on 03/15/2026 from 3:00 PM to 11:00 PM. Licensed Practical Nurse #1 stated they did not receive report from their staff that Resident #1 did not eat or drink in their shift. Licensed Practical Nurse #1 stated they offered and provided oral fluids to Resident #1 when they give medications to them. Licensed Practical Nurse #1 stated if they knew that Resident #1 did not eat anything at breakfast or lunch or dinner, they would encourage Resident #1 to eat and drink, and they will report to their supervisor. Licensed Practical Nurse #1 stated they did their rounds during meal times, and they did not observed Resident #1 not eating. Licensed Practical Nurse #1 stated they did not observed Resident #1 weak or less responsive in their shift.During an interview on 03/30/2026 at 10:54 AM, Licensed Practical Nurse #2 stated they worked on 03/15/2026 from 7:00AM-3:00 PM shift. Licensed Practical Nurse #2 stated staff did not report to them that Resident #1 did not eat breakfast or lunch. Licensed Practical Nurse #2 stated if they received report, they would notify their supervisor. Licensed Practical Nurse #2 stated they gave medications to Resident #1 with no problem. Licensed Practical Nurse #1 stated on 03/15/2026, Resident #1's family member #1 was at their bedside encouraging them to drink and they assisted them in giving the supplement and Resident #1 drank some of it.During an interview on 03/30/2026 at 11:14 AM, Registered Nurse Supervisor #1 stated they worked on 03/14/2026 and 03/15/2026 from 8:00 AM to 4:00 PM. Registered Nurse Supervisor #1 stated they did not receive any report that Resident #1 had poor appetite or did not eat on both days. Registered Nurse Supervisor #1 stated the Certified Nursing Assistant should notify the unit nurse when Resident #1 refused or did not eat anything and they will notify the medical doctor. Registered Nurse Supervisor #1 stated if they reported to them, they would come and observe Resident #1's eating and continue to offer their supplement. Registered Nurse Supervisor #1 stated the nurse manager on the unit are responsible for running the report to check the certified nursing assistant's documentation. During an interview on 03/23/2026 at 1:01 PM, Registered Nurse Supervisor #2 stated they were the unit manager where Resident #1 resided. Registered Nurse Supervisor #2 stated they knew Resident #1 had history of poor appetite, combative behavior, at times refuses medications or meals and they addressed them in their care plan meeting on 02/25/2026. Registered Nurse Supervisor #2 stated the Health Care Proxy and Adult Sibling #1 were very involved with Resident #1's care. Registered Nurse Supervisor #2 stated they reviewed the 24-hour report on 03/16/2026, and they did not observed Resident #1 in the report for any unusual changes in their condition or for not eating. Registered Nurse Supervisor #2 stated they are responsible for checking the completeness of documentation for their staff but unable to see the percentage of oral intake of Resident #1. Registered Nurse Supervisor #2 stated they observed Resident #1 's sudden change in condition on 03/16/2026 (unsure of time) and they notified the medical doctor immediately and health care proxy. During an interview on 03/24/2026 at 5:20 PM, Director of Nursing stated the change in Resident #1's condition was sudden, and the facility took immediate action on 03/16/2026 until the medical doctor decided to transfer Resident #1 to the hospital. Director of Nursing stated that as they are reviewing the certified nursing assistant's documentation for the month of March for Resident #1 in eating, they observed from 03/13/2026 of 4:00 PM, Resident #1 had zero (0) percent eaten until 03/16/2026 of 1:00 PM. Director of Nursing stated they were not aware that some staff were not documenting the fluid consumption as well taken by Resident #1. Director of Nursing stated the staff should have reported to the unit nurses when Resident #1 did not eat or refused to eat. Director of Nursing stated the unit managers were responsible in running the certified nursing assistant's documentation to ensure the completeness of care provided but unable to view the percentage of how much Resident #1 ate. Director of Nursing stated they taught the unit managers to run the report to check the eating/fluid consumption to prevent the recurrence of the incident. Director of Nursing stated they followed up Resident #1 in the hospital and they said they admitted them but did not provide them with diagnosis.During an interview on 03/30/2026 at 12:28 PM, Medical Doctor #1 stated they last examined Resident #1 on 03/13/2026 and documented Resident #1 was eating well. Medical Doctor #1 stated they did not receive a call on 03/15/2026 that Resident #1 was not eating or drinking. Medical Doctor #1 stated if they notified them, they would start an intravenous fluid for hydration and blood work up. Medical Doctor #1 stated they notified them of change in condition on 03/16/2026 (unsure of time) and examined Resident #1. Medical Doctor #1 stated the sudden decline in Resident #1's condition was not the result of Resident #1's not eating but because there were other underlying conditions. 10 New York Codes, Rules, and Regulations 415.12

Based on record review and interviews conducted during an abbreviated survey (NY00351563), the facility did not permit a resident to return to the facility following hospitalization . This was evident for one (1) of six (6) residents (Resident #1). Specifically, on 09/10/2024 Resident #1 was transferred to the hospital for an evaluation of severe dysphagia. During an interview with Resident #1's Representative on 02/07/2025 at 11:50 AM, they stated that the facility refused to readmit Resident #1 to the facility. Additionally, the facility did not notify Resident #1, or their representative, and the Long-term Care Ombudsman in writing of the discharge, including notification of appeal rights. The hospital transferred Resident #1 to another facility. The findings include: The facility policy and procedure titled Admissions Process dated 10/2024 documented Resident-applicants to the facility will be screened to determine the applicant the level of care available at the facility. Residents returning to the facility within 24 hours following a hospital emergency room evaluation are not classified as a readmission. Readmission is same as admission protocol. The facility policy and procedure titled Discharge Planning: Discharge Notification to Resident/Family dated 08/2024 documented it is the policy of this facility and to the best of the ability of the Facility's discharge planning Social Worker, to plan and facilitate a resident's discharge in recognition of the residents right to receive considerate and timely notice of such plan; in collaboration and coordination with the resident and his or her representative, so as to best insure appropriate placement for the resident who has care needs that cannot be met by the Facility. The facility policy and procedure did not identify a protocol for a resident who was transferred to the hospital from the facility but is not being accepted back into the facility. Resident #1 was admitted to the facility on with diagnoses of Cerebral Infarction, Cardiovascular Accident with left sided weakness, and left hemiparesis. The Minimum Data Set (an assessment tool) dated 08/05/2024 documented Resident #1 was cognitively intact. The Minimum Data Set, dated dated dated [DATE] titled Nursing Home Discharge documented return anticipated. A nursing progress note dated 09/10/2024 at 11:55 AM by Registered Nursing Supervisor #1 documented Resident #1 was seen and assessed by the medical doctor post a swallowing test that was performed by Speech Therapist. The test result showed Resident #1 was not able to tolerate their diet. Family was contacted and made aware that resident needs further evaluation and possible feeding tube placement. Resident #1 was transferred to hospital on 09/10/2024 for severe dysphagia. A Physician's progress note dated 09/10/2024 at 11:13 AM documented they met with the Interdisciplinary Team and discussed the findings of the swallowing test results and that it was not safe to continue a diet of any consistency. The swallowing test results were discussed in detail with Resident #1's representative. Recommendation was made for Resident #1 to be transferred to the hospital for an additional dysphagia evaluation and an alternative method of feeding (such as feeding tube) if necessary. The family verbalized understanding. A Transfer/Discharge document dated 09/10/2024 at 12:47 PM by Registered Nurse Supervisor #1 documented Resident #1 was being transferred to the hospital for severe dysphagia, possible tube placement. A Hospital and Community Patient Review Instrument dated 09/10/2024 documented primary diagnoses as Dehydration and Dysphagia. According to the Patient Review Instrument Resident #1 was observed, tested , and evaluated for the ability to orally consume solid foods and liquids. A modified barium swallow test was done. Impressions: Resident presents with mild-moderate oropharyngeal dysphagia with noted silent aspiration across trials of liquids (aspiration eliminated given use of chin tuck maneuver). Recommendations: initiate diet of soft and bite sized solids, and mildly thick liquids with consistent use of chin tuck for intake of liquids. Maintain aspiration precautions (head of bed elevated to 90 degrees during oral intake and no less than 45 degrees for 30 minutes following oral intake, small bite, small sips, slow pacing). Speech-language pathologist to follow up for dysphagia management and training in consistent use of chin tuck maneuver. A documented titled CarePort - Printable Review Referral dated 09/13/2024, revealed several email communications between the facility and hospital staff. Email dates ranged from 09/13/2024 through 09/19/2024. Email entry dates from 09/18/2024 to 09/19/2024 showed documentation from the facility to the hospital stating they are unable to accept Resident #1 due to care needs exceeding current capacity. There is no documented evidence that a written Notice of Discharge with appeals rights was send to Resident #1 or their representative. There is no documented evidence that the Ombudsman was notified of Resident #1's discharge and appeals rights. During an interview on 02/07/2025 at 11:50 AM, Resident #1's representative stated Resident #1 was transferred to the hospital for a feeding tube placement and the facility refused to readmit Resident #1. Resident #1's Representative stated that the hospital physician stated Resident #1 did not need a feeding tube and the facility refused to accept Resident #1 back to the facility. Resident #1's Representative stated that the facility did not give them nor Resident #1 a discharge notice with appeals rights. During an interview on 02/07/2025 at 2:48 PM, the Director of Social Service stated a meeting was held on 09/10/2024 with Resident #1's representative regarding the Resident changed in condition. The Director of Social Service stated that the swallowing evaluation and test result was discussed with the family by Medical Doctor. The Director of Social Service stated that Resident #1's family member was notified that Resident #1 was high risk for aspiration pneumonia and cannot have anything by mouth. The Director of Social Worker stated that the Medical Doctor recommended Resident #1 to be transferred to the hospital for further evaluation. The Director of Social Service stated that they did not send Resident #1 nor their representative a 30-day notice of discharge with appeals rights. The Director of Social Service stated the Medical Doctor spoke with Resident #1's representatives and explained to them that it would be medically unsafe to accept Resident #1 back at this time. During an interview on 02/07/2025 at 2:55 PM. Admission Staff #1 stated that they received a Hospital and Community Patient Review Instrument from the hospital for Resident #1's return on 09/13/2024. Admission Staff #1 stated that the Patient Review Instrument was reviewed by the medical team including the Medical Director and it was determined that Resident #1 would not be returning to the facility. During an interview on 02/10/2025 at 3:00 PM, the Medical Doctor stated that they were involved in the decision to transfer Resident #1 to the hospital on 09/10/2024 for possible Gastronomy Tube. The Medical Doctor stated that they had some concerns regarding Resident #1 being at high risk for aspiration. The Medical Doctor stated Resident #1 was status post stroke and was placed on a puree diet with thicken liquid, but Resident #1 and their family was not compliant with the diet. The Medical Doctor stated that the dietician and speech therapist had numerous conversations with the family regarding the safest possible diet for the dysphagia to prevent aspiration pneumonia. The Medical Doctor stated that the test result reveals that Resident #1 was at risk for aspirating in all consistency. The Medical Doctor stated that they recommended Resident #1 to be transferred to the hospital for a follow up evaluation to determined how to move forward. The Medical Doctor stated that they spoke with the hospital staff and informed them that Resident #1 was transfer for evaluation and to treat the dysphagia and, if possible, to determine safe feeding practices. The Medical Doctor stated the team had decided until the dysphagia issues were addressed or corrected the facility would not be able to take care of Resident #1. Resident #1 did not come back to the facility. 10NYCRR415.3(e)(2)(ii)(d)

