Every finding on record at The Monarch at Brooklyn Rehabilitation and Nursing

Based on observation, record review, and interview during the Recertification and Abbreviated Survey (Incident 673700) the facility failed to ensure each resident received adequate supervision to prevent elopement. This was evident for one (1) (Resident #203) of two (2) residents reviewed for wandering and elopement out of 35 total sampled residents. Specifically, on 09/01/2024, Resident #203, who was severely impaired in cognition and had a wander alert device (a device that alerts staff when the resident is exiting the building), left the building undetected through the front door at 11:25 AM. Resident #203 was located by the facility staff approximately 300 feet from the facility and returned to the facility at 1:11 PM. The findings include:The policy and procedure titled Wandering and Elopement Risk with a last revised date of 05/20/2025 defined elopement as an occurrence when a resident leaves the premises or safe area without authorization and/or any necessary supervision to do so. The policy documented if a resident is identified as at risk for wandering, elopement, or other safety issue, the resident's care plan will include strategies and interventions to maintain the resident's safety. Residents identified as having an elopement risk will have a wander alert device applied. The wander alert device will be checked daily and as needed for placement and functioning. A photograph will be placed in the elopement binders on the units and at the front desk. Resident #203 had diagnoses of Cerebrovascular Accident, Non-Alzheimer's Dementia, and Parkinson's Disease. The Minimum Data Set (a resident assessment tool) dated 08/08/2024 documented Resident #203 had severely impaired cognition and exhibited wandering behavior. A comprehensive care plan for Unsafe Wandering at Moderate/High Risk was initiated for Resident #203 on 08/29/2024. The care plan documented that resident was walking off unit and had verbal threats to leave or escape. The facility interventions include use of wander alert device; check wander alert device for placement and functioning every shift; replace the wander alert device per manufacturer's recommendation; ascertain the resident's whereabouts during each shift; maintain the resident's photo on the unit and at the receptionist's desk; and alarmed doors on either end of the hallway on the unit.A behavior note dated 08/29/2024 at 9:57 PM documented Resident #203 was wandering and seeking to exit the floor by attempting to press the elevator. A wander alert device was placed on the left wrist. A nurse's note dated 08/29/2024 at 10:16 PM documented that Resident #203 was wandering in the hallway at around 9:00 PM, and at about 9:09 PM rushed to the elevator when they saw a family member leaving the unit. A physician's order dated 08/29/2024 included wander alert device to left wrist, check placement every shift. An order to check wander alert device function every night shift was entered on 09/18/2024. The Treatment Administration Records from 08/29/2024 to 02/11/2025 documented the wander alert device was in place every shift.A physician's order dated 07/10/2024 documented every 30-minute safety visual check. The Medication Administration Record documented that 30-minute checks were completed on 09/01/2024 for the 7:00 AM to 3:00 PM shift. A nurse's notes dated 09/03/2024 at 6:41 PM documented 09/01/2024 at 12:27 phone call received that resident was missing from unit. Resident returned to the facility at 1:11 after elopement procedure was initiated.Review of the staff written statements dated 09/01/2025 revealed that on 09/01/2024, Resident #203 was in the dining room at 8:00 AM for breakfast. The resident was administered medications at 9:30 AM and received their 10:00 AM Ensure supplement. At about 10:30 AM, the resident went to the bathroom and refused to go back to the dining room and was walking up and down the hallway. Certified Nursing Assistant #6 documented in their written statement that the last time they saw Resident #203 was at 11:00. The Resident Incident/Investigation Report dated 09/01/2024 documented that based on review of camera footage, Resident #203 left the unit at approximately 11:20 AM on 09/01/2024. The resident was observed in the lobby area and exited the building at 11:25 AM. The front desk security guard was interacting with two (2) visitors who needed assistance with entering information on the kiosk when the resident walked by him and exited through the front entrance. The facility investigation documented all wander alert mechanisms were checked and working, however, Resident #203's wander alert device was not working at the time. On 08/11/2025 at 2:23 PM an interview was conducted with Certified Nursing Assistant #6 who was on the unit at the time Resident #203 eloped. They stated the resident was on 30-minute checks and that the resident was a wanderer. They stated on the day of the incident; they found out that Resident #203 was missing when they cannot find the resident during lunch time. They stated they immediately started searching for the resident. On 08/12/2025 at 12:37 PM, an interview was conducted with the Receptionist, who stated that the front desk has one receptionist during the day and a security guard at nighttime. They stated they are responsible for screening visitors and making sure residents do not leave the facility unescorted. The receptionist stated they have pictures of residents who are wanderer at the front desk. The receptionist stated that elevators will not move when a resident with a wander alert device board and the front will lock when a wander alert device is near the door, the door will not open. The Receptionist stated they were not working on the day of the incident.On 08/14/2025 at 10:42 AM, an interview was conducted with the Assistant Director of Nursing who stated that they reviewed Resident #203's elopement incident and they discovered that the resident's wander alert device was not working at the time the resident exited. They also stated that at the time of the elopement, the elevator does not stop even when a resident with wander alert device gets in. On 08/14/2025 at 9:43 AM, an interview was conducted with the Director of Nursing who stated they were recently hired at the facility and was not working at the facility at the time of the elopement incident. They stated they reviewed the records related to the incident and found that the resident's wander alert device was not working at the time of elopement. They also stated that the security was distracted as they were attending to visitors10 NYCRR 415.12(h)(2)

Based on record review and staff interviews conducted during the Recertification survey from 08/07/2025 to 08/14/2025, the facility did not ensure that residents' Comprehensive Care Plans were reviewed and revised after each assessment. This was evident for one (1) (Resident #8) of five (5) residents reviewed for Unnecessary Medications. Specifically, there was no documented evidence that the Comprehensive Care Plans for Anticoagulation Therapy and Psychoactive Drug Use were reviewed and revised after the last quarterly Minimum Data Set assessment was completed.The findings include: The facility policy and procedure titled Comprehensive Care Plans dated 05/25/2025 stated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The interdisciplinary team reviews and updates the care plan at least quarterly, in conjunction with the required quarterly Minimum Data Set assessment. Resident #8 had diagnoses including Acute Embolism, Diabetes Mellitus, and Non-Alzheimer's Dementia. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #8 had severe cognitive impairments and was prescribed an anticoagulant. The Physician's Order dated 03/20/2025 and renewed on 08/04/2025 documented that Resident #8 was prescribed Xarelto 20 mg daily for Acute Embolism and Thrombus of the Lower Right Extremity. The Physician's Order dated 10/01/2024 documented that Resident #8 was prescribed Quetiapine 50 mg daily for Bipolar Disorder. The Physician's Order dated 04/14/2025 documented that Quetiapine was decreased to 25 mg daily, and then discontinued entirely on 04/27/2025. The Anticoagulation Therapy Comprehensive Care Plan dated 03/20/2025 documented that Resident #8 was on an anticoagulant related to a history of Deep Venous Thrombosis. On 03/31/2025, the Comprehensive Care Plan was updated to document that the plan of care was reviewed and would continue for the next 90 days. There was no documented evidence that the facility reviewed the Anticoagulation Therapy Comprehensive Care Plan following Resident #8's Quarterly Minimum Data Set Assessment on 06/13/2025. The Psychoactive Drug Use Comprehensive Care Plan dated 10/01/2024 documented that Resident #8 was prescribed psychoactive medication to treat Bipolar Disorder. On 04/17/2025, the Comprehensive Care Plan was updated to document that Resident #8 was seen by the psychiatrist who had decreased their Quetiapine dose from 50 mg daily to 25 mg daily, with plans to discontinue the medication entirely two weeks later. There was no documented evidence that the facility reviewed the Psychoactive Drug Use Comprehensive Care Plan following Resident #8's Quarterly Minimum Data Set Assessment on 06/13/2025, or after Quetiapine was discontinued on 04/27/2025. On 08/13/2025 at 11:58 AM, Registered Nurse #2, who is a Registered Nurse Supervisor, was interviewed and stated that Resident #8 takes an anticoagulant for Deep Venous Thrombosis prevention and had previously taken an antipsychotic medication which has since been discontinued. Registered Nurse #2 stated that Comprehensive Care Plans are updated quarterly, typically before the Minimum Data Set assessment is completed. They further stated that the Minimum Data Set department sends out a schedule of care plans that are due to be updated, and that nurses can also see which care plans need to be updated in the electronic medical record. Registered Nurse #2 stated that they were not aware that Resident #8's Comprehensive Care Plans were overdue for a review, and that they should have been reviewed before the Quarterly Minimum Data Set assessment dated [DATE] was completed. On 08/14/2025 at 10:20 AM, the Director of Nursing was interviewed and stated that Comprehensive Care Plans are updated quarterly when the Minimum Data Set assessments are conducted. The Director of Nursing stated that the nurse manager on the unit is responsible for updating the Anticoagulant Therapy and Psychoactive Drug Use Comprehensive Care Plans, and that they did not know why they were not updated when the Quarterly Minimum Data Set assessment dated [DATE] was completed. On 08/14/2025 at 12:15 PM, the Administrator was interviewed and stated that Comprehensive Care Plans are updated quarterly when the Minimum Data Set assessments are conducted. The Administrator stated that they were unaware that Resident #8's Comprehensive Care Plans had not been reviewed and would investigate why that occurred in conjunction with the nursing department. NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews, the facility failed to maintain a resident's right to a safe, clean, comfortable homelike environment. This was evident in one (1) (Unit 4) of 5 units observed. Specifically, the unit hallway, dayroom, and pantry room were observed with dark, brown-colored stains on the floor. The floor edges were observed with old, yellow-colored grease-like stains. A heavy strong old odor was also noted. The findings include: The facility was not able to present a policy related to the deficiency. On 08/07/2025 at 10:15 AM, during observation in Unit 4, the floors in the hallway in front of the nursing station and in front of the elevator, entrance by the dayroom, and the pantry were observed with dirt, dark stains, and with old, yellow-colored grease-like stain. A heavy strong odor was also noted. There were 26 residents in the day room at the time of this observation. On 08/07/2025 10:59 AM, an interview was conducted with Licensed Practical Nurse #3. They stated that the hallway, at the front of the elevator, and towards the day room have always been dirty. They stated that this unit is a dementia floor, and that residents throw food all over and spit liquids on the floor. Licensed Practical Nurse #3 stated they informed the housekeeping staff about this concern, and nothing was done about it. On 08/07/2025 at 11:20 AM, an interview was conducted with Registered Nurse #2, who was the nursing supervisor, who stated that they were aware of the dirty floor and that the management is aware of this environment issues and is being currently worked on. On 08/07/2025 at 10:40 AM, an interview was conducted with Housekeeping Staff #1 who stated their duty is to ensure that the floor is clean and that garbage is removed. They stated that the evening housekeeping staff is responsible for scrubbing the floor. On 08/07/2025 at 11:30 AM, an interview was conducted with Housekeeping Staff #2 and stated they are assigned in Unit 4 and that the evening staff are responsible for mopping the floor. On 08/12/2025 at 11:00 AM, an interview was conducted with the Director of Housekeeping. They stated that they have at least one housekeeper on each unit. They stated they have two (2) porters who work in the evening shift and they pick-up the garbage and dirty linen and buff the hallway. The Director of Housekeeping stated they were aware of the dirty floor in Unit 4; however, the floor has residents with dementia and takes more time to clean.10 NYCRR 415.5(h)(2)

