Every finding on record at Woodcrest Rehabilitation & Residential Health Care

Based on observation, record review, and interviews during the Recertification Survey conducted from 07/01/2025 to 07/09/2025, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. This was evident in 2 (Resident #150 and #85) of 4 residents reviewed for Rehabilitation and Restorative Care. Specifically, 1.) Resident #150 was observed without hand rolls and no knee abductor cushion in place that were ordered for the use and prevention of increased contractures of the bilateral upper and lower extremities. 2.) Resident #85 was observed without hand rolls in place as ordered by the physician. The findings include: The facility document titled Policy and Procedure for Assistive Devices which was last reviewed on 11/2024 documented that assistive and adaptive devices may include, but not be limited to hand rolls, hand/arm splints, arm/leg braces, slings, and heel/elbow pads. The policy stated it is the charge nurse's responsibility to monitor the utilization and correct application of assistive devices as per rehabilitative department's recommendation. 1. Resident # 150 had diagnoses that included Muscle Spasm, Hemiplegia and Cardiovascular Disease. The Quarterly Minimum Data Set Assessment with a reference date of 05/31/2025 documented Resident #150 had severe cognitive impairment, with bilateral upper and lower extremity impairment both sides, and was dependent for all activities of daily living care and needs. The Occupational Therapy progress note dated 06/30/2025 documented a referral to Skilled Occupational Therapy Services for Resident #150 secondary to contractures to bilateral upper extremities especially to bilateral hands and elbows. The note documented Resident #150 will benefit from Skilled Occupational Therapy Services to decrease risk of further contractures with splinting and passive range of motion to extremities. The Physical Therapy progress note dated 07/03/2025 documented Resident # 150 was screened for Skilled Physical Therapy Services. Resident #150 was lying in bed with both hips and knees flexed, presented with pre-existing knee flexion contracture in right and left lower extremity. Apply Abductor / Contracture cushion to lower extremities at all times except range of motion and hygiene to prevent further contracture and provide comfort. A physician's order dated 07/06/2025 documented to apply bilateral hand roll at all times, except for range of motion and hygiene and to apply abductor/contracture cushion to lower extremities at all times except for range of motion and hygiene. A Comprehensive Care Plan for Contractures had documented interventions that included application of bilateral hand rolls at all times except for range of motion and hygiene and abductor/contracture cushion to lower extremities at all times except for range of motion and hygiene. During observations on 07/07/2025 at 8:50 AM and 12:11 PM, Resident #150 was in bed, nonverbal, and with contractures on both hands and both knees. Resident #150 was observed with no hand rolls and abductor in place. The abductor cushion was noted sitting on top of the clothes bin while the hand rolls were noted lying on the windowsill. On 07/07/2025 at 12:18 PM, the assigned Certified Nurse Aide #2 was interviewed and stated Resident #150 uses hand rolls and knee separator for contractures. They stated they did not notice Resident #150 wearing them in the morning when they started their shift. Certified Nurse Aide #2 stated they changed Resident #150 earlier and was in a hurry and planned to return to complete their care. On 07/07/2025 at 1:02 PM, Registered Nurse #2, who was the nursing supervisor, was interviewed and stated Resident #150 had orders for assistive devices to prevent further joint damage and prevent damage to skin integrity. They stated that the resident has a neurology appointment at 1:00 PM, which is why the abductor cushion was not placed on the resident. Registered Nurse #2 could not explain why the hand rolls were not in place. On 07/09/2025 at 10:06 AM, the Director of Rehabilitative Services was interviewed and stated residents are assessed to determine if they are candidate for assistive devices to prevent muscle tightening. They stated fine motor skills such as the hands, shoulders, and elbows are assessed by the Occupational Therapist while the hips, knees, and ankles are assessed by the Physical Therapist. They stated there is a recommendation made for Resident #150 for the application of the abductor cushion to be placed in between the resident's knees to help separate the inner thigh muscles and prevent inner thigh muscle tightening. On 07/08/2025 at 8:55 AM, the Director of Nursing was interviewed and stated that residents are evaluated by the Rehabilitation Department in collaboration with the medical doctor to determine if they would benefit from adaptive devices, to improve the resident's functional status, and help prevent deterioration as it relates to their limbs and extremities. They stated information for assistive devices are included in the care plan and charge nurses and nursing supervisors are responsible for ensuring that assistive devices are being applied as ordered. The Director of Nursing stated nurses on the units should be making rounds and observing residents and staff for compliance with care and services as per medical orders. 2. Resident #85 had an active diagnosis of Non- Alzheimer's, Seizure Disorder and Depression. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #85 had impaired cognition and was dependent in all areas of activities of daily living. The Minimum Data Set assessment also documented that Resident #41 had an impairment on both sides of the upper and lower extremity. A care plan for self-care deficit was initiated on 01/22/2025. The care plan documented, Resident #85 had inability to provide for own activities of daily living needs and was totally dependent on staff for assistance as evidenced by bilateral hand contractures. The facility interventions include utilizing pressure relief devices and occupational/physical therapy referral. A physician's order dated 11/08/2021 and was last renewed on 06/24/2025 documented orders to always apply left hand roll, remove for range of motion and hygiene. During observations on 07/02/2025 at 10:17 AM, 07/03/2025 at 12:36 PM, and on 07/07/2025 at 11:59 AM, Resident # 85 was observed with no left-hand roll in place. On 07/09/2025 at 12:07 PM, the Occupational Therapist was interviewed and stated that they had last evaluated Resident #85 on 05/21/2025 and has a standing order for use of left-hand roll. The Occupational Therapist stated that it is important to apply the left hand roll as ordered in order to help with contractures, prevent skin breakdown, and hygiene purposes, so there will be no redness or tightening in the hands. On 07/07/2025 at 12:21 PM, the Certified Nursing Assistant #7 was interviewed and stated that they are responsible for bathing, shaving, clothing, dressing and transferring Resident #85 using Hoyer lift. Certified Nursing Assistant #7 stated that Resident #85 had no assistive devices in place for their hands or feet. Certified Nursing Assistant #7 further stated that they did not place any device on Resident #85 today. When the Surveyor asked if a hand roll was placed today, Certified Nursing Assistant #7 stated that they were not aware that Resident #85 was supposed to have a hand roll in place and did not recall seeing an order in the system to do so. Certified Nursing Assistant #7 further stated that on the electronic medical record, the highlighted care areas are what the Certified Nursing Assistants are responsible for addressing and documenting. Certified Nursing Assistant #7 stated that since the restorative nursing rehabilitation box was not highlighted, they were not aware that it had to be done. On 07/07/2025 at 03:17 PM, the Licensed Practical Nurse #4, was interviewed and stated they need to double check if Resident #85 indeed was prescribed a hand roll or not. They stated, if there is an order for it, it is the responsibility of the floor nurses to ensure that the assistive device is in place for the resident. Licensed Practical Nurse #4 further stated it is important to apply the hand roll as ordered because residents fingernails can dig into the skin, putting pressure and causing the skin to open up. On 07/07/2025 at 02:17 PM, the Registered Nurse #3, who was the nursing supervisor, was interviewed and stated that the Certified Nursing Assistants are responsible for applying hand rolls. They stated most importantly hand rolls are ordered for residents who have contractures to prevent further contractures. Registered Nurse #3 stated Resident #85 has a standing order for application of left hand [NAME] that they were just informed that Resident #85 was missing a hand roll. They stated they ran downstairs to the therapy room to obtain one for Resident #85. Registered Nurse Supervisor #3 stated that there are a lot of residents on the floor, so it is difficult to oversee everything. Registered Nurse Supervisor #3 further stated that there is also no section for the Certified Nursing Assistants to document under nursing rehabilitation and splint device. On 07/09/2025 at 12:12 PM, The Director of Rehabilitation was interviewed and stated a hand roll is prescribed in order to prevent further contracture and to maintain the resident's current level of function. On 07/08/2025 at 2:10 PM, the Director of Nursing Services was interviewed and stated that prior to 07/2025, the application of devices was documented for information on the electronic medical record and there was no spot for the aides to sign for it. The Director of Nursing Services stated that regardless, whether the aides have to sign off on it or not, it is the responsibility of the nursing staff on the unit including the nursing supervisors and nurses to ensure that the plan of care is being implemented for the residents and to ensure that assistive devices are in place. The Director of Nursing Services stated that it is important that assistive devices including hand rolls are applied to prevent deterioration of contractures. 10 NYCRR 415.12 (e)(2)