Based on record review and interviews during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, the facility reported short staffing on weekends confirmed by a review of the weekend staffing and the Payroll Based Journal Staffing Data Report. The findings include but are not limited to: The facility policy titled Staffing dated 10/2024 stated it is the policy of the facility to provide enough nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and facility assessment. The Payroll Based Journal Staffing Data Report for the 4th quarter of 2024 (07/01/2024 to 09/30/2024) documented that excessively low weekend staffing was triggered. The Facility Assessment Tool last updated on 06/2024 documented a facility capacity of 188 residents with a staffing plan by shift as follows: Day shift: 13 Licensed Nurses providing direct care and 24 Certified Nursing Assistants Evening shift: 9 Licensed Nurses providing direct care and 19 Certified Nursing Assistants Night shift: 6 Licensed Nurses providing direct care and 10 Certified Nursing Assistants Total staffing for 24-hour period: 28 Licensed Nurses providing direct care and 54-Certified Nursing Assistants The undated document titled Certified Nursing Assistant Staffing Par Levels and Nurses Par Levels documented a staffing plan by shift and unit as follows: Day shift by units: Unit 2AB: 3 Nurses and 5 Certified Nursing Assistants Unit 2 CD: 3 Nurses and 5 Certified Nursing Assistants Unit 3 AB: 2 Nurses and 5 Certified Nursing Assistants Unit 3 CD: 3 Nurses and 5 Certified Nursing Assistants Unit 4 CD: 2 Nurses and 4 Certified Nursing Assistants Day shift total: 13 Nurses and 24 Certified Nursing Assistants Evening shift by units: 2 RN supervisors on shift for all units Unit 2AB: 2 Licensed Practical Nurse and 4 Certified Nursing Assistants Unit 2 CD: 2 Licensed Practical Nurse and 4 Certified Nursing Assistants Unit 3 AB: 1 Licensed Practical Nurse and 4 Certified Nursing Assistants Unit 3 CD: 1 Licensed Practical Nurse and 4 Certified Nursing Assistants Unit 4 CD: 1 Licensed Practical Nurse and 3 Certified Nursing Assistants Day shift total: 9 Nurses and 19 Certified Nursing Assistants Night shift by units: 1 RN supervisors on shift for all units Unit 2AB: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants Unit 2 CD: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants Unit 3 AB: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants Unit 3 CD: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants Unit 4 CD: 1 Licensed Practical Nurse and 2 Certified Nursing Assistants Day shift total: 6 Nurses and 10 Certified Nursing Assistants Total staffing for 24-hour period: 28 Nurses and 54 Certified Nursing Assistants Review of the actual weekend facility staffing schedule from 07/01/2024 to 09/30/2024 documented the following: On 07/06/2024 on the 7 AM-3 PM shift, there was a shortage of: 1 Nurse on 2 CD. On 07/07/2024 on the 7AM-3 PM shift, there was a shortage of: 1 Nurse on 3 CD. On 07/07/2024 on the 3-11 PM shift, there was a shortage of: 1 Nurse on 2 AB. On 07/13/2024 on the 3-11 PM shift, there was a shortage of: 1 Nurse on 2 AB, 1 CNA on 2 CD. On 07/21/2024 on the 7AM-3 PM shift, there was a shortage of: 1 Nurse and 1 Certified Nursing Assistance on 2 AB. On 07/28/2024 on the 7AM-3 PM shift, there was a shortage of : 1 Certified Nursing Assistant on 2AB, 1 Nurse on 2CD and 1 Certified Nursing Assistant on 3 CD. On 07/28/2024 on the 3PM-11 PM shift, there was a shortage of : 1 Nurse on 2AB, 1 Certified Nursing Assistant on 2 CD and 3 AB. On 08/03/2024 on the 3PM-11 PM shift, there was a shortage of : 1 Nurse on 2AB, 1 Certified Nursing Assistant on 3 AB. On 08/04/2024 on the 3PM-11 PM shift, there was a shortage of : 1 Nurse on 2AB, 1 Certified Nursing Assistant on 3 AB. On 08/10/2024 on the 7AM-3 PM shift, there was a shortage of : 1 Certified Nursing Assistant on 2CD and 3 CD. On 08/10/2024 on the 3AM-11PM shift, there was a shortage of : 1 Certified Nursing Assistant on 3 CD. On 08/11/2024 on the 7AM-3PM shift, there was a shortage of : 1 Nurse on 3 CD. On 08/17/2024 on the 7AM-3PM shift, there was a shortage of : 1 Nurse on 2 AB , 3 CD. On 08/18/2024 on the 7AM-3PM shift, there was a shortage of : 1 Nurse on 2 CD. On 08/25/2024 on the 3PM-11PM shift, there was a shortage of : 1 Certified Nursing Assistant on 2 CD and 3 AB. ON 08/31/2024, on the 7AM- 3 PM shift, there was a shortage of : 1 Certified Nursing Assistant on 2 AB. ON 08/31/2024, on the 3PM- 11 PM shift, there was a shortage of : 1 Certified Nursing Assistant on 4CD. On 09/01/2024, on the 7AM- 3 PM shift, there was a shortage of : 1 Nurse and 1 Certified Nursing Assistant on 2 AB, 1 Nurse on 2CD, On 09/07/2024, on the 3PM-11PM shift, there was a shortage of: 1 Certified Nursing Assistant on 2AB. On 09/08/2024, on the 7AM- 3 PM shift, there was a shortage of : 1 Nurse on 2 AB and 2CD. On 09/08/2024, on the 3PM-11PM shift, there was a shortage of: 1 Nurse on 2CD. On 09/14/2024, on the 7AM- 3 PM shift, there was a shortage of : 1 Certified Nursing Assistant on 3 AB and 3 CD. On 09/15/2024, on the 3PM-11PM shift, there was a shortage of: 1 Nurse on 2CD. On 09/21/2024, on the 3PM-11PM shift, there was a shortage of: 1 Certified Nursing Assistant on 2CD. On 09/22/2024, on the 7AM- 3 PM shift, there was a shortage of : 1 Nurse on 2CD. On 09/28/2024, on the 7AM- 3 PM shift, there was a shortage of : 1 Certified Nursing Assistant on 4CD. On 09/28/2024, on the 3PM- 11PM shift, there was a shortage of : 1 Certified Nursing Assistant on 2AB and 3 CD. A review of the facility weekend staffing As part of the Staffing facility task, staffing sheets were also reviewed for the weekend of 02/08/2025 - 02/09/2025. On Saturday, 02/08/2025, on the 7AM- 3 PM shift there was a shortage of 1 Nurse on 3 CD. On Saturday, 02/08/2025, on the 3PM-11PM shift there was a shortage of: 1 Certified Nursing Assistant on 3 AB. On Sunday, 02/09/2025, on the 7AM-3PM shift there was a shortage of : 1 Nurse on 3 CD and 1 Certified Nursing Assistant on 4 CD. On Sunday, 02/09/2025, on the 3PM-11PM shift there was a shortage of : 1 Certified Nursing Assistant on 3 AB and 3 CD. On 02/12/2025 at 11:19 AM, Resident #77 was interviewed and stated they are short staffed and there are days when Certified Nursing Assistants have 14-15 residents assigned to each aides particularly on the weekends. On 02/05/2025 at 04:50 PM, Resident #116's next of kin was interviewed and stated the facility had issues with staffing and the Resident was smelly when they came to visit this past Saturday. On 02/05/2025 at 10:16 AM, Resident #34 was interviewed and stated the facility is short staffed most weekends. On 02/11/2025 at 03:35 PM, Certified Nursing Assistant #10 was interviewed and stated they work every other weekends and there are days when they have 13 residents on their assignment instead of 10. They stated they had to rush when providing care and difficult for them to take a break. On 02/11/2025 at 03:41 PM, Certified Nursing Assistant #16 was interviewed and stated they work on weekends and there will be days when they 13 to 14 residents on their assignment. They stated it is too much for them, they do not take breaks, and will be rushing to provide care. They stated residents complain about not getting changed on time due to not having enough staff. On 02/11/2025 at 11:55 AM, Registered Nurse Supervisor #6 was interviewed and stated there is usually 1 Registered Nurse Supervisor during the weekends and there are a lot of staff call outs. When a nurse calls out, other nurses will be transferred to a different floor with less coverage and the Registered Nurse Supervisor will come in to help the Licensed Practical Nurses. Registered Nurse Supervisor #6 stated they move the Certified Nursing Assistants to another unit when they are short to evenly distribute the staff across all units. The Staffing Coordinator was not available for interview during the survey period. On 02/12/2025 at 10:34 AM, Director of Nursing #1 was interviewed and stated census and acuity determine staffing levels. Staffing levels are often reassessed at least every 3 months. The Director of Nursing stated they have a list of staff available to work in case there are call outs. They stated one of the major issue they have is that new staff cannot meet the schedule because they failed to inform the facility they have another job. Director of Nursing #1 stated they have a high turn over rate of staff due to staff having a second job or some are in school. On 02/12/2025 at 12:39 PM, Administrator #1 was interviewed and stated they were not aware they were not reaching their targeted staffing levels over the summer. They stated they have increased absences during summer due to vacations and holidays. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, record review and interview during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure individual resident financial records were made available to resident and resident representatives through quarterly statements. Specifically, quarterly statements were not provided in writing to residents and/or resident representatives within 30 days after the end of the quarter. This was evident in 1 (Resident #142) of 2 residents reviewed for Personal Funds out of 39 total sampled residents. The findings are: The facility Policy and Procedure titled Resident Funds Accounts with a last revision date of 07/2024 documented that the facility will provide on request, and at least quarterly to the resident or resident's designated or legal representative, a statement showing the account balance including funds deposited and withdrawn and interest accrued. This will be documented in resident's chart. On 02/05/25 at 11:20 AM, Resident #142 was interviewed and stated they have an account with the facility, but they have not been getting copy of their account statement from the facility. The Quarterly Minimum Data Set, dated dated dated [DATE] documented that Resident #142 had intact cognition and participated in assessment and goal setting. Resident #142's Fund Ledger dated 04/15/2024 for the period of 01/01/2024 - 03/31/2024 documented an open balance of $75.00 and a combined current total balance of $100.00. Resident Fund Ledger dated 10/29/2024 for the period of 07/01/24 - 09/30/24 documented an open balance of $75.00 and a combined current total balance of $25.00. Resident Fund Ledger dated 01/20/25 for the period of 10/01/2024 - 12/31/2024 documented an open balance of $25.00 and a combined current total balance of $25.00. There was documentation on the statements that resident was unable to sign. There was no documentation in any of the resident's medical record that a copy of the statement has been provided to the resident or that the Resident declined to receive the copy and requested that the copy be mailed to their family On 02/10/2025 at 09:51 AM, Registered Nurse #7, who was the Unit Manager, was interviewed and stated that the Social Worker is responsible for giving residents their account statement. They stated nursing is not in charge of keeping or monitoring the residents' funds. On 02/10/2025 at 09:59 AM, Social Service Director was interviewed and stated they distribute copy of the statement to the alert and oriented residents quarterly and mail copy to the family of the residents that are not alert and oriented, residents signed the copy when they are given, and the copies of the signed statement are kept on file. They stated that Resident #142 was seen about a week ago and was verbally informed of the account balance, copy of the statement mailed to the family because resident is unable to sign the copy. On 02/10/2025 at 02:14 PM, the Financial Controller was interviewed and stated the statement is printed out and given to the Social Worker to give to the residents or mail to the resident's family, and the statement should be signed for, by the resident, or resident's family when they receive the copy. The Controller stated they are not aware that Resident #142 is not being given the statement. The Controller further stated that residents that are alert and oriented should be given the statement, even if they cannot sign for it. The Controller stated if a copy is not given to cognitively intact residents, then the staff are not following directions. On 02/12/2025 at 02:43 PM, the Administrator was interviewed and stated that they were not aware that Resident #142 was not provided a copy of their quarterly statement. They stated they were informed by the Social Worker that Resident #142 does not want to have a copy of the statement and that it should be mailed to the family. 10 NYCRR 415.26(h)(5)(iii)