Based on observation, record review, and interview, the facility failed to ensure that the Minimum Data Set assessment accurately reflected a resident's status. This was evident for 2 (Resident #12 and #188) of 35 total sampled residents. Specifically, 1.) Resident #188's Minimum Data Set assessment did not accurately reflect their fall history; 2.) Resident #12's Minimum Data Set assessment documented they had diagnosis of Post Traumatic Stress Disorder. There was no documented evidence that the resident had this diagnosis. The findings include: The facility policy and procedure titled Minimum Data Set Accuracy dated 5/20/2025 documented that it is the policy of the facility that any person completing a portion of the Minimum Data Set (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. 1.) Resident #188 had diagnoses of Anoxic Brain Injury, Seizure, Depression and Asthma. A comprehensive care plan for falls was initiated for Resident #188 on 07/09/2024 and was last reviewed on 04/29/2025. The care plan documented that Resident #188 had actual fall occurrences on: 09/18/2024, 12/14/2024, 02/01/2025, 03/07/2025, 04/02/2025, and 04/27/2025. The Annual Minimum Data Set assessment dated [DATE] did not document any fall occurrence for Resident #188. On 08/14/2025 at 12:22 PM, the Minimum Data Set Coordinator was interviewed and stated they are responsible for scheduling the Minimum Data Set assessments and monitoring the assessments for completion. The Minimum Data Set Coordinator stated Resident #188 had fall occurrences after the last assessment and it should have been coded on the annual Minimum Data Set. 2.) Resident #12 had diagnoses of Unspecified dementia, Schizophrenia, and Major depressive disorder. The Annual Minimum Data Set assessment dated [DATE] documented Resident #12 had severely impaired cognition, had no behavior symptoms, and had diagnosis of Post Traumatic Stress Disorder. A review of Resident #12's medical record did not reveal a diagnosis of Post Traumatic Stress Disorder. On 08/12/2025 at 10:59 AM, the Minimum Data Set Coordinator was interviewed and stated their main responsibilities include scheduling the Minimum Data Set assessment and care plan meetings, monitoring them for completion, and submission of Minimum Data Sets. They stated they did not check Resident #12's assessment for accuracy since the assessors who completed the assessment were professionals. They stated that they reviewed the resident's medical record and spoke with the assessor; and they confirmed that Resident #12 had no diagnosis of Post Traumatic Stress Disorder. 10 NYCRR 415.11(b)

Based on observation, record review, and interviews conducted during an abbreviated survey (incident 673540), the facility failed to ensure that an alleged violation involving abuse, neglect, exploitation or mistreatment are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident for one (1) out of five (5) residents (Resident #3) sampled for abuse. Specifically, on 07/10/2024 at 9:00 PM, Resident #3's family reported to Registered Nurse Supervisor #2 that on 07/10/2024 at around 5:45 PM, Resident #3 reported to them that they were hit on the left side of their head and upper back. Registered Nurse Supervisor #2 assessed Resident #3. Resident #3 had no bruises, scratches, lacerations, or discoloration. The facility investigated the alleged allegation and concluded that it was inconclusive. The facility did not report the alleged allegation of abuse to NewYork State Department of Health or law enforcement within two hours. The facility reported the allegation on 07/11/2024 at 8:15 PM.The findings are:The facility's Policy and Procedure titled Freedom from Abuse, Neglect, and Exploitation, dated 04/05/2021documented all alleged violations involving mistreatment, neglect, abuse, care plan violations, including injuries of unknown origin, are reported immediately to the Administrator/designee and the Director of Nursing. When there is reasonable cause to believe abuse has occurred, a report is also made to the State Certification agency and all other agencies as required, immediately.Resident #3 was admitted to the facility with diagnoses including Alzheimer's Disease, Depression, and Hypertension.The Minimum Data Set, dated [DATE] documented that Resident #3 had severely impaired cognition.A statement by Registered Nurse Supervisor #2 dated 07/10/2024 documented that they received a call from Resident #3's family reporting that Resident #3 informed them that they were hit on the left side of their head and upper back. Resident #3 was assessed and had no bruises, scratches, lacerations, discoloration, or bleeding. Resident #3 also denied pain on assessment.A Webform Submission from: Nursing Home Facility Incident Report dated 07/11/2024 showed the facility submitted the report to the New York State Department of Health on 07/11/2024 at 8:15 PM.During a telephone interview on 07/10/2025 at 10:11 AM, Registered Nurse Supervisor #2 stated they were informed by Resident #3's family at approximately 9:00 PM via telephone that Resident #3 alleged they were hit in the head by Certified Nursing Assistant #3. Registered Nurse Supervisor #2 stated they called the Director of Nursing and reported the allegation to them on 07/10/2024 after 9:00 PM.During a telephone interview on 07/10/2025 at 12:56 PM, Director of Nursing #1 stated they could not recall the incident or Resident #2. They stated they are no longer working at the facility; however, if an abuse allegation is made, Registered Nurse Supervisor #2 should have informed them immediately so they could gather all information and report it to the Department of Health within the two-hour timeframe. They stated they do not know why the incident was not reported timely and if Resident #3 felt safe and did not want law enforcement to be contacted, they would not inform law enforcement. During a telephone interview on 07/29/2025 at 3:22 PM, the Administrator stated they were not working at the facility during that incident; however, any allegation of abuse should be reported to the Department of Health and law enforcement within two hours.10 NYCRR 415.4(b)(2)

Based on observations, record review, and staff interviews conducted during the Recertification survey from 09/10/2023 to 09/15/2023, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was evident during review of the kitchen facility task. Specifically, (1) staff were not wearing hair nets in the kitchen. (2) A staff member's personal bag was on the kitchen counter next to the meat slicer. (3) Food in the freezer was stored too close to the ceiling. (4) Food stored in the refrigerator was not covered and labeled. The findings are: Facility policy and procedure titled Date for Marking Food Safety dated 7/18/2023 documents the facility adheres to date marking system to ensure the safety of ready-to-eat, time/temperature control safety for food. Facility policy and procedure titled Emergency Food Supply dated 7/18/2023 documents it is the policy of this facility to establish procedures to ensure that food is available for residents, staff, and volunteers in the case of an emergency. The amount of food needed is estimated based on the facility assessment, and considers census, total staff, and average number of volunteers/visitors. Facility policy and procedure titled Personal Cleanliness and Dress Code dated 7/18/2023 documented staff should wear hair restraints, such as hair nets. The facility policy and procedure titled Storage of Food in Freezer and Refrigerator dated 7/18/2023 documented all food items requiring refrigeration after delivery or preparation will be stored in refrigerators at 41 degrees or below. On 09/10/23 at 09:22 AM, the following was observed upon entering the main kitchen: The Food Service Director was standing in the kitchen hot food prep area without a hair net. There was a personal bag belonging to staff member on the food prep counter next to the meat slicer. The walk-in freezer had boxes stacked too close to the ceiling, and a tray of pre- made muffins dated 8/29/2023 was on top of the boxes. The walk-in refrigerator contained a pot of soup covered with plastic cling wrap that was not dated, and there was fish in an uncovered container with no date. During an interview on 09/10/2023 at 9:22 AM, the Dietary Aide (Other Staff #12) stated they forgot their bag was in the kitchen, and they forgot to come back for the bag. During an interview on 9/10/2023 at 09:30 AM, the [NAME] stated they made too many muffins and stored the rest on top of the boxes. They stated they were not sure why the other boxes were stacked too high. The [NAME] stated they did not know why the pot of soup covered with plastic wrap was not dated or why the fish was left uncovered with no date in the refrigerator. During an interview on 9/13/2023 at 10:37 AM, the Food Service Director stated they check to ensure staff are wearing hair nets prior to entering the kitchen. The FSD stated sometimes they do not wear a hair net when they are in the office. 415.14 (h)

Based on observation, interview, and record review conducted during the Recertification Survey from 9/10/2023 to 9/15/2023, the facility did not ensure infection control practices were maintained. This was evident for 1 (Resident #120) of 38 total sampled residents. Specifically, Registered Nurse (RN) #1 did not practice hand hygiene and glove changes and Licensed Practical Nurse (LPN) #5 did not properly handle sterile gauze during wound care for Resident #120. The findings are: The facility policy titled Hand Hygiene dated 5/15/2023 documented all staff will perform proper hand hygiene procedures to prevent the spread of infection. Resident #120 had diagnoses of diabetes mellitus and non-Alzheimer's dementia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #120 was severely cognitively impaired and had unhealed stage IV pressure ulcer. On 9/13/2023 at 08:46 AM, LPN #5 and RN #1 were observed preparing to provide right ischium and sacral wound care to Resident #120. LPN #5 opened 3 packets of gauze with gloved hands, took the gauze into their hand, and applied Dakin's solution to the gauze with their other hand. LPN #5 did not change gloves and sterilize after opening the packets of gauze and before taking the gauze in hand. RN #1 cleaned Resident #120's wound with gloved hands, packed the wound with Dakin's-soaked gauze, applied foam dressing, and repositioned Resident #120 in bed with a wedge cushion. RN #1 did not change their gloves and wash their hands after applying the foam dressing and before repositioning the resident. The Comprehensive Care Plan (CCP) related to sacral skin integrity initiated 4/18/2022 and last reviewed 9/12/2023 documented apply local treatment to Resident #120 as ordered by the Medical Doctor (MD). MD Orders dated 8/11/2023 documented cleanse Resident #120's right ischium and sacrum with Dakin's solution 0.25%, apply Dakin's-soaked gauze, cover with dry protective dressing, and secure with foam dressing daily. On 09/15/2023 at 01:12 PM, LPN #5 was interviewed and stated they are responsible for preparing wound care supplies by placing the supplies on a draped table. LPN #5 stated they tear open the gauze packets and either pour the Dakin's solution onto the gauze in their hands or soak the gauze after placing it on a draped table. Infection control inservice was given but not recently. On 09/15/23 at 01:06 PM, RN #1 was interviewed and stated they perform wound care by donning gloves, removing the resident's dressing, changing gloves, and sanitizing their hands, cleaning the wound, applying medication, covering the dressing, removing their gloves, and washing their hands. Gloves should be changed to prevent infection. 09/15/23 at 01:28 PM, the Director of Nursing (DNS) was interviewed, and stated hand hygiene and glove changes should be done when going from dirty dressing to clean dressing and at the end of wound care. Hand hygiene should be done during preparation for wound care. Gauze should not be touched and should be on a clean surface. After the wound is cleaned, gloves should be changed, and hand hygiene performed prior to applying medication to the wound. NYCRR 415.19(b)(4)

Based on observation, interviews, and record review conducted during a Recertification survey from 9/10/2023 to 9/15/2023, the facility did not ensure residents received proper treatment and assistive devices to maintain vision abilities. This was evident for Resident #52 and #103 reviewed for Communication. Specifically, 1) Resident #52 did not have a follow up consultation with the Ophthalmologist as recommended, and 2) Resident #103 did not have a recommended consultation with the Optometrist for glasses. The findings are: The policy titled Physician Services documented the attending physician is responsible for supervising follow-up visits. 1) Resident #52 had diagnoses of coronary artery disease and hypertension. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #52 was cognitively intact, had adequate vision, and wore corrective lenses. The Comprehensive Care Plan (CCP) related to sensory deficit initiated 1/5/2023 and last reviewed 7/26/2023 documented Resident #52 will use glasses as recommended and will received Ophthalmology and Optometry consults as appropriate. The Ophthalmology Consult dated 3/6/2023 documented Resident #52 receive artificial tears to address burning and tearing eyes. A follow up consult with the Ophthalmologist was recommended for 6/2023. There was no documented evidence Resident #52 had a follow-up Ophthalmology consult in 6/2023. On 9/14/2023 at 1:05 PM, Registered Nurse (RN) #5 was interviewed and stated Resident #52 was not seen by the Ophthalmologist because their attending physician was on vacation from June to August 2023. The attending physician is given the consult recommendations and sets up the appointment. 2) Resident #103 was diagnosed with anemia and hypertension. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #103 had mild cognitive impairments and impaired vision. The Comprehensive Care Plan (CCP) related to sensory deficit initiated 1/8/2021 and last reviewed 7/12/2023 documented Resident #103 receive Ophthalmology and Optometry consults as appropriate. The Ophthalmology Consult dated 5/1/2023 documented Optometry consult for glasses and follow up consult with the Ophthalmologist in 8/2023. There was no documented evidence Resident #103 had a follow up consult with the Ophthalmologist in 8/2023. On 9/14/2023 at 12:20 PM and 01:20 PM, Registered Nurse (RN) #5 was interviewed and stated RN #5 looks at the consults from the Ophthalmologist and places recommendations for follow up appointments in the computer and lets the scheduler know to make the appointment. The Ophthalmologist was on vacation and will be starting visits again. NYCRR 415.12(3)(b)