Based on observation, record review, and interviews, during the Recertification Survey conducted from 07/01/2025 to 07/09/2025, the facility failed to ensure each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was evident for 1 (Resident #150) of 35 total sampled residents. Specifically, Resident #150, who had a physician's order to use a mouth guard in the morning, was observed without a mouth guard applied on 2 occasions. The findings include: The facility's policy title Mouth Guard Use and Management with a revised date of 10/2024 documented the staff will ensure proper management, storage, cleaning, and supervision to maintain resident safety, and oral health. Resident #150 had diagnoses of Muscle Spasm, Gastrostomy, and Cerebrovascular Accident. The Minimum Data Set assessment with reference date of 05/31/2025 documented that Resident #150 had severely impaired cognition and required total assistance for all areas of activities of daily living. A comprehensive care plan for impaired oral/dental condition was initiated for Resident #150 on 11/28/2024 and was reviewed on 05/30/2025 documented that the resident had potential for alteration of oral mucous membranes. The facility interventions include removal of upper night guard at night, replace in the morning, and monitor gum and teeth for any symptom of infection. A dental progress note dated 05/22/2025 documented that Resident #150 presented with bruxism (grinding of teeth). Delivery of upper night guard, good retentive fit. The case was left at bedside A physician's order for dated 07/06/2025 documented to remove upper night guard at nights and replace in AM; monitor gum and teeth and report any signs of infection. During observation on 07/07/2025 at 8:50 PM and at 12:11 PM, Resident #150 was in bed, non-verbal, and had an audible teeth grinding sound. Resident #150 was not wearing a mouth guard. The mouth guard was observed inside a blue denture cup at the bedside table. The electronic Medication Administration Record documented that mouth guard was applied on 07/07/2025, 7:00 AM – 3:00 PM. Certified Nurse Aide #2 was interviewed on 07/07/25 at 12:18 PM who stated that were assigned to Resident #150. They stated Resident #150 uses a mouth guard to protect their mouth and teeth from getting worse. Certified Nurse Aide #2 stated they were in a hurry to provide care to the resident this morning and did not apply the mouth guard. Licensed Practical Nurse #2 was interviewed on 07/07/2025 at 1:56 PM and stated that Resident #150 had contractures and uses a mouth guard to help protect the teeth from being grinded. They stated the certified nurse aides remove the mouth guard at night and apply them in resident's mouth in the morning. Licensed Practical Nurse #2 stated they assessed Resident #150's gums and signed off on the electronic Medication Administration Record. They stated they believed they saw the mouth guard in place this morning. Registered Nurse #2, who was the nursing supervisor, was interviewed on 07/07/2025 at 1:02 PM and stated that Resident #150 has an order for mouth guard to prevent further damage because they grind and clenches their teeth. The Director of Nursing was interviewed on 07/08/2025 at 8:55 AM and stated that the unit charge nurses must be monitoring the placement of mouth guards as well as any mouth or gum issues. They stated charge nurses and nursing supervisors are responsible for ensuring a resident's care and services are being offered. 10 NYCRR 415.12

Based on observation, record review, and interviews during the Recertification Survey conducted from 07/01/2025 to 07/09/2025, the facility failed to ensure a resident received care, consistent with professional standards of practice to prevent pressure ulcers. This was evident for 1 (Resident #150) of 3 residents reviewed for Pressure Ulcers. Specifically, Resident #150, who was at high risk to develop pressure ulcer and had physician's order for bilateral heel booties while in bed, was observed on 2 occasions in bed without heel booties. The findings include: The facility's policy titled Pressure Ulcer Prevention and Intervention dated 09/2024 documented the facility will have a pressure injury prevention program to identify risk factors, pressure injury formation when avoidable and promote skin integrity as well as interventions to heal existing pressure injury and prevent development of additional pressure injuries. Resident #150 was admitted with diagnoses that included Hemiparesis and Cerebrovascular Accident. The Quarterly Minimum Data Set assessment with reference date 05/31/2025 documented Resident #150 had severe cognitive impairment, upper and lower extremity impairment on both sides, and required total staff assistance for activities of daily living. The assessment further documented that Resident #150 was at high risk to develop pressure ulcers and uses pressure reducing devices for bed and chair. A Braden Scale (a scale for determining pressure ulcer risk) dated 05/31/2025 documented a score of 12, indicating Resident #150 was at high risk for pressure ulcer development.A Comprehensive Care Plan for impaired skin integrity dated 05/31/2025 had facility interventions that included heel pad, heel protector boots while in bed.A physician's order dated 07/06/2025 included heel protector booties while in bed. On 07/07/2025 at 8:50 AM and 12:11 PM, Resident #150 was observed in bed, with upper and lower extremity contractures. There were no heel protector booties noted in place.On 07/07/2025 at 12:18 PM, Certified Nurse Aide #2 was interviewed and stated Resident #150 was in their assignment. They stated they are familiar with Resident #150's care and that Resident #150 uses heel booties to prevent their skin from breaking down. They stated they washed the resident and left to attend to another resident without applying the heel booties. Certified Nurse Aide #2 stated they were in a [NAME] but planned to come back to complete Resident #150's care. On 07/07/25 at 1:02 PM, Registered Nurse #2, who was the nursing supervisor was interviewed and stated heel protectors are important to maintain the skin integrity of the resident's heels. They stated they make rounds to ensure that residents are turned and repositioned, showered, and if assistive devices are in place. 10 NYCRR 415.12(c)(1)

Based on observations, record review, and interviews conducted during the Recertification Survey from 07/01/2025 to 07/09/2025, the facility did not ensure that residents are free of any significant medication errors. This was evident for 1 (Resident #46) out 7 residents sampled during the Medication Administration Task. Specifically, Resident #46 was not administered 8 milliliters of Levetiracetam 100 milligram/milliliters by oral route for seizures as ordered by the physician. The findings include:The facility's policy titled Medication Administration that was last reviewed on 10/2024 documented that all medications are administered safely and appropriately to aid residents to resolve illness, relieve and prevent symptoms and help in diagnosis. Resident #46 had diagnoses of Seizure Disorder and Dementia.The Minimum Data Set assessment dated [DATE] documented that Resident #85 had severely impaired cognitive skills and had seizure disorder and was taking an anticonvulsant. A care plan for potential for injury related to seizure activity with a last reviewed date of 07/10/2025 documented interventions which included to administer Levetiracetam 8 milliliters twice daily and monitor laboratory values.A physician's order with a renewal date of 06/11/2025 documented to give 8 milliliters (800 milligram) of Levetiracetam 100 milligram/ 1 milliliters oral liquid by oral route 2 times per day, every day at 9:00 AM and 9:00 PM.During observation of medication administration for Resident #46 on 07/07/2025 at 10:30 AM, Levetiracetam oral solution was missing from the medication cart and was not administered. Licensed Practical Nurse #3 went through all the drawers in the cart and could not locate the Levetiracetam oral solution. Licensed Practical Nurse #3 stated they would inform the nursing supervisor as it was missing from the cart. The Medication Administration Record for 07/07/2025 at 9:00 AM documented that Levetiracetam was not administered, medication was not available.On 07/07/2025 at 10:36 AM, Licensed Practical Nurse #3 was interviewed and stated they are not regularly assigned to this floor and had just noticed that Resident #46's Levetiracetam solution was missing. They stated they informed the nursing supervisor about the missing medication. Licensed Practical Nurse #3 stated that it is important to give the said medication timely and as ordered, to prevent seizures. They stated, when a medication is running low, the protocol is for the medication nurse to take a piece of paper, place the ordering code on it and give it to the nursing supervisor for it to be re-ordered. The nursing supervisor then follows up on the medication. On 07/07/2025 11:10 AM, Registered Nurse #3, who was the nursing supervisor, was interviewed and stated they were just made aware by Licensed Practical Nurse #3 that Resident #46's Levetiracetam solution was missing from the cart. They stated they worked the morning shift yesterday and was not informed by anyone that it was running low. Registered Nurse #3 stated the usual protocol to reorder medications is for the nurse to alert the nursing supervisor. They stated other Registered Nurses can also reorder the medication through the electronic medical record. Registered Nurse #3 further stated that Levetiracetam must be given in a timely manner as ordered by the doctor to prevent seizures. Registered Nurse #3 stated, if Levetiracetam if a dose is not administered, then the doctors order is not being followed.On 07/07/2025 at 11:42 AM, Registered Nurse #6 was interviewed and stated they administered the last dose of Levetiracetam solution to Resident #46 yesterday and had reordered the medication by clicking refill on the electronic medical record. They stated the medication usually comes the same day or the next morning. Registered Nurse #6 stated they did not document in the medical record that they were awaiting for Levetiracetam refill. On 07/08/2025 1:34 PM, the Pharmacist was interviewed and stated medication refill request are usually made by calling the pharmacy, faxing, or through the electronic medical record. They stated a refill request for Resident #46's Levetiracetam was submitted on 07/04/2025 at 2:45 PM and was flagged as too soon to refill and they set a refill reminder for 07/07/2025. The pharmacy stated they delivered the medication on 07/07/2025 at 3:30 PM. Prior to 07/07/2025, the Pharmacist state they sent a 29-day supply of Levetiracetam for Resident #46 on 06/11/2025 and was delivered at 7:45 PM. The Pharmacist stated a missed dose of Levetiracetam can result in seizures depending on a resident's comorbidities. On 07/08/2025 at 2:14 PM, the Director of Nursing Services was interviewed and stated that medications are supposed to be ordered 3 days prior to the end of quantity. They stated Resident #46's Levetiracetam was reordered on 07/04/2025 but for some reason was not delivered. The Director of Nursing Services stated they had Resident #46's Levetiracetam delivered from a local pharmacy on 07/07/2025 when they were made aware that it was missing. The Director of Nursing stated the usual protocol is that medication nurses must notify the nursing supervisor on duty that a medication needs to be refilled. The nursing supervisor then reaches out to the pharmacy. They stated in some cases, the nurses can directly reach out to the pharmacy. The Director of Nursing Services stated that even though it was a holiday weekend, there should have been no excuse for not ensuring that Resident #46 had enough supply of anticonvulsant. The Director of Nursing Services further stated that it is important that a resident does not miss a Levetiracetam dose, because the blood medication level will be affected, and the resident can be prone to having seizures.On 07/09/2025 at 12:44 PM, during a subsequent interview, the Director of Nursing Services stated they were not aware that Resident #46 was flagged as too soon to refill when a request was made on 07/04/2025 and was not delivered. They stated they did not have a definitive response as to why the medication supply ran out earlier than it should have.On 07/08/2025 at 3:03 PM, the Physician Assistant was interviewed and stated they were informed in the morning of 07/07/2025 that Resident #46's Levetiracetam was not available. They stated missing a dose of Levetiracetam could affect long term blood serum levels and lead to negative effects including seizures. 10 NYCRR 415.12(m)(2)