Based on record review and interview during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure that, to the extent practicable, the resident or resident representative participated in the development, review, and revision of the comprehensive care plan. This was evident in 1 (Resident #36) of 4 residents reviewed for Care Planning. Specifically, Resident #36's representative has been unable to attend care plan meetings. The facility failed to ensure that the care plan meeting invitations were mailed and received by Resident #36's representative. The findings are: The facility policy titled Comprehensive Care Plan with a reviewed date of 06/2024 documented that the facility will have a Comprehensive Care Plan completed in accordance with Federal and State requirements. The development of the Comprehensive Care Plan is prepared with an interdisciplinary team approach. The team members include the resident and the resident's family or their legal representative. Resident #36 had diagnoses which included Dementia, Alzheimer's Disease, and Major Depressive Disorder. The Minimum Data Set assessment dated [DATE] documented that Resident #36 was severely impaired in cognition. The Minimum Data Set assessment also documented Resident # 36 and their representative participated in the assessment. On 02/06/2025 at 10:22 AM, Resident #36 was interviewed and stated they did not recall having care plan meeting with the interdisciplinary team and was not sure if their representative participated in the care plan meeting for them. On 02/07/2025 at 10:11 AM, the State Surveyor called the primary representative on Resident #36's face sheet. The message from the phone service carrier saying the phone number was not in service. On 02/10/2025 at 10:13 AM, the State Surveyor called Resident #36's primary representative again after the facility updated their phone number in the Resident's medical record. The representative stated the Director of Social Services called their family member and got their phone number on 2/7/2025. The representative stated they lived in the state of New Jersey and did not receive any invitation letter or call from the facility to participate in the care plan meetings for Resident #36. The representative also stated they would like to participate in the care plan meeting for Resident #36 if they were invited to the meetings. The representative further stated the address listed at Resident #36's medical record for them was Resident #36's address in [NAME] of New York City before their admission to the facility. The 2024 care plan schedule documented Resident #36 had care plan meetings scheduled on 1/2/2024, 2/13/2024, 4/16/2024, 7/9/2024, 10/1/2024, and 12/31/2024. The Social Services note dated 1/2/2024, 2/14/2024, 4/16/2024, 7/9/2024, 10/1/2024, and 12/30/2024 documented Resident #36 was unable to meaningfully participate in the care plan meeting. The Social Services notes also documented letters were mailed to representative for invitation to care plan meeting. The Social Services notes further documented the representative did not call back to participate in the care plan meetings. The care plan meeting reports dated 1/2/2024, 2/13/2024, 4/16/2024, 7/9/2024, 10/1/2024, and 12/31/2024 documented family was invited to and did not attend the care plan meetings. The envelopes for care plan meeting invitation to Resident #36's representative had Resident #36's address in [NAME] of New York City before their admission to the facility. The Social Services note dated 2/7/2025 documented the social worker called Resident #36's representative to discuss plan of care and the phone was not working. The Social Services note dated 2/7/2025 documented the social worker finally spoke to the representative and updated the contact information of the representative in Resident #36's medical record. There was no documented evidence in Resident #36's medical records that the care plan meeting invitations were mailed to the designated representative, that the facility had confirmed the representative's correct contact information, and any follow up to confirm invitations to care plan meeting were received by the representative. On 02/10/2025 at 11:20 AM, the Social Services Director was interviewed and stated they mailed the invitation of the care plan meeting to the representative after receiving the care plan meeting schedule from the Minimum Data Set Department about 1 month ahead of the care plan meetings. Social Services Director also stated the invitation of care plan meeting was mailed by regular mail. Social Services Director further stated they assumed the invitation of care plan meeting was delivered to the representative if it was not returned to the facility. Social Services Director stated they did not call the representative to follow up if they received the invitation and did not call them on the day the care plan meeting was held. Social Services Director also stated they just used the address in the medical record to mail the invitation and did not confirm if the address was updated or correct. Social Services Director further stated they had no proof that the invitation of care plan meeting was mailed to the representative. 10 NYCRR 415.3(f)(1)(v)

Based on interview and record review conducted during the Recertification survey from 02/05/2025 through 02/12/2025, the facility did not ensure that a resident has a right to make choices about aspects of their life in the facility that are significant to the resident. This was evident for 1 (Resident #7) of 1 resident reviewed for Choices. Specifically, Resident #7 was not consistently showered twice a week or according to their preference. The findings are: The facility Policy and Procedure titled Activities of Daily Living dated 3/12/2018 and reviewed 6/2024 stated that all residents will be showered at least twice a week. All showers will be done on the 7AM -3PM or 3PM -11 PM shift. The policy also stated that refusals are documented on the Certified Nursing Assistant accountability record and the nurse must be informed. Resident #7 was admitted to facility with diagnoses that included Atrial Fibrillation, Heart Failure, and Diabetes Mellitus. The Admission Minimum Data Set assessment dated [DATE] documented that Resident #7 had intact cognition and required dependent assistance with showering and bathing. The Admission Minimum Data Set assessment also documented that it was very important for Resident #7 to choose between a tub bath, shower, bed bath, or sponge bath. On 02/05/25 at 02:34 PM, Resident #7 was observed sitting on their wheelchair, neatly dressed and groomed. During an interview Resident #7 stated that they could not recall when last they had received a shower, and that while they would like to shower every day, they could go along with whatever the facility can offer. Resident #7 also stated that they could not recall if showers were discussed with them on admission, however they have hardly had shower since they were admitted and have received regular bed baths. The Resident Nursing Instructions stated that effective 12/11/2024 Resident was to be showered every week on Tuesday at Saturday 3:00 pm-11:00 pm. The Resident CNA (Certified Nursing Assistant) Documentation History Detail dated 11/1/2024 to 2/10/2025 documented that Resident #7 received showers on the following days: 12/17/2024 at 4:36pm, 12/24/2024 at 5:03pm, 01/03/2025 at 5:20pm, 01/13/2025 at 4:45pm, 01/21/2025 at 9:49pm and 02/08/2025 at 9:03pm for a total of six showers since admission on 11/13/2024. On 02/10/25 at 03:12 PM, Certified Nursing Assistant #11 stated during interview that they float throughout the building, but they are familiar with Resident #7 and is assigned to assist with them with care on occasion. Certified Nursing Assistant #11 also stated that they start their day by checking the shower book and computer to know when a resident is scheduled for a shower, and if the resident refused, they would inform the nurse and document the event. Certified Nursing Assistant #11 also stated that they had never provided a shower to Resident #7, as sometimes they check the computer after Resident #7 had already been placed back in bed and then they realized that Resident #7 was supposed to have been showered on that date. Certified Nursing Assistant #11 further stated that the Resident #7 had never refused care from them. On 02/10/25 at 03:27 PM, Licensed Practical Nurse #3 was interviewed and stated that their responsibility is to ensure that residents are properly taken care of and that they are safe. Licensed Practical Nurse #3 also stated that residents are usually showered two times a week. Licensed Practical Nurse #3 further stated that skin checks are done for the resident on shower days. Licensed Practical Nurse #1 stated that they work on the unit two or three times per week and their duties also include checking the Certified Nursing Assistant's accountability report every shift. Licensed Practical Nurse #3 stated that some residents do refuse shower on cold days, but they did not recall that Resident #7 had not refused a shower. On 02/10/25 at 04:36 PM, Registered Nurse #3 was interviewed and stated that they cover all units on the 2nd Floor, and supervise 4 Licensed Practical Nurses, 8 Certified Nursing Assistants and do admissions. Registered Nurse #3 also stated that the schedule for showers is twice a week, and residents can take a shower every day if they want, but they need to let the facility know. Registered Nurse #3 further stated that there is no one that would check the accountability daily, and that the Certified Nursing Assistants would report to the nurse if the resident refused care. Registered Nurse #3 stated that Resident #7 has not complained about not getting showers and it was not brought to their attention, and it is the duty of Licensed Practical Nurse to inform the Certified Nursing Assistants to check the shower schedule. On 02/10/25 at 04:58 PM, the Director of Nursing was interviewed and stated that scheduled showers are mandatory at least twice a week, and residents can get a shower as often as they want if they request it. The Director of Nursing also stated that if residents do not want to shower on the designated shift, the facility can accommodate them. The Director of Nursing further that shower days are assigned to residents on admission. Residents should be asked their preference, and they would like to believe this is being asked, but it is not documented on the actual admission assessment. The Director of Nursing stated that on the shower day the Licensed Practical Nurse goes with the Certified Nursing Assistant to do a skin check. The sign off should be that a shower was given, and that the skin check done. If a resident is refusing the shower, it should be documented. If we are seeing a pattern (three or more) that the resident is not receiving showers, and that only bed baths are documented, then the nurses and supervisor should be discussing with the resident. The Director of Nursing also stated that supervisors should be checking accountability sheets at the end of the shift to make sure all tasks are done. On 02/11/25 at 11:33 AM, a telephone interview was conducted with Certified Nursing Assistant #5 who stated that Resident #7 can be difficult sometimes and tries to be independent. Certified Nursing Assistant #5 also stated that they give showers to Resident #7 and assist them with clean them up after they use bathroom. Certified Nursing Assistant #5 further stated that there is a book that they check to know a resident's shower days. Certified Nursing Assistant #5 stated that sometimes Resident #7 would refuse showers, and they would then just provide a bed bath which they would inform the nurse of sometimes. Certified Nursing Assistant #5 also stated that they offered Resident #7 a shower on their designated days, and they did not document that Resident #7 was refusing showers. 10 NYCRR 415.5 (b)(1-3)