Based on record review and interviews conducted during the Recertification survey of 9/10/23 - 9/15/23, the facility did not ensure that the comprehensive care plans (CCPs)were reviewed and/or revised after each assessment and as needed to reflect changes in the resident needs. This was evident for 1 (Resident #60) of 8 residents reviewed for Activities of Daily Living (ADL) and 1 (Resident #46) of 5 residents reviewed for Unnecessary medications, out of an investigative sample of 38 residents. Specifically, (1) the Diabetes Mellitus CCP for Resident #46 was not reviewed and revised quarterly and after an episode of hypoglycemia. (2) the Dysfunctional coping or interaction CCP for Resident #60 was not reviewed and/or revised quarterly. The findings are: The facility policy and procedure titled Comprehensive Care Plan, effective date, and last review date of 5/15/23, documents each resident will have an individualized interdisciplinary plan of care in place. The comprehensive care plan will be reviewed and revised on a quarterly basis, with a significant change in condition, on readmission from an inpatient hospital stay, and as requested by the Resident/Representative. The policy further stated the CCP will be resident centered. 1) Resident #46 had diagnosis of Diabetes Mellitus (DM), Heart Failure, and Hypertension. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #46 was cognitively intact, had a diagnosis of Diabetes, and received insulin injections for seven days. From 9/10/2023 through 9/15/2023 Resident #46 was observed in room and confirmed was diabetic, take medications daily and monitoring of fingerstick daily. The CCP related to Diabetes, initiated 12/6/2021 and last updated 12/24/2022, had a goal to demonstrate a blood glucose level within normal limits. The interventions included: Administer medications as ordered. Assess skin daily. Coordinate all aspects of daily nutritional care. Implement diet as ordered. Monitor blood glucose level as per MD orders. Monitor for signs/symptoms of hypo/hyperglycemia. Monitor weights as ordered. Provide regular podiatry care as ordered by MD. Nursing progress notes dated 08/07/2023 at 11:47 pm documented Resident #46 was status post an episode of Hypoglycemia. Resident #46 was alert and verbally responsive continue to monitor for hypoglycemia. Blood Glucose currently is 87mg/dl. Resident in bed eating Peanut Butter sandwich and drinking orange juice. No distress noted. Plan of care continues. Medical monthly note dated 8/27/2023 documented resident has diagnosis of Diabetes and receives Basaglar Kwik Pen U-100 Insulin 100-unit, Insulin 100-unit, insulin aspart (U-100) 100 unit/mL subcutaneous pen and receives Nesina 25 mg tablet for Diabetes. Physician's Orders dated 8/28/2023 documented Basaglar Kwik Pen U-100 Insulin 100 unit/mL (3 mL) subcutaneous inject 20 units by subcutaneous route once daily at bedtime. Insulin aspart (U-100) 100 unit/mL (3 mL) subcutaneous pen inject 5 units by subcutaneous route 3 times per day before meals. Monitor Blood Glucose three times daily. The CCP was not reviewed and revised at least Quarterly and as needed to include the episode of Hypoglycemia. On 09/14/23 at 10:12 AM, an interview was conducted with License Practical Nurse (LPN #2). LPN #2 stated resident #46 is a diabetic, and receives insulin injections daily, and fingerstick monitoring daily. LPN #2 did not know who was responsible for the CCPs. On 09/15/23 at 08:18 AM, an interview was conducted with Registered Nurse who is the Unit Supervisor ( RN #5). RN #5 stated everyone updated care plans quarterly, annually, for significant changes, and in the discharge meeting. RN #5 stated at the care plan meeting, all disciplines update their specific care plans. The Diabetes CCP is updated by nursing. RN #5 stated the care plan is updated by the RN, and, if needed, the RN will initiate care plans. RN #5 stated if there is an episodic issue, the LPN will document and inform the supervisor, and the supervisor will initiate the Comprehensive Care Plan (CCP) and updated the CCP. RN #5 was unable to give a reason why the resident CCP was not updated and stated CCP's are updated by looking at the goals, as well as reviewing and revising the interventions and putting an evaluation note on the CCP. RN #5 stated they will follow-up. On 09/15/23 at 03:34 PM, an interview was conducted with Director of Nursing (DON). The DON did not state who is responsible for initiating and updating CCP. DON stated this is an issue that was identified in the facility, and they will continue to work on correcting this issue. The DON stated they will continue to in-service staff so staff can the review and revised the CCP the correct way. 45349 2) Resident #60 had diagnoses which include Diabetes Mellitus (DM), Non-Alzheimer's Dementia, and Heart Failure. The quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #60 had intact cognition with no behaviors. The resident required extensive assistance of 2 persons for bed mobility and total assist of two persons for transfer and toilet use. Resident #60 was always incontinent of bowel and bladder. A comprehensive care plan (CCP) titled Dysfunctional Coping or Interaction, effective Date: 4/16/2021, documented Resident #60 had anxiety and difficulty adjusting to illness, lost roles, and status. As Evidenced By dissatisfaction, difficult to please, unfounded accusations, criticism of staff, seeks to ascribe blame, frequent refusal of care/staff, easily offended, is super sensitive, assumes the worst, assumes others are talking about her, rehashes past negative situations as if they just happened; becomes upset with others if they do not do things the way they think they should be done and claims nothing is being done. The goal was for Resident #60 to feel supported. The interventions included encourage family and resident to engage in meetings; explore areas of conflict with resident and family; encourage resident to identify feelings and appropriate coping behavior and encourage family support and involvement. The last evaluation note was dated 3/20/23, and documented Resident is encouraged to work with new staff, reassurance is provided, Continue. with plan of care. There was no evidence that the CCP was reviewed and/or revised after the quarterly assessment dated [DATE]. An interview was conducted on 9/14/23 at 11:38 am with Social Worker #7, who stated that they create and update the care plans related to social work, such as mood and behavior. The SW stated care plans are updated quarterly, annually, or for a significant change. A schedule is given by the MDS coordinator, and the care plan is update based on the MDS schedule. They will do an interim note if there is a need. The SW stated the failure to update the Dysfunctional Coping CCP after the June 2023 assessment was an oversight. 415.11(c)(2)(i-iii)

Based on observations, record reviews and staff interviews during the recertification survey, the facility did not ensure that nursing staff implemented the interventions of a resident's comprehensive care plan (CCP). This was evident for 1 of 7 residents reviewed for Pressure Ulcer (Resident #25) out of a total sample of 38 residents. Specifically, Resident #25 did not have heel booties applied at all times as per the CCP for Pressure Ulcer prevention. The findings are: The Facility's Policy and procedure titled Skin and Wound Management issued on 2/07/2017 documented that it is the policy of the facility to maintain intact skin and to prevent avoidable pressure ulcer injury. Some of the limited measures that will be utilized to prevent skin breakdown include turning positioning, pressure relieving mattress, incontinence management, skin barrier, heel booties, heel offloading, wheelchair cushion and other positioning device, adequate nutrition and resident/family education. Resident #25 was admitted with diagnoses which include Dementia, Peripheral Vascular Disease (PVD), and Cerebral Vascular Accident (CVA). The Annual MDS dated [DATE] documented Resident #25 had severely impaired cognition. The resident required the total assist of two poeple for bed mobility, toilet use and transfer. The resident had range of motion impairment in one side of the lower extremity. The resident was at risk of developing pressure ulcers, and pressure relieving devices were applied to the chair and bed. The Comprehensive Care Plan for Skin Integrity dated 10/15/2021 included the intervention to keep Resident #25's heels in protective booties at all times (added 10/21/21). On 09/10/23 at 10:11 AM, the resident was observed in bed with no heel booties in place. On 09/12/23 at 10:20 AM, On 09/12/23 at 02:23 PM, and on 09/13/23 at 10:58 AM, the resident was observed seating in wheelchair in the day room with no heel booties in place. The Braden Scales for predicting pressure sore risk dated 05/06/23 and 08/06/23 documented the resident was at moderate risk for skin breakdown. A Physician's order initiated 10/21/22 and last renewed on 09/08/23 documented orders for heel booties to be applied at all times. The Nursing Notes from August 1, 2023 to September 14, 2023 did not document application of heel booties. The CNA Accountability sheets from August 1, 2023 to September 14, 2023 did not document application of heel booties. During an interview on 09/14/23 09:44 AM, the Certified Nursing Assistant (CNA #4) stated that the resident is assisted with ADL Care. The resident needs extensive to total assist for ADL care. CNA #4 stated that the resident is only supposed to wear booties while in bed. CNA #4 further stated that the resident does not wear booties while in the day room. During an interview on 09/14/23 at 10:23 AM, the Licensed Practical Nurse (LPN # 3) stated the resident is supposed to wear heel booties in bed only. LPN#3 stated they were not aware Resident #25 should wear heel booties at all times. During an interview on 09/14/23 at 10:27 AM, the Wound Care Nurse( RN #1) stated that the resident is supposed to wear heel booties at all times to prevent skin breakdown. RN #1 stated when residents are risk of developing pressure ulcers; staff implement turn and positioning, application of heel booties and wedges right away. Turning and positioning is done every two hours. RN #1 stated that the staff should only remove the heel booties for hygiene and skin observations. The resident must have the heel booties on. Resident #25 has a history of DTI in the past. The wound care team is trying to prevent future deep tissue injuries (DTIs). RN #1 stated they did not know why heel booties were not being applied, and the heel booties should have been applied at all times. Nursing staff are responsible for ensuring that heel booties are applied per physician's order. During an interview on 09/14/23 at 11:17 AM, RN #2 stated that that her job responsibilities include supervising the assigned units and the nursing staff (RNs, LPNs and CNAs). RN #2 stated the nursing supervisors make rounds very often, RN #2 d cehcks to ensure all doctor's orders are being followed. When an order is made, the RN Supervisor on duty is responsible for updating the care plan and adding the instructions under the CNA tasks. The CNAs and the LPNS staff are aware that Resident #25 has orders to wear booties at all times, and the order should be carried out. The heel booties should be removed for ADL and skin checks. The CNAs should apply the booties, and the LPN must ensure the booties are in place. RN # 2 stated that going forward, staff will ensure that all doctor's orders are carried out. During an interview on 09/14/23 at 11:49 AM, the Director of Nursing (DON) stated that there are a wound management protocols in place. The Wound Doctor enters orders, and skin care plans are developed and updated as needed. The LPNs assigned to the unit are supposed to check all residents and ensure all devices and pressure relieving devices are in place. The CNAs are supposed to apply the booties daily. All CNAs and nurses were trained on preventing skin impairments. The heels booties should have been applied at all times per the doctor's order. The DON further stated that we have to find a better way to ensure that the application of heel booties are clearly defined in the CNA accountability. All CNAs and all Nurses will be in-service immediately on ensuring pressure ulcer prevention protocols are followed. 415.11(c)(1)