Based on observation, record review, and interviews during the Recertification Survey conducted from 07/01/2025 to 07/09/2025, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident in 1 (Resident #9) of 37 total sampled residents. Specifically, Registered Nurse #4 failed to practice hand hygiene during wound care.The findings include:The facility's undated policy titled Dressing Change documented in the procedure to wash hands and don gloves: after preparing the area and equipment for wound dressing change, and after removing and discarding the soiled dressing. Resident #9 had diagnoses of Stage 4 Pressure Ulcer of Sacral Region, Parkinson's Disease, Non-Alzheimer's Dementia, and Malnutrition.The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #9 had severely impaired cognition and Stage 4 pressure ulcers.The physician's order dated 06/13/2025 documented to cleanse sacrum open wound with normal saline, pat dry, apply collagen sheet, cover with bordered gauze daily and as needed.On 07/08/2025 at 9:24 AM, wound care observation was conducted for Resident #9 with Registered Nurse #4. Registered Nurse #4 came into the room, washed their hands and donned gloves. They cleaned the over bed table, removed gloves, used hand sanitizer, donned gloves, and placed down the supplies, then washed their hands. Registered Nurse #4 donned gloves, then removed Resident #9's soiled dressing from the wound on their sacrum. Registered Nurse #4 removed gloves and without performing hand hygiene, donned gloves, and proceeded to clean the wound. Registered Nurse #4 then removed gloves and without performing hand hygiene, donned gloves and then applied the treatment and placed the clean dressing on the wound. Registered Nurse #4 then removed their gloves and performed hand hygiene.On 07/08/2025 at 9:40 AM, Registered Nurse #4 was interviewed and stated they received in-service education to wash their hands after removing the soiled dressing and also after cleansing the wound. Registered Nurse #4 stated they forgot to do that.On 07/08/2025 at 9:50 AM, Registered Nurse #2 who was the nursing supervisor was interviewed and stated that Registered Nurse #4 should have performed hand hygiene after removing the soiled dressing and then again after cleaning the wound.On 07/09/2025 at 12:47 PM, the Director of Nursing was interviewed and stated that nurses are given in-service education to perform hand hygiene after removing the soiled dressing, and also after cleaning the wound.10 NYCRR 415.19(b)(4)

Based on record review and interviews conducted during an Abbreviated Survey (NY00347821, NY00348092 and NY00354868), the facility did not ensure that the alleged violations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property were reported immediately, but not later that two (2) hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involved abuse and do not involve serious bodily injury, to the administrator of the facility and to other officials (including to the State Agency). Additionally, the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within five (5) working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This was evident in three (3) out of seven (7) residents (Resident #1, #2 and #4). Specifically, on 07/10/2024 at 11:00 AM, Resident #1 reported that Licensed Practical Nurse #1 punched them in their face and was observed with small cut in their upper lip. On 07/10/2024 at 3:04 PM, The facility reported the incident to New York State Department of Health and the facility did not report the results of the investigation within five (5) days to the New York State Department of Health. On 07/12/2024 at 12:30 AM, Resident #2 complained of lower back pain and stated that Licensed Practical Nurse #2 pulled their left arm backward while they were sleeping. On 07/12/2024 at 4:48 PM, the facility reported the incident to New York State Department of Health. The facility did not submit the follow up investigation summary within five (5) days to the New York State Department of Health. On 09/05/2024 at 5 AM, Resident #4 was assessed by the Registered Nurse (#1) after hitting their head on the bed and observed with an open wound to the left scalp and bleeding in the left eye. Resident #4 and was transferred to the hospital. On 9/12/2024, Resident #4 was re-admitted to the facility with a hospital discharge note documented Resident #4 had head injuries are had staples to the forehead. On 09/20/2025, the facility reported resident neglect occurred on 09/05/2025 to the Department of Health. The findings include: The Facility's Policy and Procedure titled Abuse, Neglect and Exploitation: Prevention and Reporting dated 07/2024, documented allegations of abuse or neglect; serious bodily injury due to neglect, exploitation, mistreatment or an injury of unknown source must be reported within two (2) hours. The Director of Nursing/designee will investigate injuries of unknown origin and report findings to the Administrator. The Administrator will determine if other reporting is required by law. All findings of investigations will be documented. An investigative report will be completed within five (5) days and summarize the findings and outcome as well as any corrective action(s). If abuse cannot be ruled out the New York State Department of Health will be notified. Resident #1 was admitted to the facility with diagnoses including Schizophrenia, Anxiety Disorder and Hypertension. The Minimum Data Set (a resident assessment tool) dated 07/08/2024 documented Resident #1 cognition was intact. In the facility's Accident/Incident Report dated 07/10/2024 at 11:30 AM, documented Resident #1 reported that they were punched by the Licensed Practical Nurse #1 in their face. Resident #1 was observed with a small tear on upper lip. The facility concluded that there was no evidence to support that Resident #1 was punched in their face. There was no swelling or bruising on the face. The Licensed Practical Nurse #1 sustained a superficial skin break and bleeding in their finger. It was concluded that Resident #1-bit Licensed Practical Nurse #1 on their finger as they were attempting to administer the medication. Resident #1 sustained trauma in their lip when Licensed Practical Nurse #1 pulled away their finger from Resident #1. The facility reported the incident to New York State Department of Health on 07/10/2024 at 3:04 PM and did not report the results of the investigation within five (5) working day to the Department of Health. Resident #2 was admitted to the facility with diagnoses including Chronic Obstructive Pulmonary Disease, chronic pain and anxiety. The Minimum Data Set (a resident assessment tool) dated 06/22/2024 documented Resident #3 cognition was intact. In the facility's Accident/Incident Report dated 07/12/2024 at 9:30 AM, documented Resident #1 complained of lower back pain and reported that Licensed Practical Nurse #2 pulled their left arm backward while they were sleeping. The facility's summary of investigation dated 07/15/2024, documented that Resident #2 was angry when they were awakened at midnight for administration of medications by Licensed Practical Nurse #2. Resident #2 was assessed and there was no injury. The radiology results of lumbar spine, left forearm, left arm and left elbow were negative. The facility's investigations concluded no abuse occurred. The facility reported the incident to New York State Department of Health on 07/12/2024 at 4:48 PM. The facility did not report the results of their investigation within five (5) working days to New York State Department of Health. Resident # 4 was admitted to the facility with diagnoses including Alzheimer's Disease, seizure disorder and adult failure to thrive. The Minimum Data Set (a resident assessment tool) dated 08/01/2024, documented Resident #4 was severely cognitive impairment and is non-ambulatory. In the facility's Incident Report dated 09/5/2024 at 5 AM, completed by the Registered Nurse (#1) documented Resident #4 was seen with a left scalp three (3) centimeters x 0.1centimeters open area to the head. Resident unable to state what happened. Resident #4 was transferred to hospital as ordered by the physician/nurse practitioner. The facility's summary of the investigation documented that on 9/12/2024, Resident #4 was re-admitted to the facility. The hospital discharge notes documented Resident #4 had head injuries that required staples to close the wound. During an interview on 06/23/2025 at 9:00 AM, Director of Nursing stated they reported to New York State Department of Health of the allegations and stated they did not report timely. Director of Nursing stated they are aware that any allegations of abuse should be reported within two (2) hours. Director of Nursing further stated they failed to submit the follow up report within five (5) days to New York State Department of Health. During an interview on 06/23/2025 at 6/23/25 9:51 AM, the Administrator stated they were not aware that the incidents were not reported timely, and they were not aware the results of the investigations were reported within five (5) days to New York State Department of Health. During a follow up interview on 6/24/2025 the Administrator and Director of Nursing at 5:20 PM and 5:23 PM respectively, the Director of Nursing stated on 9/5/2024, Resident #4's injuries were assessed as superficial scratches but after Resident #4 returned to the facility on 9/12/2024 they realized the injury was worse as Resident #4 had staples according to the hospital's records. The Administrator stated when they were informed on 9/19/2025 the incident was reported to New York State Department of Health. 10 NYCRR 415.4 (b)(1)(ii)