Based on observation, record review, and interview during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure that infection control practices were maintained. This was evident in 11 (Residents # 1, # 8, #26, #31, #39, #44, #54, #82, #102, #145 and #157) of 24 total sampled residents during the Dining Task. Specifically, Certified Nursing Assistant #7 failed to clean their hands in between residents while assisting multiple residents with hand hygiene before meal service. The findings are: The facility policy titled Dining Meal Service with a reviewed date of 01/2025 documented the Certified Nursing Assistant provide residents with hand wipes to perform hand hygiene or assist with performing hand hygiene prior to the meal service. The facility policy titled Handwashing and Hygiene with a reviewed date of 09/2024 documented staff will perform hand hygiene in accordance with Centers of Disease Control guideline and facility policy. Hand hygiene will be performed between providing direct care to residents and before moving from one resident to another resident to provide direct care. During dining observation conducted on the 3rd Floor on 02/05/2025 between 12:02 PM - 12:20 PM, Certified Nursing Assistant #7 was observed assisting Residents #1, #8, #26, #31, #39, #44, #54, #82, #102, #145, and #157 in preparation for meal service. Certified Nursing Assistant #7 failed to perform hand hygiene in between residents, was observed picking up used hand wipes with bare hands, get clean wipes, and proceeded to clean the residents' hands. During an interview on 02/05/2025 at 12:54 PM, Certified Nursing Assistant #7 was interviewed and acknowledged they did not perform hand hygiene between residents. They stated they were not thinking. During an interview on 02/05/2025 at 2:04 PM, Registered Nurse #2 stated Certified Nursing Assistants must perform hand hygiene in between residents to prevent cross contamination. During an interview on 02/12/2025 at 3:14 PM, the Assistant Director of Nursing stated staff are required to provide hand hygiene to residents before meals and must perform hand hygiene themselves in between residents to prevent spread of infection. 10 NYCRR 415.19 (b)(4)

Based on observation, record review, and interviews during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. This was evident in 1 (Resident #101) of 35 total sampled residents. Specifically, during 2 observations conducted on 02/05/2025, medications were observed unattended in Resident #101's bedside. Licensed Practical Nurse #4 failed to ensure Resident #101 had taken the medications before leaving the room and documenting in the Medication Administration Record. The findings are: The facility policy titled Medication Administration and Documentation- General with a last revision date of 05/2024 stated that the Licensed Nurse administers full dose of medication to resident via correct route, offers resident a drink and observes resident to insure medication consumption . Licensed Nurse documents all held or refused medications on the electronic Medication Administration Record, uses prudent professional judgment by informing Physician in a timely manner when medications are held, refused, or otherwise unavailable for administration. The Minimum Data Set assessment dated [DATE] documented Resident #101 was cognitively intact. Resident #101 had diagnoses of Anemia, Coronary Artery Disease, Renal Insufficiency, Diabetes Mellitus and Malnutrition. A review of the physician's order dated 5/31/2024 documented active orders for the following: Ferrous Sulfate 325 milligram (65 mg iron) tablet, 1 tablet by oral route once daily for Iron Deficiency Anemia Eliquis 5 milligram, 1 tablet orally two times a day for Pulmonary Embolism Aspirin 81 milligram, 1 tablet once daily for Atherosclerotic Heart Disease Famotidine 40 milligram/5 milliliter (8 milligram/milliliter) oral suspension, give 2.5 milliliters (20 milligram) by oral route once daily for Gastroesophageal Reflux Disease Riboflavin (Vitamin B2) 100 milligram tablet, give 2 tablets by oral route 2 times per day for Essential Tremor The electronic Medication Administration Record for 02/05/2025, documented that Ferrous Sulfate, Eliquis, Aspirin, Famotidine , and Vitamin B2 were documented as administered at 9:00 AM. On 02/05/2025 at 10:06 AM, Resident #101 was observed sleeping in bed with medications in a pill cup at bedside table. The pill cup contained 2 yellow pills, 1 oval pill, one round pink pill, and one red pill. There was also a liquid medication sitting in another pill cup. On 02/05/2025 at 10:48 AM, Resident #101 observed sleeping in bed with same medications still at the bedside table. The State Surveyor brought these medications to the attention of Licensed Practical Nurse #4 who stated the medications were liquid Iron, Eliquis, Chewable Aspirin, Famotidine, and Vitamin B2. Licensed Practical Nurse #4 stated they thought Resident #101 already took them. On 02/05/2025 at 10:52 AM, Licensed Practical Nurse #4 was interviewed and stated that Resident #101 was eating when they went to administer medication in the morning. Licensed Practical Nurse #4 stated they placed the medication in Resident #101's hand who stated they would take the medications. Licensed Practical Nurse #4 stated they stepped out to talk to another resident in the same room and didn't realize Resident #101 did not take the medications. Licensed Practical Nurse #4 stated they are aware they should be watching the residents take the medication and should be with them until it is taken. On 02/11/2025 at 12:10 PM, the Registered Nurse #6 , who was the Registered Nurse Supervisor was interviewed and stated that the Licensed Practical Nurse #4 should have made sure Resident #101 had taken the medications before signing off on the electronic Medication Administration Record. Registered Nurse #6 stated licensed nurses are discouraged to leave the medications at resident's bedside even if a resident requested because of the risk that other residents may come and take those medications. Registered Nurse #6 stated residents need to be assessed for medication self-administration before they are allowed to take their own medication. They stated Resident #101 was not assessed for self-administration of medication. On 02/12/2025 at 10:45 AM, Director of Nursing #1 was interviewed and stated that medications should never be left at resident's bedside. Director of Nursing #1 stated it is a resident safety issue and must be certain that the resident takes the medications. 10 NYCRR 415.12

Based on record review and interview during the Recertification and Complaint Survey (NY00331525) conducted from 02/05/2025 to 02/12/2025, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, to the State Survey Agency. This was evident in 1 (Resident #97) of 2 residents out of 39 total sampled residents reviewed for Abuse. Specifically, on 01/12/2024 at approximately 8:08 AM, Resident #97 alleged that a staff slapped them in the face. The facility reported the abuse allegation to the New York State Department of Health on 01/12/2024 at 7:03 PM. The findings are: The facility policy titled Abuse Prevention with a last reviewed date of 08/2024 documented that physical abuse includes hitting, slapping, pinching, and kicking. The abuse policy also documented all alleged abuse violations must be reported immediately but not later than 2 hours if the alleged violation involves abuse. Resident #97 was admitted to the facility with diagnoses of Unspecified dementia, Vascular dementia, and Cerebrovascular disease. The Minimum Data Set assessment dated [DATE] documented Resident # 97 had severe impairment in cognition and had no behavior symptoms directed towards others. The facility investigation report documented Resident #97 reported at approximate 09:15 AM on 01/12/2024 that they were slapped on left face by a staff earlier in the morning. The Accident/Incident Report by Licensed Practical Nurse #1 documented Resident #97 reported to them at about 9:15 AM that a certified nursing assistant slapped their face 3 times. The New York State Department of Health Aspen Complaint Tracking System intake documented the incident happened on Friday 01/12/2024 at 08:08. The intake also documented the Administrator was first made aware of the incident on Friday 01/12/2024 at 18:00. The auto reply email from New York State Department of Health to Director of Nursing documented the facility submitted the report to Department of Health on Friday 01/12/2024 at 19:03. On 02/10/2025 at 09:36 AM, Certified Nursing Assistant #2 was interviewed and stated they were assigned to Resident #97 during the day shift from 7:00 AM to 3:00 PM on 01/12/2024. Certified Nursing Assistant #2 stated they made round to their assigned residents between 7:15 AM to 7:30 AM when Resident #97 told them that someone slapped their left face earlier at the night time. Certified Nursing Assistant #2 stated they reported the incident to Licensed Practical Nurse #1 immediately. On 02/10/2025 at 11:38 AM, Licensed Practical Nurse #1 was interviewed and stated Certified Nursing Assistant #2 reported between 7:00 AM and 8:00 AM on 1/12/2024 that Resident #97 made an allegation that someone slapped their left side of the face 3 times. Licensed Practical Nurse #1 stated they reported the allegation to Registered Nurse #1 at about 8:00 AM on 1/12/2024. 02/10/2025 at 11:51 AM, Registered Nurse #1 was interviewed and stated Licensed Practical Nurse #1 reported the allegation made by Resident # 97 upon their arrival to the unit at around 8:00 AM on 1/12/2024. Registered Nurse #1 stated they reported the incident to Director of Nursing immediately as it was an allegation of abuse. On 02/10/2025 at 12:14 PM, Director of Nursing was interviewed and stated they were responsible to report allegations of abuse to the New York State Department of Health. The Director of Nursing stated they had to report allegation of abuse within 2 hours to Department of Health. They stated Registered Nurse #1 reported the allegation in the morning on 1/12/2024. The Director of Nursing stated they did not report the allegation to the New York State of Department of Health because they do not believe the allegation occurred becasue there was no injury and numerous inconsistencies in Resident #97's account. The Director of Nursing stated they decided to report the allegation after Resident #97 accused a Certified Nursing Assistant #1 as the person that slapped them. 10 NYCRR 415.4(b)(2)