Based on observations, record reviews, and staff interviews, during the recertification survey, the facility did not ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers. This was evident for 1 of 7 residents reviewed for Pressure Ulcer (Resident #25). Specifically, during multiple observations, Resident #25 was observed without heel booties in place as ordered. The findings are: The Facility's Policy and procedure titled Skin and Wound Management issued on 2/07/2017 documented that it is the policy of the facility to maintain intact skin and to prevent avoidable pressure ulcer injury. Some of the limited measures that will be utilized to prevent skin breakdown include turning positioning, pressure relieving mattress, incontinence management, skin barrier, heel booties, heel offloading, wheelchair cushion and other positioning device, adequate nutrition and resident/family education. Resident #25 was admitted with diagnoses which include Dementia, Peripheral Vascular Disease (PVD), and Cerebral Vascular Accident (CVA). The Annual MDS dated [DATE] documented Resident #25 had severely impaired cognition. The resident required the total assist of two poeple for bed mobility, toilet use and transfer. The resident had range of motion impairment in one side of the lower extremity. The resident was at risk of developing pressure ulcers, and pressure relieving devices were applied to the chair and bed. The Comprehensive Care Plan for Skin Integrity dated 10/15/2021 included the intervention to keep Resident #25's heels in protective booties at all times (added 10/21/21). On 09/10/23 at 10:11 AM, the resident was observed in bed with no heel booties in place. On 09/12/23 at 10:20 AM, On 09/12/23 at 02:23 PM, and on 09/13/23 at 10:58 AM, the resident was observed seating in wheelchair in the day room with no heel booties in place. The Braden Scales for predicting pressure sore risk dated 05/06/23 and 08/06/23 documented the resident was at moderate risk for skin breakdown. A Physician's order initiated 10/21/22 and last renewed on 09/08/23 documented orders for heel booties to be applied at all times. The Nursing Notes from August 1, 2023 to September 14, 2023 did not document application of heel booties. The CNA Accountability sheets from August 1, 2023 to September 14, 2023 did not document application of heel booties. During an interview on 09/14/23 09:44 AM, the Certified Nursing Assistant (CNA #4) stated that the resident is assisted with ADL Care. The resident needs extensive to total assist for ADL care. CNA #4 stated that the resident is only supposed to wear booties while in bed. CNA #4 further stated that the resident does not wear booties while in the day room. During an interview on 09/14/23 at 10:23 AM, the Licensed Practical Nurse (LPN # 3) stated the resident is supposed to wear heel booties in bed only. LPN#3 stated they were not aware Resident #25 should wear heel booties at all times. During an interview on 09/14/23 at 10:27 AM, the Wound Care Nurse( RN #1) stated that the resident is supposed to wear heel booties at all times to prevent skin breakdown. RN #1 stated when residents are risk of developing pressure ulcers; staff implement turn and positioning, application of heel booties and wedges right away. Turning and positioning is done every two hours. RN #1 stated that the staff should only remove the heel booties for hygiene and skin observations. The resident must have the heel booties on. Resident #25 has a history of DTI in the past. The wound care team is trying to prevent future deep tissue injuries (DTIs). RN #1 stated they did not know why heel booties were not being applied, and the heel booties should have been applied at all times. Nursing staff are responsible for ensuring that heel booties are applied per physician's order. During an interview on 09/14/23 at 11:17 AM, RN #2 stated that that her job responsibilities include supervising the assigned units and the nursing staff (RNs, LPNs and CNAs). RN #2 stated the nursing supervisors make rounds very often, RN #2 d cehcks to ensure all doctor's orders are being followed. When an order is made, the RN Supervisor on duty is responsible for updating the care plan and adding the instructions under the CNA tasks. The CNAs and the LPNS staff are aware that Resident #25 has orders to wear booties at all times, and the order should be carried out. The heel booties should be removed for ADL and skin checks. The CNAs should apply the booties, and the LPN must ensure the booties are in place. RN # 2 stated that going forward, staff will ensure that all doctor's orders are carried out. During an interview on 09/14/23 at 11:49 AM, the Director of Nursing (DON) stated that there are a wound management protocols in place. The Wound Doctor enters orders, and skin care plans are developed and updated as needed. The LPNs assigned to the unit are supposed to check all residents and ensure all devices and pressure relieving devices are in place. The CNAs are supposed to apply the booties daily. All CNAs and nurses were trained on preventing skin impairments. The heels booties should have been applied at all times per the doctor's order. The DON further stated that we have to find a better way to ensure that the application of heel booties are clearly defined in the CNA accountability. All CNAs and all Nurses will be in-service immediately on ensuring pressure ulcer prevention protocols are followed. 415.12 (c) (1)

Based on interviews and record reviews conducted during a Recertification Survey on 09/10/2023 to 09/15/2023, it was determined that for one (Resident #55) of seven residents, the facility did not ensure Resident # 55's property was safeguarded and free from loss or theft. Specifically, personal items which included 4-night gowns went missing. The facility did not investigate or complete a timely and thorough investigation of the missing property. Review of the facility policy and procedure titled, Resident Property documents the facility will maintain a safe environment for patient/resident property and will properly investigate all allegations of lost/missing or misappropriated property. The findings are: On 09/11/23 at 11:58 AM Resident #55 reported 4-night gowns missing for over a period of 3 weeks. Resident #55 stated that a room change was done and there were laundry bins in the bathroom that had the 4-night gowns, and the clothing went to the laundry and has not seen the clothing since. Resident #55 reported to the CNA the clothing was missing and was told they will check on it. Resident #55 spoke to someone from the laundry department who stated that they will check but have not heard back about the clothes from the CNA or the laundry department. On 9/12/2023 at 12:00 PM, interview with CNA #1, who was made aware of the missing clothing by Resident #55 stated they informed the nurse on the floor at the time and the laundry department and were told they are looking into the missing clothing. On 9/13/2023 at 11:30 AM, Social Worker #8 was interviewed and stated, they were not informed or aware of the resident's missing clothing. I will investigate and get back to the resident. On 09/14/23 at 09:03 AM, Resident #55 was interviewed and stated, I spoke with the Social Worker #7 about the missing clothing and was told that it is being investigated. On 9/14/2023 at 03:19 PM, Social Worker #7 was interviewed and stated, I was just informed during a huddle meeting on 9/11/2023 that Resident #55 needed clothing for physical therapy, not that the clothing was missing. I called the resident's son and daughter yesterday. No answer. I spoke with the Resident #55, took their statement and filled out a missing property form. I will speak with housekeeping and will investigate what happened with the missing clothing and will talk with Resident #55 about replacing the missing clothing. S483.10(ii)

Based on observation, interview, and record review conducted during the recertification survey conducted 9/10/2023 to 9/15/2023, the facility did not ensure a system was established to record the receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. This was evident for 1 (6th Floor) of 5 medication carts. Specifically, the 6th Floor medication cart Narcotics Log (NL) was incomplete and did not match the narcotics medication count in 2 blister packs. The findings are: The facility policy titled Control Substance Handling dated 5/15/2023 documented upon removal of a controlled substance from the packaging for administration, doses removed shall be documented on the NL On 09/13/2023 at 02:44 PM, the 6th Floor medication cart was observed with the following blister packs of narcotics medication: 4 pills of Pregabalin 1mg for Resident #47 25 pills of Clonazepam .5mg for Resident #75 The NL dated 9/13/2023 documented the following: 5 pills of Pregabalin 1mg for Resident #47 26 pills of Clonazepam .5mg for Resident #75 On 9/13/2023 at 02:52PM, Licensed Practical Nurse (LPN) #6 was interviewed and stated they usually sign the NL right away but did not do that today because their medication pass was being observed by a SA. LPN #6 stated they made a mistake. On 9/13/2023 at 3:00 PM, Registered Nurse (RN) #5 was interviewed and stated nurses are responsible for signing the NL and documenting narcotic medication administration as they give it to the resident. RN #5 is responsible for checking the NL to ensure LPNs are signing for narcotics medication administration and that the count is correct. On 9/15/2023 at 03:15 PM, Director of Nursing Services (DNS) was interviewed and stated narcotics medication administration is documented immediately after administering the medication. Nurses have annual mandatory competencies related to medication administration and supervisors make rounds to remind the nurses daily. 415.18(b)(1)(2)(3)

Based on observation, interview, and record review conducted during the recertification survey from 9/10/2023 to 9/15/2023, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional standards. This was evident for 1 (6th Floor) of 5 floors. Specifically, an expired influenza vaccine vial was observed in the 6th Floor medication room. The findings are: The facility policy titled Medication Storage dated 5/15/2023 documented medication rooms are routinely inspected for outdated medications. These medications are destroyed in accordance with facility policy. The facility policy titled Destruction of Unused Drugs dated 05/15/2023 documented expired drugs shall be disposed of in accordance with state laws and regulations. Unused, unwanted, and non-returnable medications should be removed from their storage area and secured until destroyed. On 09/13/2023 at 02:57 PM, a 2022-2023 Quadrivalent influenza vaccine vial .5 mL with an expiration date of 6/30/2023 was observed in the 6th Floor medication room refrigerator. On 9/13/2023 at 2:57 PM, Licensed Practical Nurse (LPN) #6 was interviewed and stated the refrigerator is checked by all nurses on every shift. LPN #6 stated they usually check the medication room on their unit, but the 6th Floor is not their regularly assigned unit. On 09/13/2023 at 03:07 PM, Registered Nurse (RN) #5 was interviewed and stated LPNs on all shifts are responsible for checking the medication room refrigerators for expired medications. RN #5 stated they last checked the medication refrigerator on the 6th Floor the previous day when they were assigned to administer medications on the unit. On 09/15/2023 at 03:15 PM, the Director of Nursing (DNS) was interviewed and stated the night shift goes through the medication refrigerators to ensure no expired medications are present. 415.18(e)(1-4)

Based on the observations and interviews conducted during the recertification survey from 9/10/2023 to 9/15/2023, the facility did not ensure garbage and refuse was properly disposed. This was evident during the Kitchen facility task. Specifically, waste, debris, and trash were not properly contained in closed dumpsters and the garbage dumpster area was not maintained to prevent potential feeding and harborage for pests. The findings are: The facility's policy and procedure titled Disposal of Garbage and Refuse dated 7/18/2023 documents the facility shall properly dispose of kitchen garbage and refuse. Dumpsters shall be emptied according to the facility contract. Garbage shall not accumulate or be left outside the dumpster. On 09/14/2023 at 01:05 PM an observation was made of the garbage dumpster area. Observed the trash compactor to be closed and locked, noted large flies and insects flying near the compactor. Garbage was observed scattered on the ground within the compactor area. Located near the garbage compactor additional observations made, noted laundry bins stored with dirty laundry. There were two large uncovered dumpsters, the first overflowing with cardboard boxes and the second overflowing with trash/debris. Old equipment and furniture such as chairs, tables, medication carts, a rotted bathtub, and other debris were near the trash compactor. On 09/14/2023 at 01:15 PM, an interview was conducted with Porter/Dietary Aide (DA) #4. DA #4 stated that the dumpster is usually picked up 2x/week and not sure why the cardboard is overflowing. On 09/15/2023 at 11:56 PM a second observation was conducted with the Director of Facilities Management, and there were additional cardboard boxes scattered around the garbage area along with cardboard boxes sitting on top of a broken chair. During an interview on 09/15/2023 at 12:00PM, the Director of Facilities Management reported that the open garbage dumpster belongs to the construction company. When the cardboard boxes overflow, the dumpster company is called to pick up the dumpster. The dumpster pick up is scheduled for twice per week on Tuesday and Friday and as needed. The porters are responsible for cleaning, washing, and disinfecting the trash/garbage compactor area daily and as needed. During an interview on 09/15/23 at 3:27 PM, the Administrator stated the Director of Facilities Management is responsible for maintaining the dumpster area. The dumpsters belong to an outside contractor vendor who is responsible to pick up the dumpsters, as we are currently doing renovations. 415.14(h)