Based on record review and interviews during the recertification survey from 2/2/23 to 2/9/23, the facility did not ensure the surety bond provided security of all personal funds of residents deposited with the facility. This was evident for 122 of 194 residents with personal needs accounts (PNA) with the facility. Specifically, the facility's surety bond was less than the total amount from 122 PNAs maintained by the facility. The findings are: The facility policy titled Resident Funds dated 02/2023 documented the facility holds a surety bond to guarantee the protection of residents' funds managed by the facility on behalf of the residents. The facility's Resident Fund Listing Balance dated 02/06/2023 documented the Total Resident Fund = $219,839.48. The facility Surety Bond documented resident PNAs were protected against $150,000. The surety bond ($150,000) is less than and does not cover all of the resident PNAs ($219,839.48). On 02/07/23 at 12:44 PM, the Finance Director (FD) was interviewed and stated they just now realized the facility's current surety bond was not enough to cover all of the resident PNAs. The FD messed up by not increasing the surety bond to match the increase in PNA caused by residents receiving stimulus monies last year. The FD stated they would rectify the issue immediately. On 02/08/23 at 02:49 PM, an interview was conducted with the Administrator who started it was an oversight that the surety bond was not increased to cover the total sum of all resident PNAs. 415.26(h)(5)(v)

Based on observations, interviews, and record review conducted during the recertification survey from 2/2/23 to 2/9/23, the facility did not ensure Housekeeping and Maintenance services maintained a sanitary, orderly, and comfortable interior. This was evident on 2 (Unit 4 and 5) of 5 units. Specifically, 1) Unit 5 was observed with multiple environmental concerns throughout the unit including furniture in disrepair, dirty floors, dust, rust, and stains in resident rooms and the common areas, and 2) Unit 4 was observed with peeling paint, rusty areas, a broken closet door, and equipment in disrepair. The findings are: The facility's policy titled Resident Room Cleaning dated 3/2016 documented daily cleaning will ensure optimum levels of cleanliness and sanitation, prohibit the spread of infection and bacteria, and maintain the outward appearance of the facility. 1) Observation of Unit 5 was conducted on 02/02/2023 at 9:00AM with the following being observed: A ) in the lobby outside of the Admissions Office, 3 chairs and 1 love seat were heavily soiled, discolored and faded. A bookcase door and an end table door were hanging loosely off their hinges; B ) in the Activities Room, 2 tables had holes gauged in them and clear tape was placed on the table as a form of repair; C ) the Nursing Station had broken and missing panels exposing the inner wood of the desk, computer mouse pads were stained and dirty, and phones and computers were covered in dust; D ) the residents' common bathroom across from room [ROOM NUMBER] had a loose handle bar not securely attached to the floor, broken and missing grout at the base of the toilet, corners of the floor were embedded with dirt and black substance; E ) the Dining Room tables were layered with dirt and dust on their metal bases; F ) the following Resident Rooms: 501A - Bathroom door off bottom track preventing it from closing properly, bathroom floor corners embedded with black dirt, a heavily worn bedside table exposing the inner cork, and a rusty and dusty metal bed frame; 501B - Wall above the air conditioner chipped and broken plaster, call bell wall panel covered with dirty peeling tape, a large black stain on the back of the room door, rusty toilet paper holders, and stained and dirty wall surrounding the sink; 510B - 1/2 side rail stained with black substance, heater covered with rust stains, and a bed frame and baseboard layered with dirt and dust; 510C - Floor had ground in dirt and debris, heavily wrapped tape was used to keep the metal bed frame together, bedside heavily worn bedside table exposing the inner cork, cracked and chipped plaster on the ceiling above the bed, torn and dirty privacy curtain, stained walls around the sink, and bathroom floor corners with ground in dirt and debris; 515B - Loose door knob on closet door, rusty toilet paper holder. bathroom floor that is dirty and embedded with black substance, a loose bathroom handle bar, wobbly bedside table missing a leg; 518A - Metal bed frame with scattered brown stains, and brown stains and streaks on the walls. The Unit 5 Maintenance Log Book entry dated 02/03/23 documented room [ROOM NUMBER] had a dresser in disrepair and bathroom door difficult to open. On 02/08/23 at 09:34 AM, the Unit 5 Housekeeper was interviewed and stated they are responsible for sweeping and mopping all the floors and dusting the bed frames, bedside tables, and handrails in the corridor. The Housekeeper uses the Maintenance Log Book to report repair needs. Housekeeping performs monthly room cleanings and the Director of Housekeeping inspects the Housekeepers' work. On 02/08/23 at 10:07 AM, Certified Nursing Assistant (CNA) #2 was interviewed and stated they report repair needs to the nurse. CNA #2 does not use the Maintenance Log Book but has spoken to the Housekeeper about the wobbly bedside table in room [ROOM NUMBER]. On 02/08/23 at 11:16 AM, Unit 5 Registered Nurse (RN) # 5 was interviewed and stated staff inform RN #5 when a resident's furniture or equipment needs repair or replacement. RN #5 uses the Maintenance Log Book to inform Maintenance of repair issues and immediately informs the Housekeeper of housekeeping issues. RN #5 then makes their own observations of the reported issues. 40565 2) On 02/02/23, between 11:01 AM and 01:05 PM, and on 02/03/23, between 08:00 AM and 11:29 AM, the following was observed on Unit 4: A) 417B- Peeling paint above the head of the bed and a closet door hanging loosely off its track; B) 416- Rusty pipe under the sink and peeling paint on the walls near the door and on the left side of the room; C) Dayroom- Broken linen closet door; D) Common Bathroom near the Dayroom- rusted toilet paper holder and loose safety bar hand grip with 4 screws missing. On 02/08/23 at 10:25 AM, Certified Nursing Assistant (CNA) #1 was interviewed and stated damage in resident rooms are reported in the Maintenance Log Book and to the nursing supervisor. The nursing supervisor can call Maintenance to come immediately to get repairs done. CNA #1 was assigned to room [ROOM NUMBER] and room [ROOM NUMBER] at the beginning of this month and did not notice loose doors or other repair issues. On 02/08/23 at 10:35 AM, the Unit 4 Housekeeper was interviewed and stated the broken door in room [ROOM NUMBER] was reported to maintenance immediately when observed by the Unit 4 Housekeeper last week. the Unit 4 Housekeeper reported peeling paint and the rusty pipe to their supervisor a while ago. On 02/08/23 at 10:42 AM, the Registered Nurse (RN) #2 was interviewed and stated the Maintenance Department is notified immediately when items are damaged and [NAME] repair. The broken closet door was reported to Maintenance last week. The peeling paint and rusty pipe were supposed to be reported to Housekeeping and Maintenance. The Unit 4 Housekeeper informed RN #2 of the broken linen door and loose safety bar hand grip and RN #2 already reported these issues to Maintenance. RN #2 stated the Unit 4 Maintenance Log Book was missing this morning and could not verify when log entries were made. The Director of Housekeeping (DH) was interviewed on 02/08/23 at 10:16 AM and stated they check for cleanliness when they make daily rounds on all the units. It is important to provide a clean place for the residents, staff, and visitors. There are Housekeepers assigned to each unit and they are provided with a daily cleaning schedule. The DH inspects the Housekeepers' work daily and has the Housekeeper immediately remedy any issues. The Director of Maintenance (DM) was interviewed on 02/08/23 at 11:00 AM and stated they are the only Maintenance worker for the whole building. The facility is in the process of trying to hire another Maintenance worker. The DM checks the Maintenance Logs daily on all units and repairs what they can address. The DM looks for loose handrails, leaking faucets, and broken blinds. 415.5(h)(2)