Based on observation, record review, and interviews conducted during the Recertification survey from 1/19/23 to 1/26/23, the facility did not ensure infection control practices and procedures were maintained. This was evident for 1 of 5 resident floors (2nd Floor) and 1 (Resident #86) of 37 total sampled residents. Specifically, 1.) unmasked facility clergy was observed providing religious services to residents, and 2.) Resident #86 was placed on indefinite contact isolation in their room for colonized Candida Auris (CA) in the urine. The findings are: The facility policy titled Transmission-Based Precautions last revised 09/2022 documented transmission-based precautions are to be instituted in accordance with Centers for Disease Control (CDC) recommendations with some modifications. Implementation of applicable precautions is based on the potential for transmission, the mechanism of transmission, the emergence of pathogens in the community and the care setting. Standard precautions consist of a group of infection prevention practices that apply to all residents, regardless of suspected or confirmed infection status, in any setting which healthcare is delivered. The policy titled CA dated 12/22 documented as per latest recommendations, continue contact precautions or enhanced barrier precautions. On 01/20/23 at 03:42 PM, the facility Preacher was observed without a facial covering while speaking to 33 residents in the 2nd Floor dayroom. A surgical mask was observed hanging from on the outside of the Preacher's bag. Residents #46, 98, #162, #67, and #74 were unmasked. There were 14 of 33 residents in attendance with masks inappropriately applied leaving their nose and mouth exposed. The residents were seated within 6 feet of each and the preacher was within 6 feet of the residents while speaking. The Preacher finished speaking, donned their mask and exited the dayroom. On 01/20/2023 at 4:00 PM, the Preacher was interviewed and stated they are supposed to wear a mask in the building. The Preacher used to wear a mask when speaking to residents but does not have a microphone and they took a COVID-19 test before speaking with the residents. On 01/26/2023 at 1:13 PM, an interview was conducted with Certified Nursing Assistant (CNA) #1 who stated they noticed the Preacher was not wearing a mask. CNA #1 was attending to residents at the time and the Nursing Supervisor could have addressed the Preacher not wearing a mask. Visitors to the facility should wear masks. On 01/26/2023 at 01:25 PM, Registered Nurse (RN) #1 was interviewed and stated they have noticed visitors not wearing masks appropriately and when this happens, RN #1 offers the visitor a mask and reminds the visitor to have a facial covering. RN #1 conducts rounds on the unit frequently. On 01/26/2023 at 01:33 PM, an interview was conducted with the Infection Preventionist (IP) who stated visitors to the facility should always be wearing a mask. The IP conducts rounds twice per shift and the RNs conduct rounds also. The IP has not received reports of anyone visiting the facility without wearing their mask appropriately. Anyone coming in from the community should be wearing a mask. On 01/26/2023 at 01:37 PM, the Director of Nursing (DON) was interviewed and stated visitors entering the building must wear a mask and the front desk will tell the visitor to put a mask on if they do not have one. If staff notice a visitor without a mask, staff will remind the visitor to wear one and most people comply. 45988 2.) Resident #86 had diagnoses of CA and cerebrovascular accident. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #86 was severely cognitively impaired, enjoyed doing things with groups of people, was totally dependent on staff to perform activities of daily living, and was not on isolation or quarantine for an active infectious disease. From 01/19/23 at 10:31 AM to 1/24/23 at 3:00 PM, there were multiple observations of a Contact Precautions (CP) sign on Resident #86's room door and Resident #86 either in their bed or in a recliner inside their private room. There were no observations of Resident #86 coming out of their room. On 01/26/23 at 11:30 AM, a telephone interview was conducted with Resident #86's representative who stated Resident #86 has been on CP for approximately one year and stays in their room. Prior to being placed on CP, the resident's representative would take Resident #86 outside. They are uncertain whether Recreation visits Resident #86. It would be nice for Resident #86 to get some more stimulation. A Physician Order initiated 03/29/2022 and renewed 12/31/2022 documented Resident #86 was on contact isolation for CA. A comprehensive care plan (CCP) related to Contact Isolation- CA initiated 12/24/21 documented Resident #86 tested positive for CA in the urine on 12/10/21. Interventions included Resident #86 remaining on contact isolation and Rehab and Recreation taking place in the room. The CCP was last reviewed 12/12/22 and documented Resident #86 remained on contact isolation with no symptoms of CA reported. Nursing Note dated 11/8/22 documented Resident #86 remained on contact isolation. There was no documented evidence Resident #86 was reevaluated for CP less restrictive than contact isolation for a long-term diagnosis of CA. On 01/25/23 at 03:05 PM, the Recreation leader was interviewed and stated they visit Resident #86 every other day or every 2 days and provides sensory programs. Resident #86 does not come out of the room unless it is being cleaned. On 01/25/23 at 02:57 PM, an interview was conducted with Certified Nursing Assistant (CNA) #3 who stated they are regularly assigned to Resident #86 and transfer the resident out of bed to the recliner almost daily. Resident #86 stays in the room because they are on CP. Sometimes Resident #86 is moved to the room's entrance area, close to the door, and occasionally to the hallway. Resident #86 can communicate with people. On 01/25/23 at 03:14 PM an interview was conducted with Licensed Practical Nurse (LPN) #2, who stated that Resident #86 comes out of the room to the hallway maybe once a week and does not go to activities held by Recreation. On 01/19/23 at 09:36 AM, Registered Nurse (RN) #4, the unit supervisor, was interviewed and stated Resident #86 was on CP for CA. RN #4 could not specify how long Resident #86 had been on CP, the plan for duration of CP, or whether follow-up CA testing would be performed. On 01/24/23 at 03:04 PM and 01/26/23 at 12:12 PM, the Infection Preventionist (IP) was interviewed and stated Resident #86 returned from the hospital 12/2021 with CA in the urine and advice to start CP. The Medical Director (MDR) was notified and placed Resident #86 on CP. The IP stated they previously discussed the case with the MDR but was unclear on the rationale for keeping Resident #86 on CP for this long. Resident #86 always stayed in the room since 12/2021 and Recreation would visit 3-4 times a week. After speaking with the MDR, the IP stated an epidemiologist with the New York State Department of Health (NYSDOH) recommended to keep Resident #86 on CP. It has now been clarified that Resident #86 is allowed to come out of the room. On 01/24/23 at 05:13 PM, the MDR was interviewed and stated Centers for Disease Control (CDC) recommends placing residents with CA on CP indefinitely. The MDR conferred with an epidemiologist from the NYSDOH, but this was not documented in Resident #86's medical record. CP does not mean Resident #86 had to be kept in their room at all times. Resident #86 can come out of the room if CP were maintained. 415.19(a)(1)(b)(4)

Based on observations, record review, and interviews conducted during the Recertification survey from [DATE] to [DATE], the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards of food service safety. This was evident during the Kitchen observation. Specifically, expired cottage cheese and tofu were stored in the Kitchen refrigerator. The findings are: The facility policy titled Food Safety last reviewed ,d+[DATE] documented food is monitored to ensure quality and freshness. On [DATE] at 09:47 AM, Kitchen observation was conducted with the Food Services Director (FSD) and the following was found in the refrigerator: one 5 lb container of 4% milk-fat cottage cheese with manufacturer stamped expiration date [DATE] and two 14 oz containers of tofu with manufacturer stamped expiration date [DATE]. On [DATE] at 02:09 PM, the Dietary Aide (DA) #1 was interviewed and stated the cottage cheese was delivered 1 month ago and is not something the Kitchen has on a regular basis. The tofu was delivered approximately 1 week ago. DA #1 checks the expiration dates and discards expired items. On [DATE] at 02:17 PM, the FSD was interviewed and stated the FSD conducts daily morning rounds in the Kitchen. The tofu was purchased for a resident approximately 1 month ago and was not discarded after not being used. The FSD did not notice the tofu was expired. Cottage cheese is not used very often and is only served at breakfast to residents who don't like eggs. Food items must be discarded according to the manufacturer's expiration dates. The Kitchen uses the first in-first out method to rotate products. 415.14 (h)

Based on observation, record review and interviews conducted during the Recertification Survey initiated on 1/19/23 and completed on 1/26/23, the facility did not implement policies and procedures to ensure that all staff were fully vaccinated for COVID-19. This was evident for 2 of 5 Certified Nursing Assistants (CNA) reviewed for Infection Control (CNA #4, #5). Specifically, CNA #4 and CNA #5 did not have adequate clinical rationale for not being vaccinated against COVID-19. The findings are: The facility policy titled Novel Coronavirus Vaccination for Staff revised in 9/2022 documented all employees are required to be fully vaccinated as recommended by CDC and NYSDOH unless they meet criteria for a medical exemption: a documented history of a severe allergic reaction to any component of a Covid-19 vaccine or to a substance that is cross-reactive with a component, a documented history of a severe allergic reaction after a previous dose of the Covid-19 vaccine, or physical condition/medical circumstance. The medical exemption must be signed and dated by a licensed practitioner, must include all information specifying which of the authorized vaccines are clinically contraindicated for the staff member and the recognized clinical reasons for the contraindications. Employees who have not received at least a single dose of a covid19 vaccine due to a medical exemption will be required to get tested for covid19 once weekly. 1) The Request for Medical Exemption from COVID-19 Vaccine Form dated 11/26/21 documented CNA #4 had a physical condition such that vaccination is not considered safe. The clinical rationale was underlying heart disease and shortness of breath. The Staffing Schedule from 10/2022 to 1/2023 documented CNA #4 consistently worked in direct contact with residents 5 days a week. 2) The Request for Medical Exemption from COVID-19 Vaccine Form dated 11/18/21 documented CNA #5 had a physical condition such that vaccination is not considered safe. The clinical rationale was asthma and chronic obstructive pulmonary disease in cold weather. The Staffing Schedule from 10/2022 to 1/2023 documented CNA #5 consistently worked in direct contact with residents 5 days a week. There was no documented evidence CNA #2 and CNA #5 had recognized clinical contraindications to receiving the COVID-19 vaccine. On 01/26/23 at 11:59 AM, the Infection Preventionist (IP) was interviewed and stated the facility tests unvaccinated staff members twice weekly for COVID-19. Staff members must provide a medical exemption form signed by their doctor and with a specific reason to be exempted from taking the COVID-19 vaccine. The medical exemptions for CNA #4 and CNA #5 were accepted because they were signed by a doctor. 01/26/23 at 01:01 PM, the Director of Nursing (DON) was interviewed and stated they are aware of unvaccinated staff members but did not review the medical exemption forms. 415.19(a)(1-3)

Based on observation, record review, and interviews conducted during the Recertification survey from 1/19/23 to 1/26/23, the facility did not ensure medications and biologicals were stored in accordance with professional standards of practice. This was evident for 1 of 5 units (2A/B Unit). Specifically, two bags of expired intravenous fluid (IVF) were stored in the 2A/B Unit medication room. The findings are: The facility policy titled Medication Storage last revised 12/2022 documented Nurses will check medication carts, cabinets, and refrigerators for expired medications. All expired medications will be removed and discarded. On 01/24/2023 at 10:52 to 11:12 AM, the 2A/B Unit medication room was observed with Licensed Practical Nurse LPN #2 and the following were observed in the top drawer of the counter: one bag of 250 ml IVF (lot # V21E208) with expiration date of 11/2022 and one bag of 250 ml IVF(lot # V21F24L) with expiration date 12/2022. On 01/24/2023 at 11:12 AM, LPN #2 was interviewed and stated they check the medication room once a week for expired medications and IVF. Nothing in the medication room should be expired. LPN #2 stated they did not notice the expired bags of IVF in the medication room drawer. On 01/24/2023 at 11:31 AM, the Registered Nurse Supervisor (RNS #1) was interviewed and stated they go through the medication room to remove expired medications. The expired IVF bags were overlooked and have been thrown out. On 01/26/2023 at 01:42 PM, the Director of Nursing (DON) was interviewed and stated staff should open and check the drawers of the medication rooms for expired medications. Corrective action was taken for expired IVF bags found in 2A/B Unit medication room. 415.18(e) (1-4)