Based on observations, and staff interviews during the recertification survey, the facility did not ensure that infection control practices and procedures were maintained. Specifically, 1) Oxygen tubing was observed touching the floor on three occasions. 2) A staff member was observed entering a room with signage of contact droplet precautions without wearing the appropriate Personal Protective Equipment (PPE). 3) There was no water management plan for Legionella with required components including but not limited to a) a facility-specific environmental risk assessment, b) a site-specific water management plan, or c) a sampling plan was in place. This was evident for 3 out of 37 residents (Residents # 95, #485 and #494 reviewed in the investigation sample. The findings are. The facility policy Infection Control dated 3/17/2020 documented transmission-based precautions and standard precautions to prevent the spread of infection and maintain the least restrictive precautions for residents based on their clinical situation. Resident placed on transmission-based precautions must have documentation in the medical record stating the type of precaution and reason. Droplet precautions: in addition to standard precaution use droplet precautions for resident known or suspected to be infected with microorganisms transmitted by droplets that can be generated by the resident sneezing, coughing, talking, etc and drop form air. This includes invasive H. influenza, invasive Neisseria meningitis, adenovirus, influenza, [CONDITION(S)], [CONDITION(S)] and coronavirus (COVID-19). Contact precautions in addition to standard precautions, use contact precautions for resident known or suspected to be infected with microorganisms that can be transmitted by direct or indirect contact such as handling environmental surfaces or resident care items. Gather all equipment and supplies needed before going into the room. The facility policy Hand Hygiene effective 10/30/2018 documented hand hygiene to prevent the spread of infections. Based on Centers for Disease Control (CDC) guidelines hand rub is the most effective in killing bacteria for hand hygiene. Visibly soiled hands must be washed with soap and water. Alcohol based hand rub is less damaging to the skin. When to perform hand hygiene at a minimum before eating and drinking, before and after each resident contact, after touching a resident or handling their belongings, whenever hands as obviously soiled. 1) Resident # 95 was originally admitted to the facility on [DATE]with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Quarterly assessment dated [DATE] documented the resident is alert and oriented. The resident requires extensive to total dependence for most activities of daily living. The resident is receiving oxygen therapy. Physician's original order dated 07/28/21 documented: oxygen at 2 to 3 Liter/min via nasal cannula every shift for shortness of breath. On 12/27/21 at 11:30 AM, on 12/28/21 at 10:39 AM and on 12/31/22 at 11:23 AM, Resident #95 was observed seated in room and the oxygen tubing was observed touching the floor. The Certified Nursing Assistant (CNA #1) was observed in the room. On 12/31/21 at 11:23 AM, CNA #1 was interviewed and stated, the resident requires extensive assistance for activities of daily livings. When I go into the resident's room, I ensure there is enough oxygen in the tank. I make rounds often. CNA #1 stated that the oxygen tubing is not supposed to be on the floor. The resident was educated about ensuring that the oxygen tubing is off the floor. If tubing is found on the floor, it must be changed. The nurse will be informed, and the tubing will be changed. On 01/03/22 at 11:17 AM, Registered Nurse (RN) #1 was interviewed and stated that all staff are trained yearly and as needed about infection control procedures. All tubings should be off the floor. If the tubings are found on the floor, it should be discarded. All staff are reminded periodically to check on residents often and ensure their oxygen tubing and catheter tubings are off the floor. All staff will be in-serviced again. On 01/03/22 at 11:54 AM, the Director of Nursing Services (DNS) was interviewed and stated that all staff are trained on infection control procedures. Oxygen tubings are not supposed to be on the floor. If it is found on the floor, it must be discarded. All staff were trained on infection control procedures. All tubings should be off the floor. All staff will be in-serviced about keeping all tubings off the floor. 2) Resident #485 was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #485 had a Physicians' orders in place as of 12/20/2021 for droplet/contact precautions. Resident #494 was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #494 has a Physician'' orders as of 12/21/2021 for droplet/contact precautions. On 12/29/2021 at 12:51 PM, a Certified Nursing Assistant (CNA #6) was observed entering room [ROOM NUMBER] without first donning personal protective equipment (PPE). A sign was posted on the room door which documented Contact and Droplet precautions and the required hand hygiene and PPE to wear upon entering the room to include a isolation gown and gloves along with eye protection/face shield and protective mask. There was a PPE bin outside of the door. CNA# 6 was also observed touching resident #494's bedside table, adjusting it for dining and also the upper side rail on the left side of the resident's body when assisting the resident to adjust in bed and opening packets on the resident's meal tray for them. CNA #6 exited Room# 270 and performed hand hygiene using hand sanitizer. At 12:55PM, CNA #6 was observed entering room [ROOM NUMBER] to drop off a beverage cup and to retrieve the lunch tray from Resident #485's overbed table. CNA # 6 did not don PPE prior to entering the room. Contact and Droplet Precautions sign was observed posted at doorway. There was a PPE bin outside of the room. On 12/29/2021 at 01:01 PM, the CNA #6 was interviewed and stated they did not have a cart to put the residents lunch tray on in order to don PPE. Whenever going into room I should wear PPE. Because resident is on precautions that is why we should wear PPE. We were informed the resident was on precautions. In-service records for CNA #6 were reviewed and it was documented they received in-service on infection control, PPE competency and performed hand hygiene competency on 8/03/2021. On 12/29/2021 at 1:13 PM, Licensed Practical Nurse (LPN) # 6 was interviewed and stated before staff enter a room there is PPE container and they should don at the door before entering the room. Staff should don the PPE before entering the room. There are nine residents on quarantine for two weeks and there is one positive COVID-19 resident on the unit. Staff should don PPE to protect themselves, coworkers and residents. Every morning before shift starts I have to give a report about infection control and everyone is considered infected. Staff are informed of residents on precautions and the rooms where PPE needs to be used. During the course of their day, we look to see if staff are wearing gowns and remind staff to wear PPE. We use wet towelettes to wipe hands before meals and provide wet wipes on resident trays. On 12/29/2021 at 04:10 PM, the Director of Nursing / Facility Infection Control Representative stated that the 2nd floor is a transition floor and one resident is on Contact/Droplet precautions. Fourteen other residents are on 14 days isolation since admissions and then they will be placed on another unit with other residents. There are half of the unit 10-15 residents who are unvaccinated. They should be wearing, gown gloves, face shields and masks for any intervention with resident on contact/droplet precautions for the protection of residents, staff and others. The staff was re-inserviced on PPE today. 3) There was no documented evidence that a water management plan for Legionella was completed with required components including but not limited to (1) a facility-specific environmental risk assessment, (2) a site-specific water management plan, or (3) a sampling plan was in place. The facility did not provide a facility environmental risk assessment, a site-specific water management plan, or a sampling plan for review. In an interview on 12/29/2021 at 3:30 PM, the Administrator stated they did not have a cooling tower, the facility completed legionella sampling, and that there was a policy for water management in place that would be provided. (1) Record review revealed the facility did not complete an annual environmental risk assessment for Legionella. The facility did not provide a facility environmental risk assessment for review. On 12/31/2021, the facility provided a copy of a 4-page facility policy titled, Maintenance and Monitoring of the Water System (2018 water policy) dated 9/13/2018 and signed 9/13/2018. Record review revealed the facility documented the creation and maintenance of a water system maintenance program to include prevention, surveillance, environmental cultures, and remediation/treatment. Further review revealed no additional documentation of the referenced water system maintenance program, and the policy had not been reviewed, signed or revised since 9/13/2018. The 2018 Water Policy documented the annual completion of an environmental assessment (Prevention: Environmental Assessment), with the assessment to involve reviewing facility characteristics, hot and cold water supplies, cooling and air handling systems and any chemical treatment systems. The 2018 Water Policy also documented environmental culturing, with the Maintenance Supervisor in conjunction with the Directors of Infection Control, Environmental Services, Nursing and others as deemed necessary by the facility, to perform a clinical and environmental assessment of the facility utilizing the NYS standardized facility assessment. Further review of the 2018 Water Policy revealed it was a policy and not an assessment, and lacked required components of an annual environmental risk assessment for Legionella including but not limited to a description of the facility's water distribution system and temperature profile of the water system. (2) Record review revealed the facility did not have a functional, site-specific water management plan for Legionella. Further review of the 2018 Water Policy revealed that it documented maintenance and operation measures into the design of the system, such as hot water system recirculation pumps will be installed to mitigate 'dead legs' and other areas of stagnant water. Further review of the 2018 Water policy revealed it was a policy and not a plan, and lacked required components of a site-specific water management plan for Legionella including but not limited to personnel roles and responsibilities; specific control measures and actions to be taken if control measures were not met. (3) There was no documented evidence that the required element of a Legionella sampling plan was completed. Further review of the 2018 Water Policy revealed that it was a policy and not a plan, and lacked required components of a Legionella sampling plan including but not limited to specific monitoring sites; frequency at which each monitored site is evaluated; control limits at each control location; and policies and procedures for personnel, new staff or an outside consultant to identify specific sampling locations for the facility staff and consultants when performing sampling and maintenance activities. 415.19(a)(1-3) 415.19(b)(4)