Based on interviews and record review conducted during the Recertification and Complaint Survey (NY00305874) from 2/2/23 to 2/9/23, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations were made, to the New York State Department of Health (NYSDOH). This was evident for 3 resident-to-resident altercations involving 4 (Resident # 402, # 145, # 37 and # 97) out of 4 residents reviewed for Abuse. Specifically, 1) the facility did not report to NYSDOH after Resident #402 hit Resident #145, 2) the facility did not report to NYSDOH after Resident #402 hit Resident #37, and 3) the facility did not report to NYSDOH after Resident #402 hit Resident #97. The findings are: The facility policy titled Abuse, Neglect and Exploitation: Prevention and Reporting revised 6/2018 documented the Administrator or Director of Nursing (DON) must report allegation of abuse immediately but no later than 2 hours after the alleged incident. Resident #402 had diagnoses of Alzheimer's disease and psychotic disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #402 was severely cognitively impaired and required assistance of 1-2 people to complete activities of daily living. 1) Resident #145 had diagnoses of schizophrenia and hypertension. The MDS dated [DATE] documented Resident #145 had moderate cognitive impairments. The Accident/Incident (A/I) Report dated 10/29/22 documented Resident #402 punched and kicked Resident #145 while in the unit dining room. There was no documented evidence the facility reported the incident involving Resident #402 and Resident #145 to the NYSDOH. 2) Resident # 37 (NY00305874) had diagnoses of seizure disorder and cerebrovascular accident. The MDS dated [DATE] documented Resident # 37 was moderately cognitively impaired and did not exhibit behaviors. The Accident/Incident (A/I) Report dated 11/3/2022 documented Resident #402 entered Resident #37's room and hit Resident #37 in the left eye. There was no documented evidence the incident involving Resident #402 and Resident #37 was reported to the NYSDOH. 3) Resident # 97 had diagnoses of dementia and hypertension. The MDS dated [DATE] documented Resident #97 was severely cognitively impaired. The Accident/Incident (A/I) Report dated 11/15/2022 documented Resident # 402 punched Resident #97 in the face while the residents were in the unit dining room. There was no documented evidence the facility reported the incident involving Resident #402 and Residnt #97 to the NYSDOH. On 02/09/2023 at 01:07 PM the DON was interviewed and stated the resident-to-resident altercations involving Resident #402 were investigated by the facility and it was determined no abuse occurred. This is the reason the incidents were not reported to the NYSDOH. On 02/09/2023 at 01:46 PM the Administrator was interviewed and stated they believed resident-to-resident altercations were not reported to the NYSDOH after the facility completes their investigation. 415.4(b)(2)

Based on observation, record review and staff interviews during the Recertification Survey from 2/2/23 to 2/9/23, the facility did not ensure quarterly financial records were made available to a resident's representative. This was evident for 1 (Resident #78) of 1 resident(s) Personal Funds review. Specifically, Resident #78's designated representative (DR) did not receive quarterly statements of the resident's Personal Needs Account (PNA). The findings are: The facility policy titled Resident Funds dated 02/2023 documented statements will be distributed to residents/DR on a quarterly basis. Resident #78 had diagnoses of anemia and dementia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #78 was severely cognitively impaired and the DR participated in the assessment. On 02/02/23 at 12:34 PM, Resident #78's DR was interviewed and stated Resident #78 has a PNA with the facility but the DR has never received quarterly statements. The DR stated hey visit Resident #78 regularly and no one in the facility provided the DR with statements of the resident's PNA. The Resident Fund Listing Balance dated 02/06/2023 documented Resident #78's PNA balance was $1,011.06. There was no documented evidence Resident #78's DR was provided with quarterly statements of the resident's PNA. On 02/07/23 at 10:54 AM, Social Worker (SW) #1 was interviewed and stated the business office prints out the PNA statements and the SW distributes the quarterly statements to residents' family/DR. The Director of Social Work (DSW) is responsible for mailing the statements but does not keep a record of statements that were mailed. Resident #78's family is very involved in the resident's care. On 02/07/23 at 12:39 PM, The DSW was interviewed and stated the SW Department is responsible for mailing statements to resident family members/DR. The DSW does not document or keep record of the quarterly statements that were mailed out. On 02/08/23 at 02:49 PM, the Administrator was interviewed and stated they do not know the reason the DSW did not document mailing out quarterly statements to the resident DRs. 415.26(h)(5)(i)

Based on interviews and record review conducted during Recertification and Complaint (NY00305874) Survey from 2/2/23 to 2/9/23, the facility did not ensure residents were free from abuse. This was evident for 2 (Resident #37 and Resident #97) of 4 residents reviewed for Abuse. Specifically, Residents #37 and #97 were victims of resident-to-resident abuse from Resident #402, a resident with Dementia, aggression and a history of a previous altercation with Resident #145. The facility did not implement new interventions for Resident #402 after each incident of resident-to-resident abuse to prevent additional altercations. The findings are: The facility policy titled Abuse, Neglect and Exploitation: Prevention and Reporting revised 6/2018 documented all residents have the right to be free from abuse. Immediate intervention is necessary and staff must put a stop to potential resident harm. Resident #402 had diagnoses of Alzheimer's disease and psychotic disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #402 was severely cognitively impaired and required assistance of 1-2 people to complete activities of daily living. Resident #145 had diagnoses of schizophrenia and hypertension. The MDS dated [DATE] documented Resident #145 was moderately cognitively impaired. The Accident/Incident (A/I) Report dated 10/29/2022 documented Resident #402 punched and kicked Resident #145 while in the unit dining room. Resident #402 was administered Haldol 2mg intramuscularly (IM). The Comprehensive Care Plan (CCP) related to aggressive behavior initiated 9/28/22 documented on 10/29/22, Resident #402 had an altercation with Resident #145, was administered Haldol 2mg IM, and will be monitored. There was no documented evidence the CCP was revised to include new intervention to prevent Resident #402 from having further resident-to-resident altercations. 1) Resident #37 had diagnoses of cerebrovascular accident and seizure disorder. The MDS assessment dated [DATE] documented Resident #37 was moderately cognitively impaired and did not exhibit behaviors. The A/I Report dated 11/3/2022 documented Resident # 402 entered Resident #37's room and punched Resident #37 in the left eye. Resident #37 was sent to the hospital for evaluation. The CCP related to aggressive behavior was updated 11/3/22 and documented Resident #402 hit Resident #37. Haldol 2mg IM was administered and a psychiatry consult was ordered. There was no documented evidence the CCP was revised to include new intervention to prevent Resident #402 from having further resident-to-resident altercations. 2) Resident # 97 had diagnoses of dementia and hypertension. The MDS assessment dated [DATE] documented Resident #97 had severely impaired cognition. A Nursing Note dated 11/15/2022 documented Resident #97 was involved in a resident-to-resident altercation. Resident #97 was alert and verbally responsive with periods of confusion, and there were no injuries, swelling, bleeding, or pain. Neuro-checks were initiated, and the physician and family were notified. A Comprehensive Care Plan (CCP) related to Resident #97 being a victim of physical aggression was initiated 11/15/2022. Interventions included ensure staff is dedicated to maintaining Resident #97's safety, redirect as needed, and remove immediately from potentially escalating situations. A Social Services Note dated 11/16/2022 documented Resident #97 had a resident-to-resident altercation on 11/15/2022. Both resident's were separated. The Social Worker (SW) met with Resident #97 and provided emotional support. Resident #97 was unable to recall what happened due to confusion and was not a candidate for psychological services due to impaired cognition. The note documented the SW and staff would continue to monitor the resident. The A/I Report initiated 11/15/2022 and completed 11/17/22 documented Resident #402 punched Resident #97 while they were in the unit dining room. Resident #402 was sent to the hospital and admitted for psychiatric evaluation and treatment. On 2/9/2023 at 1:07 PM, the Director of Nursing (DON) was interviewed and stated Resident #402 had a history of physical aggression and, after the allegations were investigated, the, the facility did not see the need to change the rooms of the residents involved. The staff continuously monitored Resident #402 for safety. The DON stated the incidents involving Resident #402 were not considered abuse, and the facility investigation concluded there was no reason to believe abuse occurred. During an interview on 2/9/2023 at 1:46 PM, the Administrator stated the facility and nursing staff should follow the regulation for monitoring and protecting residents from harm. 415.4(b)(I)(i)