Based on observation, interviews, and record reviews conducted during a recertification survey from 1/19/23 to 1/26/23, the facility did not ensure that each resident was provided with the necessary care and services to attain or maintain the highest practicable mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. This was evident for 1 (Resident #86) of 37 sampled residents. Specifically, Resident #86 was placed on indefinite contact isolation in their room for colonized Candida Auris (CA) in the urine. As a result, the resident was not allowed to attend activities outside of the room since 12/24/21. The findings are: The policy titled Resident Rights last reviewed 9/2022 documented residents have a right to participate in community activities both inside and outside of facility and the right to reasonable accommodation of needs. Resident #86 had diagnoses of CA and cerebrovascular accident. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #86 was severely cognitively impaired, enjoyed doing things with groups of people, was totally dependent on staff to perform activities of daily living, and was not on isolation or quarantine for an active infectious disease. From 01/19/23 at 10:31 AM to 1/24/23 at 3:00 PM, there were multiple observations of a Contact Precautions (CP) sign on Resident #86's room door and Resident #86 either in their bed or in a recliner inside their private room. There were no observations of Resident #86 coming out of their room. On 01/26/23 at 11:30 AM, a telephone interview was conducted with Resident #86's representative who stated Resident #86 has been on CP for approximately one year and stays in their room. Prior to being placed on CP, the resident's representative would take Resident #86 outside. They are uncertain whether Recreation visits Resident #86. It would be nice for Resident #86 to get some more stimulation. A comprehensive care plan (CCP) related to Contact Isolation- CA initiated 12/24/21 documented Resident #86 tested positive for CA in the urine on 12/10/21. Interventions included Resident #86 remaining on contact isolation and Rehab and Recreation taking place in the room. The CCP was last reviewed 12/12/22 and documented Resident #86 remained on contact isolation with no symptoms of CA reported. A Physician's Order initiated 03/29/2022 and renewed 12/31/2022 documented Resident #86 was on contact isolation for CA. Nursing Note dated 11/8/22 documented Resident #86 remained on contact isolation. There was no documented evidence Resident #86 was reevaluated for CP less restrictive than contact isolation for a long-term diagnosis of CA. On 01/25/23 at 03:05 PM, the Recreation leader was interviewed and stated they visit Resident #86 every other day or every 2 days and provides sensory programs. Resident #86 does not come out of the room unless it is being cleaned. On 01/25/23 at 02:57 PM, an interview was conducted with Certified Nursing Assistant (CNA) #3 who stated they are regularly assigned to Resident #86 and transfer the resident out of bed to the recliner almost daily. Resident #86 stays in the room because they are on CP. Sometimes Resident #86 is moved to the room's entrance area, close to the door, and occasionally to the hallway. Resident #86 can communicate with people. On 01/25/23 at 03:14 PM an interview was conducted with Licensed Practical Nurse (LPN) #2, who stated that Resident #86 comes out of the room to the hallway maybe once a week and does not go to activities held by Recreation. On 01/19/23 at 09:36 AM, Registered Nurse (RN) #4, the unit supervisor, was interviewed and stated Resident #86 was on CP for CA. RN #4 could not specify how long Resident #86 had been on CP, the plan for duration of CP, or whether follow-up CA testing would be performed. On 01/24/23 at 03:04 PM and 01/26/23 at 12:12 PM, the Infection Preventionist (IP) was interviewed and stated Resident #86 returned from the hospital 12/2021 with CA in the urine and advice to start CP. The Medical Director (MDR) was notified and placed Resident #86 on CP. The IP stated they previously discussed the case with the MDR but was unclear on the rationale for keeping Resident #86 on CP for this long. Resident #86 always stayed in the room since 12/2021 and Recreation would visit 3-4 times a week. After speaking with the MDR, the IP stated an epidemiologist with the New York State Department of Health (NYSDOH) recommended to keep Resident #86 on CP. It has now been clarified that Resident #86 is allowed to come out of the room. On 01/24/23 at 05:13 PM, the MDR was interviewed and stated Centers for Disease Control (CDC) recommends placing residents with CA on CP indefinitely. The MDR conferred with an epidemiologist from the NYSDOH, but this was not documented in Resident #86's medical record. CP does not mean Resident #86 had to be kept in their room at all times. Resident #86 can come out of the room if CP were maintained. 415.12

Based on observation, record review, and interview conducted during the abbreviated survey (NY 260) the facility did not ensure that a resident drug regimen was free from unnecessary medication. This was evident for 1 out of 3 residents sampled (Resident #1). Specifically, Resident #1 was administered [MEDICATION(S)] (an antipsychotic medication) 5 mg tablet 1 tablet orally twice a day at 9:00 AM and 5:00 PM for [CONDITION(S)] with delusion. There was no documented evidence that non-pharmacological interventions were attempted prior to the administration of the antipsychotic medication. Additionally, there were no documented behaviors. The findings were: A facility Policy entitled [CONDITION(S)] Medication/Gradual Dose Reduction, revised 10/2021 documented: It is the policy of the facility to utilize [CONDITION(S)] drugs based on a comprehensive assessment of a resident. The facility shall ensure that residents who have not used [CONDITION(S)] drugs are not given these drugs unless [CONDITION(S)] drugs therapy is necessary to treat a specific condition as diagnosed and documented in the medical record. Standards: An Interdisciplinary team including of the Medical Director and Attending Physician will ensure that the use of psychopharmacological medications promotes and or maintains the resident highest practicable, mental, physical, and psychological wellbeing. Procedure: Orders [CONDITION(S)] medication only for the treatment of specific target symptoms related to medical and or psychiatric condition or when the medication meets the needs of the residents to alleviate significant distress for the resident not met using non-pharmacological approaches. Nursing: Monitor for presence of target behaviors by use of daily charting, by exception (i.e., charting only when the behaviors are present) in the EMR (Electronic Medical Record). Utilizes non-pharmacological interventions to reduce or eliminate [CONDITION(S)] medications. Pharmacy Consultant: Monitors [CONDITION(S)] drug use in the facility to ensure that medications are not used in excessive dose or for excessive duration. Resident #1 was admitted to the facility with diagnoses including [CONDITION(S)] with delusions and Dementia. The Minimum Data Set (MDS) dated [DATE] documented that Resident #1 had a Brief Interview for Mental status (BIMS) score of 12/15 indicating moderately impaired cognition. A Care Plan Activity Report (CPAR), by Registered Nurse Supervisor (RNS), dated 09/11/2020 documented that Resident #1 was seen by the Psychiatrist for hallucinations. Documented diagnosis [CONDITION(S)] and multiple medical problems. Plans/Recommendations: start [MEDICATION(S)] 0.5mg by mouth twice a day for 14 days. Re-evaluate by psychiatry in two weeks and supportive nursing care. Nurse Practitioner (NP) notified and agreed with the recommendations. Resident #1's child notified and agreed with treatment plan. A CPAR Progress Note, Registered Nurse (RN) #1, dated 12/23/2020 documented that Resident #1 was re-evaluated by the Psychiatrist on 12/21/2020 for being started on [MEDICATION(S)] ([MEDICATION(S)]) 0.5mg tablet twice a day for two weeks for [CONDITION(S)] with delusions. Documented that Resident #1's speech was spontaneous, articulate and of normal rate and volume. Resident #1's mood was okay, and affect was reactive. Thought processes was disorganized, insight and judgement were poor. Diagnosis: [CONDITION(S)] secondary to AMC (Acute Medical Condition) and multiple medical problems. Recommendations: discontinue [MEDICATION(S)] 0.5mg by mouth twice a day. Supportive nursing care. the Nurse Practitioner (NP) was notified and NP informed Resident #1's child. As per NP, Resident #1's child wants to continue the medication as it is helping the resident. Resident #1 has no behavior currently. A Psychiatrist Progress Note dated 01/04/2021 documented that Resident #1 was seen as per Resident #1's family preference. Resident #1's child made a request to place Resident #1 back on [MEDICATION(S)]. On evaluation, Resident's #1 was awake, alert, and oriented, speech was spontaneous, thought processes were disorganized, insight and judgment were poor. Recommendations: Re-start [MEDICATION(S)] 0.5 mg by oral route twice a day. A review of a CPAR, by RN, dated 01/04/2021 documented that Resident #1 had no behavior currently. A review of a Social Worker's note dated 01/04/2021 documented that Resident #1 was seen by the psychiatrist and placed back on [MEDICATION(S)] as per family request. A review of a Medical Note, by NP, 01/05/2021 documented that Resident #1's child requested that the resident be placed back on [MEDICATION(S)] as the resident was doing a lot better with [MEDICATION(S)]. [MEDICATION(S)] was re-started by the psychiatrist on 01/04/2021. The note further documented that Resident #1's medication review was completed on 01/05/2021. The medication reconciliation was completed on 01/05/2021. A Physician's Order dated 01/04/2021 documented [MEDICATION(S)] 5 mg tablet give 1 tablet (5mg) by oral route two times a day at 9:00 AM and 5:00PM for [CONDITION(S)] with delusions to known physiological condition. The order was signed off by the Medical Doctor on 01/11/2021. A review of the Medication Administration Record (MAR) from 01/04/2021 to 02/03/2021, documented that Resident #1 received [MEDICATION(S)] 5mg tablet 1 tablet (5mg) by oral route twice a day at 9:00AM and 5:00PM for [CONDITION(S)] with delusions. There was no documented evidence in the medical record that non-pharmacological interventions were implemented prior to administration of [MEDICATION(S)] on 01/04/2021. There were no documented behaviors or clinical indications for the use of the medication. Record review of the Psychiatrist notes from 12/2020 through 01/04/2021, revealed that Resident #1 was restarted on [MEDICATION(S)] because Resident #1's child requested it. Two unsuccessful attempts were made to contact RN #1. As per facility, the Psychiatrist has since retired and whereabouts unknown. During a follow up interview on 08/09/2022 at 4:09 PM, the Medical Director (MD) stated that the clinical indication for the medication use was treating psychiatric symptoms/behaviors. MD stated that the facility tried to minimize the use of [CONDITION(S)] medications. MD stated that residents who were on [CONDITION(S)] drugs would receive behavioral interventions such as recreational activities, as well as Gradual Dose Reduction (GDR). MD stated that Resident #1 was on and off the medication due to their Psychiatric Disorder. MD stated that the psychiatrist evaluated Resident #1 to determine Resident #1's improvements on the medication. MD stated that Resident #1's family saw the benefits of the medication and requested to put back on it. MD stated that he/she was not sure if the Psychiatrist spoke to staff members about Resident #1's behavior before recommending the medication. MD stated that he/she was not sure why nurses did not document Resident #1's behavior symptoms. 415.12(l)(1)