Based on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service safety to prevent foodborne illness. Specifically, potentially hazardous foods were not maintained at an acceptable temperature to prevent foodborne illness. This was evident during the Kitchen Observation task and 1 of units observed for Dining Observation task (2nd floor). The findings are: The facility policy and procedure titled Food Preparation and Handling reviewed 04/30/2016 documented to provide meals prepared using methods and techniques designed to preserve maximum nutritive value, enhanced flavor and be free of injurious organisms and substances. All meats will be heated to a safe minimum internal temperature. Final cooking temperatures. Monitor the foods internal temperature for 15 seconds. Foods should reach the following internal temperatures: poultry and stuffed foods - 165 degrees F, Ground meat, ground fish, and eggs held for service at least 155 degrees Fahrenheit (F), fish and other meats - 145 degrees F for 15 seconds. Foods that are not cooked to, held at, or stores at the right temperature are sometimes dangerous. Many foods contain small amounts of microorganisms called bacteria that will not grow if they are stored, cooked, and held correctly. However, dangerous bacteria can grow and cause foodborne illness, often referred to as food poisonings, if foods are not handled properly. Sometimes foodborne illness is mild, but other times it is severe and even fatal in some people. Food that can grow bacteria experts have identified potentially hazardous foods, those that are most likely to cause foodborne illness, these include meats, fish, poultry, seafood, and shell eggs. The temperature danger zone Food safety experts know that harmful bacteria can grow in food in the danger zone between 40 degrees Fahrenheit and 135 degrees Fahrenheit. Expert to keep foods out of this danger zone, whenever possible. Foods that are in the danger zone for too long (4 hours or more) could cause foodborne illness. Once foods are cooked to the right temperature, hold at temperature of greater than 135 degrees Fahrenheit to assure that they are safe. On 12/30/2021 between 11:09 to 11:28AM, an observation of food temperatures was conducted in the Kitchen for foods being held on heated food trucks prior to an observation of decentralized meal service on the floors. The following temperatures were taken: On the 2nd floor meal truck, baked chicken was 121.4 degrees Fahrenheit (F). On the 4th floor meal truck, baked chicken held in a cabinet underneath the steam table was 121.5 degrees F. On the 5th floor meal truck, baked chicken held in a cabinet underneath the steam table was 113.1 degrees F. On the 6th floor meal truck, baked chicken was 128 degrees F. On the 3rd floor meal truck, baked chicken was 127.9 degrees F. On 12/30/2021 from 12:30 PM to 12:39 PM, the food temperatures were observed in the 2nd floor dining room. The following temperatures were taken: baked chicken at 108.6 degrees F, baked fish at 131 degrees F, chopped fish at 104.5 degrees F. On 12/30/2021 at 12:39 PM, the 2nd floor dietary staff were observed preparing the lunch trays on the unit and resident #166 was served their meal tray in their room and resident #166 was observed consuming the chopped fish on their lunch tray. On 12/30/21 at 12:45 PM, 2nd floor lunch meal distribution was observed. Resident #166 was served a tray with chopped fish by a Certified Nursing Assistant (CNA). On 12/31/2021 at 12:28 PM, observations were made of meal preparation in the 2nd floor dining room and the chopped chicken stored in the cabinet under the food truck steam table was 100.5 degrees F. On 12/31/2021 at 12:36 PM, Resident #166 was given their lunch tray by the CNA. At 12:41 PM, Resident #166 was observed consuming meal that included chopped chicken. On 12/31/21 12:38 PM, Resident #112 was given a lunch tray that included chopped chicken. The resident was eating lunch at 12:43 PM and consumed the meal of chopped chicken, rice and green beans. On 12/30/2021 at 11:25 AM, an interview was conducted with the Cook (Cook #1). Cook #1 stated the holding temperature for hot food should be over 141 F. The cook plugs in the heated food trucks at 10:25 AM to allow time for the food trucks to heat up prior to meal service. If the truck is not maintaining temperature, they put the food back in the oven to warm it up. The issue with the trucks is a managmenet problem. The Food Service Manager is aware, and the Executives have known there is truck problem for years. If food is held below 141 F, bacteria can grow. Maintianing a temperature of 141 F is crucial to avoid bacteria growth. On 12/30/2021 at 11:31 AM, the Food Service Manger (FSM) was interviewed and stated there have been no problems with the food trucks. Occasionally, the food trucks for units 2 and 6 do not work and an email is sent to maintenance for repair. The food trucks with problems were fixed last week. They do not have any documentation regarding repairs done, and requests for repairs with the head of maintenance are made verbally or by email. The FSM stated 90% of the time the food is hot. The FSM stated they take food temperatures on the units three times per week (1 breakfast and 2 lunch) when they get a chance. Residents should not be served cold food. The correct food temperatures should be maintained to prevent foodborne illness. On 01/03/2022 at 04:04 PM, The Director of Nursing was interviewed and stated temperatures should be done to prevent salmonella and any kind of foodborne illness. The Food Service Manager monitors the food service temperatures. arantine residents, 415.14 (h)

Based on record review and staff interviews conducted during the Recertification/Complaint Survey (NY 651 & NY 00 8) from 12/27/2021 to 1/3/2022, the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. Specifically, 1) no CCP was developed and implemented for residents with skin break and 2) no CCP was developed for resident on oxygen therapy. This was evident for 3 out of 7 residents reviewed for Pressure Ulcer/Injury (Resident # 391, # 341, and # 540), and 1 out of 1 resident reviewed for Respiratory Care (Resident # 95) out of a sample of 39 residents. The findings are: The facility's policy Multidisciplinary Comprehensive Care Plan reviewed 7/2/2018 documented this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the residents' comprehensive assessment. The comprehensive plan will be developed within 7 days after the completion of the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. The comprehensive care plan will be prepared by an interdisciplinary team. The facility's policy titled Skin and Wound Management with effective date 2/7/17 and revised 8/6/19 documented the facility will implement measures to reduce risks of actual skin impairments and provide appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . It also documented under Responsibility for reporting new skin break nosocomial and community acquired that licensed nurse develops a care plan and instructs CNAs, both verbally and through documentation on the C.N.A. Accountability Record. 1 (a). Resident # 391 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident # 391 had short and long- term memory problem, no speech, and rarely/never made self understood or understood others, severely impaired in vision. It also documented Resident # 391 was totally dependent for ALDs, always incontinent in bladder and bowel, at risk of Pressure ulcer (PU), had no unhealed PU, and had PU preventions including to use pressure reducing device for bed and chair, be placed on turning/repositioning, and have application of ointments/medications other than to feet. The Nursing - Weekly Skin Check dated 3/20/2020 documented Resident # 391 had no Pressure Ulcer. There was no documented evidence that Nursing - Weekly Skin Check was done for 4 weeks between 3/21/2020 and 4/18/2020. The Nursing - Weekly Skin Check dated 4/19/2020 documented Resident # 391 had two (2) PI (Pressure Injury) at B/L (bilateral) hips. The medical note dated 3/27/2020 documented Resident #391 had the old PU at sacrum healed. The medical note dated 4/6/2020 documented Resident # 391 had small stage III PU at left hip. The medical note dated 4/13/2020 documented Resident # 391 had shallow stage lll PU at both hips. The CCP related to Skin Integrity for Presence of Skin Breakdown was not initiated until 6/19/2020. On 12/28/21 at 03:38 PM, the Resident representative presentative was interviewed over the phone. Resident representative stated family members visited Resident # 391 six times a week before pandemic (March 2020) and they assisted providing personal hygiene and repositioning. Resident representative also stated Resident # 391 had no pressure ulcer by the time pandemic broke out and the facility stopped them to visit Resident # 391 afterward. Resident representative further stated they believed Resident # 391 developed the pressure ulcers because the facility did not provide the care Resident # 391 needed. On 12/30/21 at 10:23 AM, Certified Nursing Assistant (CNA) # 3 was interviewed. CNA # 3 stated all residents at risk of skin breakdown were placed on pressure ulcer preventions in CNA Accountability and the interventions included turning position every 2 hours, applying cream/ointment during the shift to the area specified, and reporting to nurse immediately if observing any new or change in skin breakdown. CNA # 3 stated Resident # 391 was non-verbal and on total care for ADLs, and they used Hoyer lift to transfer Resident # 391 from bed to recliner chair daily or every other day. CNA # 3 also stated Resident # 391 had PU and they notified the nurses when there was any change to the PU. CNA further stated they documented in the CNA accountability for the care they provided. CNA stated they were not able to explain the treatment and pressure ulcer preventions were not performed or documented in some days in March and April 2020. On 12/29/21 at 05:21 PM, Nursing Care Coordinator (RN) # 1 was interviewed. RN # 1 stated Resident # 391 was confused, on DNI, DNR, DNH, palliative care, and had no unhealed PU when they were on leave in March 2020 and observed Resident # 391 had PU at the hips and sacral areas upon return in April 2020. RN # 1 also stated they referred Resident # 391 to wound care physician for the PU and did not recall if a new CCP related to skin breakdown was created after identifying the PU in April 2020. RN # 1 checked the care plans in medical record and confirmed no CCP was created for the newly developed PU at bilateral hips and sacral area until 6/19/2020 and was not able to explain the delay. RN # 1 further stated the nurses should create a new CCP for presence of skin breakdown when they observe a resident had any new skin breakdown. On 12/30/21 at 10:41 AM, Director of Nursing (DON) was interviewed. DON stated the nurse had to do the Nursing - Weekly Skin Check once a week during resident's shower day and during AM care if needed. DON also stated the nurses should create a new CCP for presence of skin breakdown if observing new skin breakdown. (b). Resident #341 admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] documented that resident's cognition is severely impaired. Documented extensive assistance with two persons for bed mobility, total dependence with two-person physical assist for toilet use and transfers, total dependence with one-person physical assist for eating. Also documented at risk for Pressure Ulcers (PU) and unhealed Pressure Ulcers/Injuries documented, one Stage 4. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Comprehensive Care Plan (CCP) titled Skin Integrity: at risk for skin breakdown, created on 11/25/2018, documented at high risk for skin breakdown related to Braden Scale Score, decreased mobility, incontinence, peripheral vascular disease (PVD) with goals that include resident will have reduced risk for developing pressure ulcers and skin breakdown. Interventions include Certified Nursing Assistant (CNA) evaluation of skin condition daily during care and report any skin abnormalities to nurse. Complete pressure ulcer risk assessment (Braden Scale) and review quarterly and as needed (PRN), turning and positioning every 2 hours and PRN. There was no documented evidence in the medical record that comprehensive care plans regarding actual Pressure Ulcers were developed. A wound care consult dated 10/04/2021 documented left lateral malleolus pressure injury (PI) left bunion extending to medial great toe PI now stage3, medial shin PI now stage 4, left lateral foot vascular. Right bunion closed. A physician's note dated 10/07/21 documented that the patient (resident#341) was seen by vascular today. Also documented that on examination, medial aspect of right forefoot with dry approximately 1 x 1 cm wound. Lateral aspect of left foot and lateral malleolus with ulcerations with mixed granular and [MEDICATION(S)] bases and unable to assess wounds over medial aspect of forefoot secondary to patient's position. Is advised that they continue with local wound care as per wound care team and offloading. On 01/03/22at 10:30 AM, an interview was conducted with MDS Manager who stated that the care plans titled skin integrity, at risk for skin breakdown is usually a separate care plan from when an actual pressure ulcer develops. Stated that it is fine to use an at risk for skin breakdown care plan for actual pressure ulcers, and just add the interventions on the notes, if the goals are there and that the care plan is updated. The MDS Manager did not find an any care plan for Actual skin breakdown in the resident's chart. On 01/03/22 at 11:00 AM an interview was conducted with RN#1who stated that they manage the 5th floor. Stated that they believe that at that point, when an actual wound has occurred and documented, that the care plan should no longer be 'at risk for skin breakdown' but they should have activated a new care plan for the wounds, that addresses the actual wounds. RN #1 stated that the Nurses on the floor would update the care plan, but the RN on the unit, would create a new one. Stated that they would speak with the nurses to ensure that this is addressed. On 01/03/22 at 12:13 PM, an interview was conducted with the DNS who stated that when an actual pressure ulcer develops, a new care plan should be created and added, in addition to the Skin Integrity 'at risk for skin breakdown' care plan. Stated that the Nurse on the unit would usually be the one to create a new care plan. Stated that if the RNs make rounds with the doctor and observe new wounds, a new care plan would then be created, and that the RN Managers can also do the initial care plans. (c) Resident # 540 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set assessment dated [DATE] documented the resident had short and long term memory problem. The MDS also documented that the resident required extensive assistance for Activities of Daily Living (ADL's), was at risk for pressure ulcers, had no pressure ulcer and was receiving pressure relieving devices for chair and bed and was on a turning/repositioning program. The Quarterly MDS dated [DATE] documented the resident had short and long term memory problem. The MDS also documented that the resident required dependent assistance for ADL's, was at risk for pressure ulcers, had no pressure ulcer however had Moisture Associated [CONDITION(S)] (MASD) The MDS further documented that the resident was receiving pressure relieving devices for chair and bed and was on a turning/repositioning program. Nursing note dated 10/17/20 documented that on 10/16/2020, the resident was seen for reported open area on the right buttock. The resident noted with a broken blister to the right buttock. The open area is superficial pink and clean. No drainage noted. Dr. was informed and local treatment was ordered. The Wound care Dr. ordered protective skin protocol including turning and positioning every two hours, offloading heels, and limiting time out of bed. Wound care dr. documented moisture associated skin damage (MASD) of the right buttock. The wound Size of 3x2x0.4. Wound evaluation consult dated 10/19/20 documented wound on the right buttock. Wound size of 3x2x0.4 [MEDICATION(S)] ordered daily. Preventive measures included turn and positioning every 2 hours, incontinence care every 2 hours, level 2 mattress, heel protectors, positioning wedges, wheelchair cushion, offload heels and out of bed two three hours at a time. Wound consult dated 11/9/20 documented right buttock wound size of 6x7x0.5 full thickness. resident readmitted and the wound worsened. Treatments included Dakins solution 0.125% by irrigation route daily and antiseptic triad hydrophilic paste mixed. Wound care note dated 11/30/20 documented MASD complicated with pressure ulcer. Necrotic tissue noted. Preventive measures in place. resident was hospitalized with and returned with right buttock MASD deteriorating and extending to sacrum. There was no documented evidence that a CCP (Comprehensive Care Plan) had been developed after the wound developed with the appropriate interventions to address the resident's actual skin breakdown and risk for further skin breakdown. On 12/31/21 at 03:37 PM, an interview was conducted with RN # 1. RN #1 stated that they oversee all nursing staff was not the nursing supervisor at the time the resident lived on the 4th floor. Resident #540 was first seen by wound care doctor due to right buttock open wound on 10/19/20. Two days later, the resident was transferred to the hospital. When the resident returned to the facility, the wound worsened. The wound doubled in in size during the hospital stay. The resident was being turned and position every two hours from admission. The resident was on toileting schedule every 3 hrs. The resident was on out bed schedule daily. RN #1 also stated there was no impaired skin care plan developed for the resident and they were not sure why an actual impaired skin integrity care plan was not developed. RN # 1 further stated that the wound was identified on 10/17/20 and there was no new care plan develop to reflect wound on the right buttock. On 01/03/22 at 10:00 AM, the Wound Care Physician (WCP) was interviewed. The WCP stated that the resident was seen on 10/20/20 due to Moisture Associated Skin Damage. The wound started as a linear scratch and was on the right buttock. The wound was due to moisture and the resident scratching the skin so the wound was unavoidable. The WCP also stated that the resident had a lot of comorbidities and the wound was not pressure related as it was on the side of the right buttock not on a bony prominence. The WCP further stated that they recommended that staff elevate resident's heels, turn and position and toilet the resident often. On 01/03/22 at 11:54 AM, an interview was conducted with the DON. The DON stated that care plans are initiated on admissions and revised the care plans when there are changes. The Nurse Manager is responsible for initiating care plans. The MDS Assessor, the Assistant Director of Nursing (ADON) and the DON review the medical records to ensure care plans are developed and implemented. The DON further stated that the MDS Assessor can easily check to see if care plans are initiated for residents. The DON further stated that an actual impaired skin integrity care plan should have been in place for the resident to prevent wound from getting worse and to prevent further skin breakdown. 2. Resident # 95 was originally admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS assessment dated [DATE] documented the resident was cognitively intact, and required resident requires extensive to total dependence for most activities of daily living. The MDS also documented that the resident was receiving oxygen therapy. Physician original order dated 07/28/21documented oxygen at 2 to 3 Liter/min via nasal cannula every shift for shortness of breath. On 12/27/21 at 11:30 AM, on 12/28/21 at 10:39 AM and on 12/31/22 at 11:23 AM, the resident was observed in bed receiving oxygen via nasal canula. There was no documented evidence that a CCP (Comprehensive Care Plan) had been developed for respiratory care with the appropriate interventions to address the resident's continuous use of oxygen therapy. On 01/03/22 at 22 11:17 AM, RN # 1 stated that the resident had been on oxygen since admission. Care plans are supposed to be initiated on admission when the resident's conditions changes or are resolved. RN #1 also states that the resident should have had a respiratory care plan in place for oxygen therapy. On 01/03/22 at 11:54 AM, the DON was interviewed. The DON stated care plans are supposed to be developed on admissions and when a resident's condition changes. The DON also stated that the MDS Assessor, the ADON and the DON frequently review the resident's medical record to ensure care plans are in place. The DON further stated that a care plan for respiratory care should have been in place. 415.11(c) (1)