Based on record review and interviews conducted during the Recertification Survey, the facility did not ensure Minimum Data Set 3.0 (MDS) comprehensive and non-comprehensive assessments were submitted and transmitted into the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in timely. This was evident for 2 (Resident #37 and #15) of 2 residents reviewed for Resident Assessment of a sample of 38 residents. Specifically, 1) Resident #37's quarterly and significant change MDS were submitted more than 14 days after completion, and 2) Resident #15's quarterly MDS assessments were submitted more than 14 days after completion. The findings are: The facility policy titled Submission and Correction MDS Assessments last revised 10/10/2022 documented comprehensive assessments must be transmitted within 14 days of the care plan completion date and all other assessments must be submitted within 14 days of the completion date. 1) The significant change MDS for Resident #37 with assessment reference date of 7/1/22 was completed 7/5/22 and was submitted 8/17/22, more than 14 days after the completion date. The quarterly MDS for Resident #37 with assessment reference date of 1/1/23 was completed on 1/15/23 and submitted on 2/2/23, more than 14 days after completion. 2) The quarterly MDS for Resident #15 with assessment reference date of 1/2/23 was completed on 1/16/23 and was submitted on 2/2/23, more than 14 days after completion. On 02/07/23 at 12:19 PM, an interview was conducted with MDS Director (MDSD) who stated the MDSD reviews the completed MDS assessments prior to contract staff submitting and transmitting the assessments in QIES. The MDSD discovered MDS assessments were submitted late after printing out the validation report. The delay in submission could be due to a delay in completion of the MDS, a delay in uploading the report, or staffing challenges related to COVID-19. On 02/08/23 at 11:22 AM, Medical Records (MR) was interviewed and stated they upload the MDS assessment immediately once completed. MR could not explain the late submissions because MR checks the system for completed MDS assessments every day. On 02/08/23 at 11:36 AM, the Director of Nursing was interviewed and stated the MDS coordinators must assist with providing care when there is no nurse on the units and some MDS assessments have been submitted late due to staffing issues. 415.11

Based on observation and interview during the recertification survey, the facility did not ensure that the residents' call bell system was maintained in proper working order. This was evident for 1 (Resident #76) of 9 residents reviewed for the environment. Specifically, Resident #76's call bell and light did not work when they were activated by the surveyor. The findings are: The facility's Policy and Procedure for Call Bell System dated 10/2022 documented broken call bells should be reported to the maintenance department immediately and entered into the repair book. There is a repair book on each floor at the nursing station. Resident #76 had diagnoses which include Osteoarthritis, Chronic Obstructive Pulmonary Disease, and Congestive Heart Failure. The Annual Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #76 had intact cognition and required the limited assist of one person for dressing, toileting, and personal hygiene. The resident also rquired supervision with set-up for bed mobility, transfer and eating. During observation on 02/06/2023 at 03:34PM and 02/07/2023 at 12:31PM, Resident #76's call bell was activated by the surveyor. No sound could be heard coming from the Nurses Station, and the light did not come on above the resident's door. Staff did not respond to the call bell. During an interview on 2/8/2023 at 12:48PM, Resident #76 stated that the call bell had not been working for a while. They need to use the call bell in case of emergency, to tell staff when they have pain, reqest water, and to call the Certifiedn Nursing Assistant. Resident #76 stated they reported the problem to the staff, but nothing was done. The resident stated they ask their roommate (Resident #59) to call for the staff for them when they need assistance. On 2/8/2023, at 3:38PM, Resident #59 was interviewed and stated they used their call bell to help Resident #76 call staff for help a few times. During an interview on 2/7/2023 at 10:10AM, the Maintenance Director stated they check the maintenance books on each unit every morning so that they can fix whatever needs repair. If there are no concerns documented in the log, then it means no repairs are needed. 415.29

Based on record review and interview during the re-certification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 comprehensive and non-comprehensive assessments were electronically transmitted to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system in a timely manner. Specifically, quarterly assessments were not submitted and transmitted within 14 calendar days from the MDS Completion Date, and comprehensive assessments were not submitted within 14 days of the care plan completion dated. This is evident for 7 of 12 residents reviewed for the Resident Assessment facility task (Resident #s 2, 13, 4, 45, 8, 10, and 40). The findings are: The facility policy and procedure titled, Policy and procedure on submission and corrections of the MDS assessments (Dated 10/01/2019) documented the following: .transmitting data within 7 days after a facility completes a resident's assessment .transmittal requirements within 14 days after a facility completes a resident assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS system on same above list of assessments .comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date .all other assessments must be submitted within 14 days of the MDS completion date . (1) Resident #2 had a significant change assessment with an assessment reference date of 08/09/2019. The assessment was submitted late on 09/11/2019. (2) Resident #13 had a quarterly assessment with an assessment reference date of 10/02/2019. The assessment was submitted late on 11/07/2019. An annual assessment with an assessment reference date of 12/27/2019 was submitted late on 02/06/2020. (3) Resident #4 had an admission assessment with an assessment reference date of 08/20/2019. The assessment was submitted late on 09/11/2019. (4) Resident #45 had an annual assessment with an assessment reference date of 10/03/2019. The assessment was submitted late on 11/29/2019. A quarterly assessment with an assessment reference date of 01/03/2020 was submitted late on 02/06/2020. (5) Resident #8 had a quarterly assessment with an assessment reference date of 09/30/2019. The assessment was submitted late on 02/06/2020. An annual assessment with an assessment reference date of 12/28/2019 was submitted late on 02/06/2020. (6) Resident #10 had a quarterly assessment with an assessment reference date of 01/02/2020. The assessment was submitted late on 02/06/2020. (7) Resident #40 had a annual assessment with an assessment reference date of 10/03/2019. The assessment was submitted late on 11/29/2019. A quarterly assessment with an assessment reference date of 01/03/2020 was submitted late on 02/06/2020. On 02/10/2020 at 09:45 AM, the MDS Clerk was interviewed and stated the following: She is responsible for submitting completed MDS assessments. The MDS assessors first complete MDS books, and she checks what needs to be submitted through the Visual electronic medical record. She can track all assessments including admission, quarterly, significant change, and annual books. The clerk stated she will submit MDS assessments 2 to 4 times per week. She further stated there was a delay in submitting MDS books because of the new MDS changes with PDPM model. Completed MDS books were being reviewed by all disciplines before submission. There was no change in submission dates.

Based on record review and interviews during the re-certification survey, the facility did not ensure residents comprehensive care plans (CCP) were developed and implemented to meet a resident's medical, nursing, and mental and psychosocial needs. Specifically, (1) Resident #165 did not have a CCP in place to address contact precautions for Carbapenem-Resistant [MEDICATION NAME] (CRE) Pseudomonas in the urine, and (2) Resident #187 did not have a CCP in place to address that the resident was prescribed to use bilateral hand rolls. This was evident in 2 residents out of a final sample of 38 residents (Resident #165 and #187). The findings are: (1) Resident #165 had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. There was no CCP in place to address the resident's care needs for contact precautions. On 02/07/2020 at 12:29 PM, the Registered Nurse Supervisor (RNS) #2 was interviewed. She stated nursing is responsible for implementing care plans for residents if they are new admissions or readmissions. The care plans are completed by either nursing supervisors or the Minimum Data Set (MDS) assessors. RNS #2 stated she and the MDS assessor were unable to locate the resident's CCP. (2) Resident #187 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) 3.0 dated 12/12/2019 documented the resident had functional limitation in range of motion (ROM) with impairment on both sides of the upper extremities (UE). The physician's orders [REDACTED]. There was no CCP in place that addressed the care needs for contractures or the use of bilateral hand rolls. On 02/07/2020 at 09:57 AM and on 02/10/2020 at 09:08 AM, the Rehabilitation Director was interviewed. He stated if a therapist recommends a splint device, the therapist is responsible for making sure the CCP is in place and updated. The care plan titled, Occupational Therapy (Last updated 11/01/2019) was the old CCP and the new CCP titled, Rehab Program Contractures should have been implemented. 415.11(c)(1)