Based on observations, record review and staff interviews conducted during the recertification survey, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, a resident with a contracture of 45 degrees to right hand had no assistive device in place. This was evident for 1 of 3 residents reviewed for Limited Range of Motion (ROM) out of a sample of 38 residents investigated. (Resident #56). The findings are: The facility policy titled Splinting Policy dated 10/2018 documented it is the policy of this facility to use modalities , techniques and equipment, such as a splint for splinting a part of one's upper extremity to (a) prevent the progression of a functional deficit, (b) delay limitations in function from developing deficits, injury, disease and to (c) maximize functional performance in daily living. Resident #56 was admitted to the facility with [DIAGNOSES REDACTED]. The resident Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented resident was cognitively intact, is usually able to make self understood and usually understands others, had impairment on one side upper and lower extremity, and received passive ROM on 3 of 7 days, active ROM on 5 of 7 days and received splint or brace assistance on 3 of 7 days. Physician orders [REDACTED]. physician progress notes [REDACTED]. Rehab assessment dated [DATE] documented resident continue to have increase muscle weakness of the left Upper Extremity, increasing difficulty due to increase stiffness on his right hemi limb especially his wrist and hand, difficulty for proper positioning. Device: wheel chair right hand roll splint. Contracture to right wrist. Occupational Therapy progress note dated 1/13/2019 documented Rehab screen completed. The note further documented the resident is a candidate for skilled OT services as the resident presents with increase muscle weakness of the left upper extremity, increasing difficulty with grooming, Upper Body dressing and is prone for more contractures. Rehab Assessment progress note dated 6/27/2019 documented Certified Nursing Assistant (CNA) staff reported that resident has been having increase difficulty to participate in standing program due to multiple episodes of knee buckling and not able to firmly gasp hold on to the side rail as well as increased both upper extremity and lower extremity stiffness/weakness and not able to assist/perform daily tasks or participate in activities of choice safely. Contracture to right wrist. Occupational Therapy progress noted dated 6/27/2019 documented resident is a candidate for skilled therapy services as resident presents with increase stiffness in Right Upper extremity, contracture to right wrist (45 degrees of PROM), decrease strength in Left Lower Extremity and Left Upper Extremity, increased need for assistance with Activity of Daily Living. Occupational Therapy discharge progress note dated 7/30/2019 with date of service 6/27/2019 - 7/23/2019. documented the following recommendations: Patient discharged to reside in this facility. To facilitate patient maintaining current level of performing and in order to prevent decline, development of and instruction in dressing and grooming. Resident discharged to the unit and will perform Passive range of Motion (PROM) to right upper extremity twice a day or as tolerated to maintain current functional level. Resident will be monitored for any changes. Physical Therapy Discharge note dated 8/9/2019 with date of service: 6/27/2019 to 7/24/2019 documented in recommendations: Assistive device for safe functional mobility and Rehab Nursing program. Floor Management Program. Active Range of Motion on Left leg, 3 sets of 10 reps daily or as tolerated to maintain strength and joint integrity. OT progress notes dated 11/7/2018 documented nursing reports that resident is non-compliant with use of Right hand roll splint. Resident was approached about the splint and re-educated on the importance of using the splint however he continues to refuse to use the splint. At this time the splint is discontinued due to non-compliance. Resident will be monitored for any changes. Review of Physician discontinued orders dated standing 1/11/2016 and discontinued 11/7/2018 documented apply right hand roll splint at all times, remove for hygiene care and skin checks. There was no documented evidence that resident was reassessed for splint use and that additional interventions were attempted to provide, and support splint use for the resident since device was discontinued in (MONTH) (YEAR). There was no documented evidence that the resident consistently refused the splint device. There was no documented evidence that a care plan was developed to address resident's noncompliance with the splint device. On 12/12/19 at 03:56 PM, an interview was conducted with the Director of Rehabilitation (DOR). The DOR stated the resident had a stroke and was on and off therapy for a long time. Residents are assessed quarterly and if the resident needs it is placed on therapy. The DOR also stated this resident has right hand weakness secondary to his stroke and believed the resident had a splint, which was discontinued because the resident was non-compliant with this splint. The resident does not have a splint or hand roll at present. The DOR further stated that he is unsure why OT did not recommend the splint/hand roll for the resident and was unable to state the last time a splint and or hand roll was offered to the resident and the resident refused to have splint/and or hand roll placed. On 12/13/19 at 09:43 AM, an interview was conducted with the Occupational Therapist (OT). The OT stated the resident is at risk for having contractures. When a resident is placed on therapy, especially a resident with [MEDICAL CONDITION] exercises are done to help relax the muscles and follow up with a trial of a splint if needed. The resident was given splint before and he took the splint off so the order for splint was discontinued. OT also stated a splint was started in 1/11/ and was discontinued for non-compliance in 11/7/2018. The OT further stated she was unable to state if the splint and or any device was offered to resident when he was last discharged from OT in (MONTH) 2019. The OT also offered no explanation why resident last assessment was in (MONTH) 2019 and had not been completed on a quarterly basis. On 12/13/19 at 10:18 AM, an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA #1 stated she is aware the resident had a stroke and the resident is unable to use his right hand and uses his left hand to lift the hand to move it around. CNA #1 also stated she was not told resident had a splint for his right hand, but she saw documentation in the accountability record regarding a splint but when she asked about it, she was informed that the resident does not have a splint. CNA#1 further stated that resident is not resistive to care and presents no behavioral concerns. 415.12(3)(b)

Based on observations, record reviews and staff interview conducted during the Recertification survey, the facility did not ensure that a person-centered care plans with measurable goals, time frames and interventions were developed to address resident's concerns. Specifically, there was no documented evidence that a Comprehensive Care Plan (CCP) was developed, implemented and included measurable goals, objectives and interventions to address a resident with contracture. This was evident for 1 of 3 residents reviewed for Limited Range of Motion (ROM) out of a sample of 38 residents investigated. (Resident #56) The findings are: The facility policy and procedure titled Comprehensive Assessment (MDS) and Care Planning dated 10/2018 documented that the Comprehensive Care Plan (CCP's) will summarize the medical, nursing, nutritional, social leisure, emotional, and related goals and limitations anticipated for the resident. The policy further documented all disciplines are responsible for identifying a resident's problem or need and entering it into the CCP, based upon the assessment process. Resident #56 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented resident was cognitively intact, had impairment on one side upper and lower extremity, and received passive ROM on 3 of 7 days, active ROM on 5 of 7 days and received splint or brace assistance on 3 of 7 days. On 12/10/19 at 02:36 PM, resident was observed sitting in the dining area in his wheelchair. Resident was noted to have a Left Above Knee Amputation and contracture to right hand. There was no splint device observed on resident's right. Resident was also observed using the left hand to lift and move his right hand. On 12/12/19 12:39 PM, resident was observed sitting in a wheelchair in the dining areas at lunch time. Resident observed using left hand to pick up a bowl of soup and was able to use left hand to pick up soup bowl and drink the soup. Resident was able to feed self. Resident's right hand rested in resident's lap. No splint device was observed on the right hand. On 12/13/19 at 08:37 AM, resident observed sitting in bed room watching television. Resident appeared well groomed, in no acute distress. Right hand resting in resident's lap, no splint device observed. Review of physician orders [REDACTED]. Rehab Assessment progress note dated 6/27/2019 documented Certified Nursing Assistant (CNA) staff reported that resident has been having increase difficulty to participate in standing program due to multiple episodes of knee buckling and not able to firmly gasp hold on to the side rail as well as increased both upper extremity and lower extremity stiffness/weakness and not able to assist/perform daily tasks or participate in activities of choice safely. Contracture to right wrist. Occupational Therapy (OT) progress noted dated 6/27/2019 documented resident is a candidate for skilled therapy services as resident presents with increase stiffness in Right Upper extremity, contracture to right wrist (45 degrees of PROM), decrease strength in Left Lower Extremity and Left Upper Extremity increased need for assistance with Activity of Daily Living. Rehab assessment dated [DATE] documented resident continue to have increase muscle weakness of the left Upper Extremity, increasing difficulty due to increase stiffness on his right hemi limb especially his wrist and hand, difficulty for proper positioning. Device: wheel chair right hand roll splint. Contracture to right wrist. Occupational Therapy progress note dated 1/13/2019 documented Rehab screen completed. The note further documented the resident is a candidate for skilled OT services as the resident presents with increase muscle weakness of the left upper extremity, increasing difficulty with grooming, Upper Body dressing and is prone for more contractures. The CCP titled Neurological Disease:[MEDICAL CONDITION] effective 5/5/2016 with last monitoring note dated 11/1/2019 documented the following interventions: Resident will not experience complications of immobility due to [MEDICAL CONDITION] such as ulcers or contractures. Administer medications as prescribed by MD, assist resident in ADL tasks, encourage participation in PT/OT/ST as ordered, instruct resident to seek for assistance as needed, Keep call bell within easy reach. There was no documented evidence a comprehensive care plan had been developed to address care for a resident with a contracture. On 12/13/19 at 11:14 AM, an interview was conducted with Nurse Manager (NM) for unit. NM also stated she is aware the resident has a contracture but was not aware that there was no care plan in place for contractures. The NM further stated that she was newly hired and is still familiarizing herself with the unit and reviewing the resident's records. The NM also stated she is aware of her responsibility for implementing and updating the resident care plans. On 12/16/2019 at 10:20 AM, an interview was conducted with the Director of Nursing. The DON stated the Unit Manager for the 2nd floor is new to facility and is still in the process of learning. The DON stated the Unit Managers, and Registered Nurses are responsible for implementing and updating the care plans. DON stated the issue of developing and implementing care plans has been discussed and addressed in Quality Assurance meetings. 415.11(c)(1)

Based on interviews and record review conducted during the recertification survey, the facility did not ensure that a copy of the Notice of Transfer was sent to a representative of the Office of the State Long-Term Care Ombudsman within a timely manner when a resident was discharged from the facility to the hospital. This was evident for 1 of 2 residents reviewed for hospitalization in a sample size of 38 residents. (Resident #96) The findings are: The facility policy and procedure Discharge Planning/Implementation dated 11/20/2019 documented for all facility-initiated transfers/discharges, a copy of the Discharge Notice must be forwarded to the Ombudsman when it is issued to the resident. Resident #96 was admitted to the facility with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident with intact cognition, the resident and resident's family or significant other participated in the assessment, the resident expected to be discharged to the community, and there was an active discharge plan occurring. Nursing Progress noted dated 10/24/2019 documented that the resident was transferred to the emergency room because the resident had swelling and ecchymosis to the right hand. The resident's daughter was notified, the medical provider informed, and a telephone order was received to transfer the resident to the emergency room . The Discharge MDS dated [DATE] documented that resident discharged with anticipated return, unplanned discharge to an acute hospital. Nursing Progress noted dated 11/12/2019 documented that the resident was transferred to the hospital for respiratory distress. The Discharge Minimum Data Set ((MDS) dated [DATE] documented that resident discharged with anticipated return, unplanned discharge to an acute hospital. Nursing Progress noted dated 11/25/2019 documented that the resident was transferred to the hospital for decreased oxygen saturation. The medical provider was notified, and resident was transferred per the medical providers order. The Discharge Minimum Data Set ((MDS) dated [DATE] documented that resident had planned discharge, the discharge assessment with anticipated return and discharged to acute hospital. There was no documented evidence that the facility sent a Notice of Discharge/Transfer to the Ombudsman's Office following multiple transfers to the hospital. On 12/16/19 at 11:24 AM, an interview was conducted with the Social Services Director (SSD). The SSD stated that if there is a resident-initiated discharge a notice is not sent to the Ombudsman. Notices are only sent if it is facility-initiated. The SSD further stated facility-initiated discharges include residents who are functioning at higher level who do not want to be discharged . In a case like this, the facility would look for adult home or lower level of care, provide the resident a 30-day notice and the facility would inform the ombudsman. The SSD further stated she was not sure whether hospital discharges would be considered a facility-initiated discharge which required notification to be sent to the Ombudsman's office. The facility provided a memo dated 12/16/2019 which documented for the months of (MONTH) 2019 and (MONTH) 2019, no discharge notices were sent to the Ombudsman office as there were no facility-initiated discharges during that time. All discharges were resident and family driven. 415.3(h)(1)(iv)(a-e)