Based on observation, record review and interview conducted during a Recertification survey, the facility did not ensure a clean, comfortable, and homelike environment was maintained. Specifically, the patient tubs on the 2nd and 3rd floor were noted with stains on the bathtub that were discolored with pink and rust colored in the bathtub around the drain and leading down the wall from the tub handles. This was evident for 2 of 5 resident floors observed for the Environment (Floors 2 and 3). The findings are: The facility did not have a policy and procedure related to cleaning of the tubs. 1) On 12/30/2021 at 09:24 AM, the 3rd floor tub room was observed. There was a black colored stain in the middle of the tub seat. There was a lap belt with black spots on it, and the tub had brown rust stains and red spots in the area underneath the faucet and the bottom of the tub. On 12/31/2021 at 02:52PM, the 3rd floor tub room was observed again. The stains from the first observation were still present. There was water dripping from the pipe, and a scrub brush and vinyl glove were inside the tub, behind the tub seat. The shower nozzle did not work. On 01/03/2021 at 1/03/2022 at 12:51PM, the 3rd floor tub room was observed again. The stains were still present, and the faucet was dripping into the tub. The 3rd floor maintenance book entries from 11/8/21 to 12/30/21 were reviewed. There were no entries related to the need to clean the tub room or repair the tub room faucet. An interview was conducted with a 3rd Floor Certified Nursing Assistant (CNA #7) on 12/31/2021 at 02:44 PM. CNA #7 stated that they do not use the back tub bathroom on the unit. An interview was conducted with the 3rd floor Licensed Practical Nurse (LPN #5) on 12/31/2021 at 02:45PM. LPN #5 stated that they use the tub when residents have to soak their legs and showers are done in the shower room. On 12/31/2021 at 02:47PM, the 3rd floor Housekeeper (HK #1) was interviewed. They stated that cleaning the tub was a special assignment. HK #1 stated they do not have the chemicals needed on their cart to clean the rust and water stains inside the tub. 2) On 12/30/2021 at 09:32 AM, the 2nd floor tub room was observed. There were brown rust stains inside the tub around the drain area. Staff were unable to locate the 2nd floor maintenance book. On 01/03/2022 at 02:55 PM, the Housekeeper (HK # 2) was interviewed and stated they are acting as the supervisor while the Director of Houskeeping is out on leave. HK #2 stated housekeeping is responsible for cleaning the tub, and it is a special project done at night from 10PM to 6AM. HK #2 stated the housekeeper assigned cleaned the tubs on floors 2, 5, and 6 in October 2021, which was the last tub cleaning. HK #2 stated the 3rd floor tub room was unacceptable. HK #2 stated rounds on the 3rd floor were not done since last week, prior to the survey. The Housekeeper assigned to the unit should inform their supervisor when the tubs need cleaning. The tub on the 2nd floor is not acceptable. The Houskeeping Supervisor should inform the houskeepers of any concerns identified during rounds. HK #2 stated they will have maintenance look at the 3rd floor tub room pipe. HK #2 stated the condition of the 3rd floor tub was unsanitary. 415.12(h)(1)

Based on observations and interviews during the Recertification/Complaint Survey from 12/27/2021 to 1/3/2022, the facility did not ensure that residents were cared for in a manner that maintained or enhanced their dignity. Specifically, a resident's Foley catheter bag and tubing were left uncovered and exposed to public view. This was evident for 1 of 3 resident reviewed for Dignity (Resident #70) . The findings are: The facility's policy titled Resident Rights with effective date 8/2017 documented the facility is committed to assuring that all services meet high standards and that staff is respectful of individual needs, privacy and dignity. It is also documented under Resident Rights that the resident has the right to a dignified existence, self-determination and communication with and access to persons and services inside and outside of facility. Resident #70 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set 3.0 (MDS) dated [DATE] documented that Resident #70 had intact cognition and an indwelling catheter. The resident required extensive assistance for toilet use, transfer, personal hygiene The physician ordered Foley catheter use due to Prostate CA and [CONDITION(S)] with start date 8/23/2021. The Comprehensive Care Plan (CCP) related to Elimination: Indwelling Urinary Catheter, Ostomy or Other, initiated 9/24/2021, had the goal that Resident #70 will maintain dignity and self-esteem. On 12/28/21 at 10:43 AM, 12/29/21 at 09:20 AM, 12/30/21 at 11:10 AM, and other occasions, Resident #70 was observed lying in the bed with the foley catheter drainage bag uncovered and visible from the hallway through the open door. Resident #70's Foley catheter drainage bag and catheter tubing were on the side of the bed facing the door. There was yellow urine draining into the uncovered catheter bag. On 12/30/21 at 02:50 PM, Certified Nursing Assistant (CNA) #2 was interviewed. CNA #2 stated that they ensured the catheter bag was off the floor, drained the urine as needed, did not cover it, and were not sure if the facility had a privacy bag to hold it. CNA #2 also stated they placed the Foley catheter bag in a pillowcase when Resident # 70 had the bed by door and thought it was not necessary to cover it after Resident #70 moved to the bed by window. CNA #2 stated they had training not to expose the catheter bag for dignity and knew catheter bags or a leg bag had to be covered when taking Resident #70 out of the room. On 12/30/21 at 03:11 PM, Registered Nurse (RN) #2 was interviewed. RN #2 stated they were responsible for supervising nursing staff on the unit and made rounds several times during the shift to make sure compliance of resident care. RN #2 also stated the catheter bag should be covered to avoid being exposed for dignity. RN #2 stated they had see any privacy bags used to conceal the catheter bag on the unit and was not sure if the facility had privacy bags. RN # 2 also stated they did not call central supply or check with their supervisors to see if a privacy bag was available. RN #2 stated they used a pillowcase to cover the catheter bag when Resident # 70 had the bed by door and did not cover it after their moving to the bed by window. RN # 2 also stated exposing the urine bag to the hallway when door was open was a concern for a resident's dignity and they had training for it at orientation and regular in-service throughout the year. On 12/30/21 at 04:38 PM, the Director of Nursing (DON) was interviewed. The DON stated the uncovered Foley catheter bag should not be hung on the side of bed facing the hallway because the door was open most of time and should be placed in a privacy bag to provide privacy and it was a matter of resident right. The DON also stated the nursing staff had the training on the catheter care privacy protocol during the orientation, and annual and as needed in-services. DON further stated they had privacy bags available from central supply and staff should not use pillowcase to hold the catheter bag. The DON stated they had a lot of new nursing staff and was not sure if they knew the privacy bag was available from central supply. 415.5(a)