Based on observation, record review and interview during the recertification survey, the facility did not ensure that residents receive proper treatment and assistive devices to maintain hearing abilities. Specifically, a resident who is hard of hearing did not receive a hearing aid evaluation, annual audiology exam, and ENT (Ear, Nose, and Throat) follow-up for cerumen removal as recommended by the ENT. This was evident for 1 of 1 resident reviewed for Vision/Hearing (Resident#213). The findings are: Resident #213 has [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition (Brief Interview of Mental Status score of 5 out of 15). The MDS further documented the resident did not use a hearing aid and had minimal difficulty hearing (difficulty in some environments). On 02/05/20 at 9:54 AM, Resident#213 was observed in her room. When approached, the resident stated that she was hard of hearing. No hearing aid device was in use. The ENT Consultation Report dated 4/26/18 documented that the consult was requested because the resident was hard of hearing and may benefit from a hearing aid. The ENT recommended the resident have a hearing aid consultation, annual audiology exam, and follow-up (f/u) in 6 months for cerumen removal. The attending physician's signature on the consult was undated. The Physician's (MD) Progress Note dated 5/3/18 documented the resident was seen for the monthly evaluation. There were no consults reviewed for the past month, and the MD did not refer to the ENT recommendations. The Comprehensive Care Plan (CCP) for Impaired Communication dated 12/2/18 documented the resident hard of hearing. The CCP was not updated with the recommendations from ENT or ENT follow-up. The CCP for Impaired Communication dated 12/3/19 documented no ENT evaluations or f/u for the resident until 2/5/20. There was no documented evidence that the resident ever received a hearing aid evaluation or was seen for cerumen removal. The ENT Consult dated 2/5/20 documented the consult was requested to evaluate the resident's hearing loss. The ENT documented the resident had presbycusis (hearing loss) and cerumen impaction requiring treatment with [MEDICATION NAME] BID (twice per day) for 10 days. They recommended the resident return to the clinic in 2 months. The MD Order dated 2/6/20 documented orders for ENT f/u in 2 weeks. On 02/10/20 at 10:53am, the Nursing Supervisor (RN#1) was interviewed. He stated that when a resident returns from an appointment, he reads the consultation report and calls the doctor to inform them of the findings/recommendations. If an order needs to be placed, a telephone is obtained and carried out. The RN was unable to explain what occurred after the resident's ENT consult on 4/26/18 because he was not working in the facility at that time. On 02/10/20 at 11:08 AM, the Director of Nursing (DON) was interviewed. She stated that once the resident is seen by the consultant MD, the information report is given to the attending physician so they can determine f/u and make orders based on the recommendation. The consultation report is given to the MD who signs off. The undated MD signature on the 4/26/18 ENT consultation indicates the MD was aware of the consultation. The DON stated that they are unable to locate any f/u notes or orders regarding the recommendations made by the ENT on 4/26/18. The MD monthly evaluations dated 5/3/2018 and 5/28/2018 did not contain any documentation regarding review of the ENT consult. The DON stated that f/u should have been done after the recommendations were made by ENT on 4/26/18. On 02/10/20 at 11:26 AM, the Physician (Staff #1) was interviewed and stated that f/u should have been done after the recommendations were made by the ENT on 4/26/18. He stated that he remembered that the resident was seen by the ENT last week and orders were made for ear drops and f/u in 2 weeks. On 2/10/2020, several attempts made via telephone to contact the Medical Director without success. 415.12(3)(b)

Based on observations, record reviews, and interviews during the re-certification survey, the facility did not ensure residents with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, (1) a resident did not have a right hand splint in place, as ordered; and (2) a resident did not have bilateral hand rolls in place, as ordered. This was evident in 2 of 5 residents reviewed for limited range of motion out of a total sample of 38 residents (Resident #113 and #187). The finding is. The facility policy and procedure titled, Splints and Braces (Dated 11/19) documented the following: .the splinting program is initiated by occupational therapy .the splinting program is noted in resident care plan when the occupational therapist has determined the fit and wearing time for the splint .the nurse is responsible for implementation of the splinting program when determined by occupational therapy,,,nurses periodically review the condition of residents who use splints/braces on their units. The occupational/physical therapist is notified of any changes, modifications or repairs needed. (1) Resident #113 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 Annual and Quarterly assessments dated 04/05/2019 and 11/29/2019 documented the resident had limited range of motion with impairment on one side of the upper and lower extremities. On 02/04/2020 at 09:32 AM, on 02/05/2020 from 09:10 AM to 12:17 PM, and on 02/06/2020 from 08:25 AM to 10:30 AM, the resident was observed sitting in her wheelchair in the hallway and dining room with a right hand contracture and no splint device in place. The comprehensive care plans (CCPs) titled, Physical impaired skin integrity and Rehab Program Contractures(initiated 04/05/2019 and last updated 11/29/2019) documented the resident had a right hand contracture. The interventions included providing a right hand splint at all times. The renewal physician's orders [REDACTED]. Remove for hygiene, range of motion, and skin check, and sleep time. The order was intitiated on 01/24/2018. The certified nursing assistant accountability record (CNAAR) instruction sheet was reviewed. The directive to place the right hand splint on resident was inactive as of 05/09/2018. The occupational therapy progress notes were reviewed from 01/25/2019 to 02/10/2020. Notes dated 01/25/2019, 02/14/2019, 02/21/2019, 05/02/2019, and 05/29/2019 did not document that a right hand splint was in place. The rehabilitation physical and occupational therapy screen dated 11/15/2019 documented resident with a functional limitation in range of motion to one side on the upper and lower extremity. A recommendation to apply a right hand splint was made. On 02/07/2020 at 09:07 AM, the certified nursing assistant (CNA) #1 was interviewed. CNA #1 stated the resident had a stroke with right sided weakness. She provides range of motion during care. CNA #1 further stated the resident currently does not use any hand rolls or splint devices. If the resident had any devices it would be in the accountability record. (2) Resident #187 had [DIAGNOSES REDACTED]. The MDS 3.0 Admission and Quarterly assessments dated 03/28/2019 and 12/12/2019 respectively were reviewed. Both assessments documented resident with a presence of a functional limited range of motion with impairment to both sides to his upper extremity. On 02/04/2020 at 09:35 AM, on 02/05/2020 at 09:08 AM and 12:16 PM, and on 02/06/2020 at 08:22 AM and 12:22 PM, the resident was observed in bed with a closed fist on his right hand without any splint devices in place. The CCP titled, Occupational Therapy (initiated 03/22/2019 and last updated 11/01/2019) documented the resident had decreased range of motion on both upper extremities. The interventions included a right hand roll. The CCP titled, Rehab Program Contracture (initiated 02/07/2020) documented the resident had contractures to both upper extremities. The interventions included bilateral hand rolls. The rehabilitation physical and occupational therapy screen dated 03/22/2019 documented the resident had a functional limitation in range of motion for both sides of upper and lower extremity. No recommendation for a splint device was made. The rehabilitation physical and occupational therapy screen dated 05/29/2019 documented resident with a functional limitation in range of motion for one side of upper extremity. No recommendation for a splint device was made. The occupational therapy progress noted were reviewed from 03/22/2019 to 02/10/2020. Notes dated 04/12/2019, 04/18/2019, 11/01/2019 documented the resident should use bilateral hand rolls. The nursing communication forms dated 04/12/2019, 05/29/2019, and 11/01/2019 documented recommendation for bilateral hand rolls. Nursing progress note dated 11/01/2019 documented acknowledgement of recommendation for resident to have bilateral hand rolls made by rehab. The physician's renewal order dated 1/16/2020 documented the resident should be provided with bilateral hand rolls to be worn 8 AM - 8 PM and removed for skin hygiene. The hand rolls were initially ordered on [DATE]. The rehabilitation physical and occupational therapy screen dated 12/12/2019 documented resident with a functional limitation in range of motion for both sides of upper extremity. A recommendation for bilateral hand rolls was made. The CNAAR instruction sheet was reviewed. The directive to place the bilateral hand rolls on resident was inactive as of 01/21/2020. On 02/07/2020 at 09:20 AM, CNA #2 was interviewed and stated she has known resident for one week. The charge nurse and/or supervisor gives her report on the resident. CNA #2 stated she was told the resident gets a hand roll to the left hand but nothing on the right hand. She further stated the CNAAR instructions does not indicate anything about the hand roll. On 02/07/2020 at 09:26 AM, The registered nurse supervisor (RN) #1 was interviewed and stated the following: Resident #113 and #187 were supposed to have a splint device and bilateral hand rolls on respectively. He stated the instructions in the CNAAR became inactive for both residents. RN #1 stated he is responsible to make sure the instruction is active, and he doesn't know why it became inactive. He further stated once a week he makes rounds to make sure residents have on devices as ordered. On 02/07/2020 at 09:57 AM and on 02/10/2020 at 09:08 AM, the rehab director was interviewed. The Director stated if a therapist recommends a splint device, the therapist documents it in the CCP, completes a communication form, applies the splint on the resident, educates the CNA, and documents it in sigma care. Nursing will communicate to rehab if there are issues or if a resident needs to be assessed. When a therapist completes a screen, which is done quarterly, they do visual and tactile checks and review the chart. During these times, any therapist will go check the resident to see if the recommended devices are in place. He stated it is up to nursing to communicate to rehab if a resident is missing a device. 415.12(e)(2)