Based on record review and staff interview during the recertification survey, the facility did not ensure that the residents attending physicians reviewed the total program of care at each visit. Specifically, 1)Resident #29 had a hearing deficit that the attending physician did not identify and as a result was not provided services recommended by audiologist. 2) The attending physician for a Diabetic Resident (Resident #93) receiving insulin, did not evaluate, comment on, or determine treatment for [REDACTED]. The results were recorded in the resident's medical record. This was evident for 2 of 3 resident reviewed for Vision/Hearing out of a sample of 52 residents. The undated facility policy and procedure Physician Visits, Routine/New Admission documented the resident attending physician will review the resident's total plan of care at least quarterly. The findings are: 1. Resident #29 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Significant Change MDS dated [DATE] documented short and long term memory impairment with moderately impaired decision-making skills, has no hearing aid, and required extensive assistance with activities of daily living. On 09/19/18 at 03:11 PM, the resident was observed laying in bed, but did not respond to knocking on the door, and name being called upon entering the room. The resident turned quickly in the bed and was surprised to see State Surveyor present. The resident pointed to ear, and stated that he could not hear well. The resident also stated, They tried to give me one (hearing aid), but I did not get one. The Audiology consult dated 2/27/18 documented annual audiogram with significant BL (bilateral) loss. Difficult to determine thresholds due to poor reliability of responses. Severe/profound loss BL, type A. Recommend Annual Audiogram H AID's (hearing aids) x2.Physician documented medically cleared for hearing aid. Audiology consult dated 4/18/18 documented took ear impression today. Left ear for ear mold. Ordering power bte left ear. Will call when hearing aid is ready to issue. Medical Progress Notes and Physician's Periodic Assessment and Plan of Care dated 1/18 through 9/18 did not document that the resident had a hearing deficit. There was no documented evidence that the resident was being assessed or followed up for hearing loss on the physician's monthly visits. On 09/26/18 at 02:50 PM an interview was conducted with the attending physician. The attending physician stated that the resident had a hearing problem when he was admitted , and was sent for an audiology consult. The physician stated that in his monthly notes he did not comment on the audiology consultant's report, because it is not his scope of practice. He further stated that he thought the audiologist took care of the resident getting a hearing aid. He then stated, that he thought that there was an insurance problem, that caused a delay in the resident getting the hearing aid. However, he stated that he did not document this, because he thought the consultant was following the resident's care. On 9/26/18 at 03:34 PM, an interview was conducted with the Medical Director. The Medical Director stated that physicians may only monitor acute issues and not necessarily follow the resident for chronic issues. He also stated that physicians are encouraged to seek consultations for resident issues that they cannot manage, but any issues identified by the consultant should be followed up on until the issue is resolved. He further stated that he does not monitor the work of the physicians but discusses issues during monthly meetings with all the medical staff. 415.15 (b)(2)(iii) 2. Resident # 93 a [AGE] years old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set( MDS ) 3.0 assessment dated [DATE] identified the resident with intact cognition The resident was documented as being able to make needs known, and requiring assitance with most activities of daily living. The comprehensive care plan on diabetic care dated 07/03/2018 identified that resident is at risk for abnormal glucose levels secondary to DM. The targeted goals were: resident will be free from signs and symptoms of hypo/[MEDICAL CONDITION], infection and that the blood glucose will stabilized within a desired range. The documented interventions were: to observe for signs and symptoms of [MEDICAL CONDITION] and [DIAGNOSES REDACTED], in cases of low blood sugar, administer fast acting carbohydrate unable to swallow, so administer [MEDICATION NAME] intramuscularly (IM). Monitor for sign and symptoms of infection, observe for compliance and meal completion, educate and teach resident and family on meal compliance, skin and foot care and S/six of hypo/[MEDICAL CONDITION] as appropriate and needed. The physician's orders [REDACTED]. Monitor blood sugar before meals TID and if above 240 or less than 70 milligram per dilution ( mg/dl ), call medical doctor (MD )/Nurse practitioner (NP). The resident's medication administration and treatment record for fingerstick (blood sugar readings) from 09/01/2018 to 09/27/2018 documented the following levels above 240: Date -----------------6:00 am ----------11:00 Am ---------5:00 PM 09/03/2018 214 240 231 09/04/2018 345 240 271 09/05/2018 286 240 240 09/06/2018 385 240 250 09/07/2018 381 371 509 09/08/2018 366 240 229 09/09/2018 230 240 250 09/10/2018 257 240 227 09/11/2018 370 270 240 09/12/2018 254 215 240 09/13/2018 311 240 480 09/14/2018 111 100 382 09/15/2018 372 228 434 09/16/2018 250 238 347 09/17/2018 211 188 357 09/18/2018 315 240 314 09/19/2018 314 300 385 09/20/2018 246 288 300 09/24/2018 205 09/25/2018 217 224 300 09/26/2018 253 164 254 09/27/2018 263 204 --- Of the 23 opportunities there were 16 times the resident had elevated FBS at 6:00 AM from 246 to 372 mg/dl. There were 3 times during lunch that that the resident had blood sugar levels between 270 and 371. There were 13 times during when the resident's blood sugar levels were between 250 and 509 mg/dl. The results of the [MEDICATION NAME] hemogobin (HGB A1C ) taken on 10/5/2017 was 7.7 %. There was no HGBAIC done from (MONTH) (YEAR) to (MONTH) (YEAR). The most recent test was taken on 09/05/2018, and the reading was 10.5 %, normal range is 4.0-5.6. The interdisciplinary notes from 06/01/2018 to 09/27/2018 were reviewed. The nurse's note dated 7/27/18, documented that the nurse called the physician to inform him of FBS of 480 mg/dl. There was no note indicating that the physician or Nurse Practitioner (NP) acknolwedged this FBS. There were no other notes indicating that that the nurses informed the medical staff of FBS over 240mg/dl. Further review of the medical and nurse practitioner notes revealed no documented evidence that the elevated blood sugar were addressed. The NP was interviewed on 09/27/2018 at 3:00 PM and stated I cover the attending physician when he is not here and if the licensed nurses will call me for any concerns or issues, I will attend to it. If the licensed nurses will not bring to my attention a resident with elevated blood sugar level , I would not know about it. She then proceeded to review the blood glucose results including the HGBA1C of 10.5 % and stated, they are high. The attending physician was interviewed by phone on 09/27/2018 at 4:00 PM and stated I know the resident very well , she has a lot of issues. She has been stable now for the last 2 months . The SA (state agency ) asked how often he sees and review the blood sugar of the resident? He stated I see the resident three (3) times a week. Furthermore, the MD was informed that the resident's hgbA1C from (YEAR) was 7.7 and is now 10.5 %. He could not provide an answer to how the resident was treated or if a change was made to care plan after elevated hgbAIC. He stated that there are times when nursing staff contacted him about elevated blood sugars, but there was no documented evidence to corroborate. When asked what does he do when informed by the nurse of a changes in the resident's condition. An answer was not provided. 415.15(h)(2)(iii)

Based on observation, record review and staff interviews, during the recertification survey, the facility did not immediately consult with the resident's physician a change in the resident's physical condition (that is, a clinical complication). Specifically, Nursing staff recorded elevated blood sugars for Resident #93 on multiple occasions. However, the resident's attending physician was not informed of the elevated blood sugar or consulted with for appropriate treatment and evaluation. There was a pattern of deficient practice that affected 1 out f 52 sampled residents. The finding is: The facility policy and procedure on management of the diabetic resident states: The facility will ensure that all diabetic residents receive appropriate care and services to manage the residents' diabetes . Services to be provided will include therapeutic diet , medications , blood glucose testing as well as other laboratory and diagnostic testing. Such monitoring will allow the staff to implement timely and or revised therapeutic interventions to assist in managing the residents' diabetes. Resident # 93 is a [AGE] years old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ( MDS ) 3.0 assessment done on 07/31/2018 assessed the resident with intact cognition. The resident requires assistance in most activities of daily living. The comprehensive care plan on diabetic care dated 07/03/2018 identified that resident is at risk for abnormal glucose levels secondary to DM. The targeted goals were: resident will be free from signs and symptoms of hypo/[MEDICAL CONDITION], infection and that the blood glucose will stabilized within a desired range. The documented interventions were: to observe for signs and symptoms of [MEDICAL CONDITION] and [DIAGNOSES REDACTED], in cases of low blood sugar, administer fast acting carbohydrate unable to swallow, so administer [MEDICATION NAME] intramuscularly (IM). Monitor for sign and symptoms of infection, observe for compliance and meal completion, educate and teach resident and family on meal compliance, skin and foot care and S/six of hypo/[MEDICAL CONDITION] as appropriate and needed. The physician's orders [REDACTED]. Monitor blood sugar before meals TID and if above 240 or less than 70 milligram per dilution (mg/dl ), call medical doctor (MD )/Nurse practitioner (NP). Review of the resident's medication administration and treatment record for fingerstick from 09/01/2018 to 09/27/2018 documented the following: Date -----------------6:00 am ----------11:00 Am ---------5:00 PM 09/01/2018 --------- 226 178 152 milligram per dilution (mg/dl) 09/02/2018 226 235 130 09/03/2018 214 240 231 09/04/2018 345 240 271 09/05/2018 286 240 240 09/06/2018 385 240 250 09/07/2018 381 371 509 09/08/2018 366 240 229 09/09/2018 230 240 250 09/10/2018 257 240 227 09/11/2018 370 270 240 09/12/2018 254 215 240 09/13/2018 311 240 480 09/14/2018 111 100 382 09/15/2018 372 228 434 09/16/2018 250 238 347 09/17/2018 211 188 357 09/18/2018 315 240 314 09/19/2018 314 300 385 09/20/2018 246 288 300 09/24/2018 205 09/25/2018 217 224 300 09/26/2018 253 164 254 09/27/2018 263 204 --- Of the 23 opportunities there were 16 times the resident had elevated FBS at 6:00 AM from 246 to 372 mg/dl. There were 3 times during lunch that that the resident had blood sugar levels between 270 and 371. There were 13 times during when the resident's blood sugar levels were between 250 and 509 mg/dl. The results of the [MEDICATION NAME] hemogobin (HGB A1C ) taken on 10/5/2017 was 7.7 %. There was no HGBAIC done from (MONTH) (YEAR) to (MONTH) (YEAR). The most recent test was taken on 09/05/2018, and the reading was 10.5 %, normal range is 4.0-5.6. The interdisciplinary notes from 06/01/2018 to 09/27/2018 were reviewed. The nurse's note dated 7/27/18, documented that the nurse called the physician to inform him of FBS of 480 mg/dl. There was no note indicating that the physician or Nurse Practitioner (NP) acknolwedged this FBS. There were no other notes indicating that that the nurses informed the medical staff of FBS over 240mg/dl. Further review of the medical and nurse practitioner notes revealed no documented evidence that the elevated blood sugar were addressed. The NP was interviewed on 09/27/2018 at 3:00 PM and stated I cover the attending physician when he is not here and if the licensed nurses will call me for any concerns or issues , I will attend to it. If the licensed nurses will not bring to my attention a resident with elevated blood sugar level, I would not know about it. She then proceeded to review the blood glucose results including the HGBA1C of 10.5 % and stated, they are high. The attending physician was interviewed by phone on 09/27/2018 at 4:00 PM and stated I know the resident very well , she has a lot of issues. She has been stable now for the last 2 months . The SA (state agency ) asked how often he sees and review the blood sugar of the resident? He stated I see the resident three (3) times a week. Furthermore, the MD was informed that the resident's hgbA1C from (YEAR) was 7.7 and is now 10.5 %. He could not provide an answer to how the resident was treated or if a change was made to care plan after elevated hgbAIC. He stated that there are times when nursing staff contacted him about elevated blood sugars, but there was no documented evidence to corroborate. When asked what does he do when informed by the nurse of a changes in the resident's condition. An answer was not provided. 415.3(e)(2)(ii)(jj)(b)