Based on observation, interviews and record review conducted during an abbreviated survey (NY 395) the facility failed to ensure that a resident remained free from resident to resident abuse. This was evident for 2 out of 3 residents sampled (Resident #1 and Resident #2,). Specifically, Resident #1 was observed lying in bed with blood all over their face, blood at the back of the head; with swollen eyes and swollen and bleeding lips. Resident #1 was admitted to the hospital and was diagnosed with Acute Bilateral Nasal Fracture and Soft Tissue Swelling of the Face. Facility failed to protect Resident #1 from Resident #2, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] This resulted in actual harm to Resident #1 that was not an immediate jeopardy. The Findings Include: Review of the Facility's Policy and Procedure on Freedom from Abuse, Neglect and Exploitation effective on 2/11/2020 documented that the Facility is in full compliance and intent with all aspects of the Freedom from Abuse, Neglect and Exploitation Legislation to protect all residents from abuse, neglect and exploitation while residing at the facility. Abuse, neglect, either verbal or physical and exploitation is prohibited under any circumstance. The residents will not be subject to abuse, neglect, exploitation or mistreatment by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of the agencies serving the individual, family members or legal guardians, friends, significant others, or other individuals. Review of the Facility's Accident/Incident Report and Internal Investigation dated 02/17/2021, revealed that on 02/09/2021, Resident #1 was observed lying on the bed with blood on their face. Resident #1 stated a person came in and beat me up. Local treatment and pressure compression were applied to Resident #1's face. An assessment revealed that Resident #1's lips and eyes were swollen. Blood was observed on the floor and the overbed table was turned over. The investigation also revealed that Resident #1 had swelling to the eyes and the left side of the face. Resident #1 was bleeding from the nose, mouth and from the back of the head. Resident #2 had blood on their hands and scratches on their skin. Resident #2 was placed on 1:1 observation and both residents were transferred to the hospital for further evaluation. Resident #1 : diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS (Minimum Data Set, a resident assessment tool) dated 01/26/2021, documented that Resident #1 had a BIMS score of 6/15, indicated Severe Impairment. Resident #1 required extensive assistance with activities of daily living. Review of a nurse's note dated 02/10/2021 at 1:16a.m. documented that Resident #1 was found in the bed next to the door (not Resident #1's bed). Resident #1's head was at the foot of the bed. Resident #1 had blood all over their face, swollen eyes; upper lip swollen and bleeding. Resident #1 nose was swollen, and blood was coming from their nose. Resident #1 had blood to the back of the head. Blood was observed on the floor close to the bed that Resident #1 was lying in. The night table and telephone were on the floor. Resident #1 responded to their name but did not say what happen. Resident #1 was cleaned up and a dressing applied to the back the head. The doctor was notified, and Resident #1 was transferred to the hospital. A Hospital Discharge Summary, documented Resident #1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nurse's readmission note dated 02/18/2021 at 3:44a.m. documented that Resident #1 was readmitted to the unit on 02/17/2021 at 7:50p.m. from the hospital. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Assessment revealed slight swelling to Resident #1's upper and lower lips and swelling to Resident #1's entire face with areas of dark discoloration to the periorbital area. Resident #1 kept their eyes closed during the assessment. Resident #2: diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented that Resident #2 was severely impaired. A CCP related to Physical Abuse dated 11/08/2020, revealed Resident #2 exhibited physically aggressive behavior towards staff/others. The interventions included identifying pattern of behavior, remove resident from situation triggering behavior, allowing resident time to deescalate when agitated. Document the intensity, duration, or frequency of behavior. There were no interventions to keep Resident #2 from entering other residents' rooms. A CCP related to Behavioral Symptoms dated 11/09/2020, documented that Resident #2 exhibited inappropriate behavior: disrobing in hallway, invading other residents' space, and swinging a metal object at another resident. There were no interventions to keep Resident #2 from going in and out of other resident's room and there were no investigations regarding Resident #1 attempting to hit another resident with a metal object. Review of a nurse's note dated 11/14/2020 at 9:54 p.m., revealed that Resident #2 was standing next a Resident while holding a footrest from the resident's wheelchair. The residents were separated. Resident #2 stated that they told the other resident to get out of the room. Resident #2 pushed the other resident out. Resident #2 was encouraged not to touch any resident and always call for assistance. Resident #2 stated that they pushed another resident out of their wheelchair. The supervisor was on the unit at the time. A CCP related to Behavioral Symptoms dated 12/11/2020, revealed that Resident #2 exhibited inappropriate behavioral problems as evidenced by disrobing in hallway, invading other resident's space. Going into roommate's closet, removed clothes, and washed the clothes in the bathroom sink causing a flood. Resident #1 had aggression towards others. Resident #2 swinged a metal object at another resident but did not making contact. There were no changes in interventions and no documentations of the effectiveness of the interventions. Review of the Nurse's note dated 12/17/2020 documented Resident #2 was physically and verbally aggressive towards caregivers and putting others at risk for physical injury. It is also documented that Resident #2 significantly intrudes on the privacy or activity of others by entering other resident's room. Review of a nurse's note dated 01/16/2021 documented Resident #2 was noted pushing an IV pole in the hallway then grabbing the pole to hit a nurse. Resident #2 continued pushing the IV pole to another resident's room. Resident #2 was observed picking up food from the garbage. Review of the Observation Record Sheet, for Resident #2, dated 02/09/2021, revealed that Resident #2 was being monitored every 30 minutes. The record sheet documented that Resident #1 was near the nurse's station on 02/09/2021 from 8:00 p.m. to 10:30 p.m. Review of the Facility's Surveillance Video Recording dated 02/09/2021, revealed at 8:35 p.m., Resident #2 was observed walking up and down the hallway. Resident #2 was opening and closing residents room doors. Resident #2 was pacing along the hallways without shirt and footwear. At 8:37 p.m., Resident #2 was observed standing in front of Resident #1's room then entering the room. At 8:45 p.m. Resident #2 exited Resident #1's room and briefly entered into another resident's room. At 8:45p.m. Resident #2 exited the other resident's room and was noted walking along the hallway. Camera ended at 9:07p.m. During an interview on 02/16/2021 at 2:15 p.m. CNA #1 stated that Resident #2 was extra agitated on the evening of the incident and refused to go to bed despite encouragement. CNA #1 reported that Resident #2 went into another resident's room and removed a wheelchair. CNA #1 took the wheelchair away from Resident #2. CNA #1 stated that at approximately 8:45 p.m. they observed Resident #2 had blood on their fists and scratches to their chest and didn't know at that time where it was from and reported it to LPN #1. CNA #1 stated they did not hear any yelling or screaming on the unit. During an interview on 02/16/2021 at 2:45 p.m., CNA #2 stated Resident # 2 was observed to be agitated on the evening of the incident and they reported it to LPN #1, who instructed them to allow Resident #2 to calm down and reapproach the resident at another time. CNA #2 said that they took snacks to Resident #1's room at 9:15 p.m. and observed medium amount of blood on the floor in Resident #1's room. Resident #1's face was bloody and swollen. CNA #2 immediately called for LPN #1. There was no documentation that Resident #2 had been placed on a 1:1 observation due to increased agitation. A nurse's note, for Resident #2, dated 02/09/2021 at 11:32p.m., revealed that Resident #2 was observed with [NAME] on their chest and blood on their hands. Resident #2 was very agitated, pacing back and forth on the unit. The supervisor and the Medical Doctor were notified. During a follow up interview on 3/11/2021 at 10:10a.m., CNA #2 stated that when they were giving out snacks to the residents, they observed that Resident #1 was lying in the wrong bed (bed at the door) which was strange. CNA #2 called out to CNA #1 stating that Resident #1 was in the wrong bed and asked CNA #1 to assist with putting Resident #1 in the correct bed (bed W), CNA #2 stated that they went into Resident #1's room and observed that Resident #1's face was bloody. CNA #2 stated that she called out Resident #1's name and asked the resident if they were okay. Resident #1 responded yes. CNA #2 said she observed that Resident #1's bed W and wheelchair were both pushed all the way into the corner of the room. A lot of blood was on the floor next to the nightstand at bed D. CNA #2 stated that Resident #1 usually sits in the wheelchair in their room next to the window before being put to bed. Resident #1 was quiet and does not bother anyone. CNA #2 voiced that they have never observed Resident #1 ambulating independently or lying in the wrong bed. CNA #2 stated that she called out and asked CNA #1 to get the nurse. On the evening of the incident, CNA #2 stated that Resident #2 was aggressive, and LPN #1 was notified. CNA #2 continued to state when Resident #2 was first noted with blood on their hands and scratches on their chest, staff members were not aware that Resident #1 was hurt. During an interview on 02/16/2021 at 3:00 p.m. and a follow up interview on 03/10/2021 at 5:46p.m with LPN #1, stated he/she were at the nurse's station when CNA #1 reported that Resident #2 was observed with blood on their fists and scratches on their chest. LPN #1 stated at approximately 9:15 p.m., CNA #2 informed him/her that there was blood on the floor of Resident #1's room. LPN #1 stated upon entering Resident #1's room, there was moderate amount of blood on the floor. The nightstand was in an upright position, the telephone sitting on top of the nightstand and the overbed table tilted, resting on the nightstand. Resident #1 was lying on their back in the bed next to the door (bed D). LPN #1 continued to state he/she observed blood on the nightstand and Resident #1's face was swollen and bleeding. LPN #1 voiced that they did not hear any yelling or screaming during the time leading up to him/her entering Resident #1's room. LPN #1 stated prior to the incident, Resident #1 was left in their room sitting in their wheelchair next to the foot of their bed (bed W). LPN #1 verbalized that Resident #1 can only see shadows and does not ambulate independently. LPN #1 stated that Resident #2 was agitated on the evening of the incident and staff were told to allow Resident #2 to calm down. The Medical Doctor (MD) was notified and ordered to transfer both residents to the hospital. LPN #1 stated he/she was aware that Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 also stated when Resident #2 became agitated, she would encourage Resident #2 to go back to the room and to lay down. During an interview on 02/18/2021 at 4:31 p.m., Registered Nurse #1 (RN #1) stated at approximately 9:05 p.m., LPN #1 informed him/her that Resident #2 had blood on their hands and [NAME] on the skin. RN #1 went on to say that LPN #1 called again at approximately 9:20 p.m. to report there was an emergency on the unit. RN #1 stated she/he immediately went onto the unit and assessed Resident #1 who was noted with swollen, bloody face and lip. RN #1 stated that Resident #2 was observed walking in the hallway with scratches to the chest and blood under their fingernails. The MD was informed and ordered to transfer both residents to the hospital for further evaluation. RN #1 stated they were familiar with Resident #2's behavioral pattern and encouraged the staff to provide diversional activities such as allowing Resident #2 to watch television or listen to music. RN #1 asserted that when Resident #2 gets agitated, it can be scary at times; however, once calm, Resident #2 was manageable. During an interview with the Director of Nursing Service (DNS) on 02/24/2021 at 12:59 p.m., the DNS stated that the incident involving Resident #1 and Resident #2 was unforeseen. Upon inquiry, the DNS stated that staff were not aware that Resident #2 would have gone into Resident #1's room. The DNS stated that they were aware of Resident #2's behavior from admission to the most recent incident and based on the behavior, Resident #2's Physician was notified, psychiatry was asked to evaluate Resident #2 and the staff were told to redirect Resident #2. The DNS stated that when Resident #2 showed episodes of agitation, activities would be based on Resident #2's attention span and redirection would be provided. DNS reported that they evaluated the effectiveness of its interventions by monitoring and observing Resident #2. Resident #2's actions against Resident #1 were considered a negative behavior. During an interview with Resident #2's Physician on 03/2/2021 at 2:59 p.m., the Physician stated that Resident #2 has sundowning and Dementia. The Physician stated Resident #2 constantly walked back and forth and gets aggressive when attempts were made to redirect; however, Resident #2 was manageable. The Physician voiced that psychiatry had been evaluating and had prescribed medications for Resident #2 which assisted in handling Resident #2's behavior. The Physician stated Resident #2's medications were working given that Resident #2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During a follow up interview with the DNS on 03/10/2021 at 3:22p.m., the DNS stated that the incident was not reported to law enforcement and that the facility does not have a policy on reporting suspicion of a crime to law enforcement. Upon inquiry regarding interventions to modify the environment to discourage Resident #2 from entering other residents' rooms, the DNS stated, I thought we did our best. I have no idea, maybe we should have sent the resident out. During an interview on 03/22/2021 at 10:30a.m. DNS stated that a Protection Care Plan was not initiated and implemented for Resident #1, and that one should have been initiated. DNS stated that the Social Worker was responsible for initiating a Protection Care Plan for Resident #1. 415.4(b)(1)(i)