Based on observation, record review and interview during the recertification survey, the facility did not ensure that the physician reviewed the resident's total program of care. Specifically, the physician did not follow-up on a resident's ENT (Ear, Nose, and Throat) recommendations for a hearing aid evaluation, annual audiology exam, and ENT follow-up for cerumen removal. This was evident for 1 of 1 resident reviewed for Vision/Hearing (Resident#213). The findings are: The Policy & Procedure for Physician Services, revised 2/1/19, docmented the phsycian must review the resident's condition, total program of care, including medications and treatments, and evaluate the continued appropriateness of the resident's current medical regime at each visit. The Policy & Procedure for Consultation visits, reviewed 10/19, documented the consultant physicians write orders on resident's charts, but the orders cannot be implemented without approval of an attending or covering physician. Such orders must be counter-signed by an attending or covering physician. Resident #213 has [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition (Brief Interview of Mental Status score of 5 out of 15). The MDS further documented the resident did not use a hearing aid and had minimal difficulty hearing (difficulty in some environments). On 02/05/20 at 9:54 AM, Resident#213 was observed in her room. When approached, the resident stated that she was hard of hearing. No hearing aid device was in use. The ENT Consultation Report dated 4/26/18 documented that the consult was requested because the resident was hard of hearing and may benefit from a hearing aid. The ENT recommended the resident have a hearing aid consultation, annual audiology exam, and follow-up (f/u) in 6 months for cerumen removal. The attending physician's signature on the consult was undated. The Physician's (MD) Progress Note dated 5/3/18 documented the resident was seen for the monthly evaluation. There were no consults reviewed for the past month, and the MD did not refer to the ENT recommendations. The Comprehensive Care Plan (CCP) for Impaired Communication dated 12/2/18 documented the resident hard of hearing. The CCP was not updated with the recommendations from ENT or ENT follow-up. The CCP for Impaired Communication dated 12/3/19 documented no ENT evaluations or f/u for the resident until 2/5/20. There was no documented evidence that the resident ever received a hearing aid evaluation or was seen for cerumen removal. The ENT Consult dated 2/5/20 documented the consult was requested to evaluate the resident's hearing loss. The ENT documented the resident had presbycusis (hearing loss) and cerumen impaction requiring treatment with [MEDICATION NAME] BID (twice per day) for 10 days. They recommended the resident return to the clinic in 2 months. The MD Order dated 2/6/20 documented orders for ENT f/u in 2 weeks. On 02/10/20 at 10:53am, the Nursing Supervisor (RN#1) was interviewed. He stated that when a resident returns from an appointment, he reads the consultation report and calls the doctor to inform them of the findings/recommendations. If an order needs to be placed, a telephone is obtained and carried out. The RN was unable to explain what occurred after the resident's ENT consult on 4/26/18 because he was not working in the facility at that time. On 02/10/20 at 11:08 AM, the Director of Nursing (DON) was interviewed. She stated that once the resident is seen by the consultant MD, the information report is given to the attending physician so they can determine f/u and make orders based on the recommendation. The consultation report is given to the MD who signs off. The undated MD signature on the 4/26/18 ENT consultation indicates the MD was aware of the consultation. The DON stated that they are unable to locate any f/u notes or orders regarding the recommendations made by the ENT on 4/26/18. The MD monthly evaluations dated 5/3/2018 and 5/28/2018 did not contain any documentation regarding review of the ENT consult. The DON stated that f/u should have been done after the recommendations were made by ENT on 4/26/18. On 02/10/20 at 11:26 AM, the Physician (Staff #1) was interviewed and stated that f/u should have been done after the recommendations were made by the ENT on 4/26/18. He stated that he remembered that the resident was seen by the ENT last week and orders were made for ear drops and f/u in 2 weeks. On 2/10/2020, several attempts made via telephone to contact the Medical Director without success. 415.15(b)(2)(iii)

Based on observation, record review, and interviews during the re-certification survey, the facility did not ensure infection control practices were maintained to help prevent the development and transmission of communicable diseases and infections. Specifically, a staff member was observed entering the room of a resident on contact precautions for Carbapenem-Resistant [MEDICATION NAME] (CRE) Pseudomonas in the urine without donning Personal Protective Equipment (PPE) (Resident #165). This was evident for 1 of 5 resident floors observed for Infection Control (2nd Floor). The finding is: The facility policy and procedure titled, Contact Precautions (Dated 11/01/2019) was reviewed. Contact precautions are to be used for specific residents known to be infected that can be transmitted with indirect contact with environmental surfaces or resident care items in the resident's environment. Contact precautions also apply where the presence of discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. Gown and gloves are to be worn for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. The facility policy and procedure titled, Transmission-Based Precautions (Dated 11/01/2019) was reviewed. .wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment . The facility policy and procedure titled, Personal Protective Equipment (PPE) for Healthcare Personnel (Dated 11/01/2019) was reviewed. .when contact precautions are used, donning of both gown and gloves upon entry is indicated if exposure to potentially infectious organism or contaminated environmental surfaces is anticipated . Resident #165 had [DIAGNOSES REDACTED]. physician's orders [REDACTED]. On 02/05/2020 at 11:51 AM, the housekeeper on the second floor was observed entering into resident #165 room without donning PPE despite presence of signage and supplies. He was observed mopping the floor from inside of the room around and under the bed and then back out towards the door while the resident was in bed. He then placed the yellow caution wet floor sign on the floor in front of room. The housekeeper proceeded to place the mop inside the yellow bucket and pushed it into the porter closet for storage. On 02/10/2020, multiple attempts were made to speak with the housekeeper but the housekeeper was not available. On 02/10/2020 at 11:58 AM, the Housekeeping Director was interviewed and stated the housekeepers are supposed to wear the gown, mask, and gloves when entering into a resident room who is on contact precautions. They can also ask the nurse to make sure if they need a gown, mask, or gloves when they see the sign posted and the supply set up. It is preferred the housekeepers clean contact precaution rooms last to prevent the spread to other rooms. After cleaning a contact precaution room, the used water is dumped and the mop head changed and replaced. On 02/10/2020 at 12:18 PM, the Assistant Director of Nursing and Infection Preventionist stated all staff including housekeeping were in-serviced on taking proper measure for residents on contact precautions and needing to wear PPE. Resident #165 is on contact precautions because he has CRE Pseudomonas in the urine. She further stated the staff needs gown and gloves to enter the room, especially if the resident is in the room because this infection is difficult to control. 415.19(a)(1-3)

Based on observations, record review, and interview during the re-certification survey, the facility did not ensure proper sanitation and food handling practices to prevent food-borne illness were performed. Specifically, food was not stored and served under sanitary conditions. The following were observed, (1) cold food items (tuna and salami sandwiches, turkey) on the tray line were not held at proper temperatures of 41 degrees Fahrenheit or below, (2) the ice cream refrigerator was observed with pink, brown, and white drippings on the inside of the door and base of the refrigerator and was stuffed with boxes preventing air flow, (3) observed cross contamination practices between food items during temperature testing (puree turkey and potato salad) and when handling food (transferring turkey slices with gloved hands instead of using a serving utensil). This was evident during mulitple observations made during the Kitchen and Food Service task. The findings are: The facility policy and procedure titled, Dietary Department Policy and Procedure F371 Sanitary Conditions and F441 Infection Control (Dated 6/5/18) was reviewed. Documentation revealed the following. .All cold foods must be served at the tray line at 36 Degrees .cold food 41 degrees or below .Daily cleaning of kitchen and refrigerators .gloves must be changed before and after taking food temperatures and in between if needed .thermometer must be clean and sanitized after each food item temperature is taken. All food must be handle and serve with proper utensils . (1) On 06/04/18 at 12:12 PM the cold food temperatures were observed measured and the following results were found: A tuna sandwich was tested twice with temperatures of 58 and 60 degrees Fahrenheit. A salami sandwich was 50 degrees Fahrenheit. On 06/05/18 from 11:40 AM to 11:45 AM, additional cold food temperatures were measured. The Surveyor observed that the tray line compartments were filled with 75% water and 25% ice. The pureed turkey was 50 degrees Fahrenheit and the turkey slices was tested twice with temperatures of 49 and 51 degrees Fahrenheit. A tuna and salami sandwich was also re-tested and the temperatures were 42 degrees Fahrenheit. (2) On 06/04/18 at 09:20 AM and 12:19 PM, the ice cream refrigerator was observed stuffed with multiple boxes of ice cream preventing air flow. Observed pink, white, and brown colored drippings on the inside part of the door to the bottom base of the refrigerator. On 06/05/18 at 11:56 AM, the ice cream refrigerator was observed again with pink colored drippings on the bottom base of the refrigerator door. (3) On 06/05/18 from 11:40 AM to 11:45 AM during observation of food temperatures on the tray line, the food service manager (FSM) was observed not wiping or sanitizing the thermometer in between testing food items when he tested the pureed turkey and the potato salad. On 06/05/18 at 11:48 AM, the FSM was observed taking out the turkey slices with his used gloved hands and placed them on an aluminum serving tray without using a serving utensil. The FSM also did not change his gloves prior to handling the turkey slices. On 06/08/18 at 10:03 AM, the FSM was interviewed. He stated the refrigerators are cleaned two to three times a week by one of the kitchen staff and the ice cream refrigerator lack of cleanliness was overlooked. The FSM stated cold food items such as the tuna and salami sandwiches, and the pureed turkey and turkey slices should be 41 degrees or below. He further stated the sandwiches were not prepared ahead of time and the turkey slices were not divided properly for the items to be stored in the freezer to maintain temperature. The FSM stated he should've calibrated and cleaned the thermometer when testing temperature of each food item. He also stated he should've used a serving utensil when handling the turkey. 415.14(h)