Based on observations, record review, and interviews during the recertification and abbreviated (NY00358321 and NY00368342) surveys conducted 2/19/2025-2/25/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 11 residents (Residents #46 and #99) reviewed. Specifically, Residents #46 and #99 were not assisted with showering as planned. Findings include: The facility policy Activities of Daily Living revised 10/2022 documented the facility would assist and encourage all residents to their highest practicable level of independence and to provide the necessary support in all activities of daily living functioning. Activities of daily living included bathing- inclusive of showers, tub bath, and bed bath. Activities of daily living would be completed on a daily basis for the resident with the assistance of the facility resident care staff as needed. The facility policy, Bathing or Showering a Resident, revised 11/2022 documented the facility would provide a safe environment for bathing and showering of residents to promote cleanliness and comfort to the resident. 1) Resident #46 had diagnoses including chronic obstructive pulmonary disease (lung disease) and muscle weakness. The 10/10/2024 Minimum Data Set assessment documented the resident was cognitively intact, did not reject care, felt it was somewhat important to choose between a bed bath, tube bath or a shower, and required substantial/maximal assistance with showering. The Comprehensive Care Plan dated 2/202/2025 documented the resident required assistance with activities of daily living. Interventions included substantial/maximal assistance for showering and bathing. The resident care instructions documented the resident required substantial/maximal assistance for showering/bathing, was dependent on 2 for shower transfers, preferred showers, and was scheduled for a shower on Thursdays during the evening shift. The undated 4B shower schedule documented the resident's shower day was Thursday during the day shift. During an observation and interview on 2/19/2025 at 12:58 PM, Resident #46 was sitting in their wheelchair wearing a hospital gown. Their hair was not combed and appeared wet and greasy on top. They stated they had not received a shower in weeks, and they wanted to take one at least once a week. During an observation and interview on 2/20/2025 at 2:08 PM, Resident #46 was sitting in their wheelchair, their hair was not combed and appeared wet and greasy on top. They stated they did not receive their shower even though it was their shower day. The certified nurse aide documentation record documented the resident did not receive a shower by Certified Nurse Aide #45 during the day shift on 2/6/2025, 2/13/2025, and 2/20/2025. During an interview on 2/25/2024 at 12:36 PM, Certified Nurse Aide #45 stated they looked at the unit's shower sheet to know when resident showers were scheduled. The shower sheet was updated more than the resident care instructions. When there were not a lot of staff on the unit or staff was not willing to help, bed baths were given instead of showers. They frequently took care of Resident #46, and the resident did not refuse their showers. They stated it was important for Resident #46 to be offered and receive their showers to make them feel better, for good personal hygiene, and it was their right. During an interview on 2/25/2025 at 11:55 AM, Licensed Practical Nurse #48 stated resident showers were listed on the unit shower list. The certified nurse aides documented all care provided, and any refusals of care. If a resident refused a shower, they should document the refusal, notify the nurse, and they were not notified of Resident #46 refusing their showers. They stated it was important for Resident #46 to be offered and given a shower for general cleanliness and it was their right. During an interview on 2/25/2025 at 12:54 PM, Registered Nurse Unit Manager #44 stated the certified nurse aides looked at the shower sheet to know when residents were scheduled for their shower, and it was also written on the daily assignment sheet. They were not aware that Resident #46 had not received their shower for 3 weeks. It was important for Resident #46 to receive their shower weekly as scheduled because it was dignified and a resident right. During an interview on 2/25/2025 at 1:49 PM, the Director of Nursing stated residents should receive their showers when they were scheduled. The certified nurse aides should let the licensed practical nurse or unit manager know if a shower could not be given for any reason. They stated Resident #46 should not have gone 3 weeks without a shower and it was important for them to get their scheduled shower to make them feel better and have good hygiene. 2) Resident #99 had diagnoses including cerebral palsy (disorder of movement, muscle tone, or posture) and muscular dystrophy (causes progressive weakness and loss of muscle mass). The 1/16/2025 Minimum Data Set assessment documented the resident was cognitively intact, did not reject care, had upper and lower extremity impairments on both sides, and required substantial/maximal assistance with showering. The Comprehensive Care Plan dated 1/15/2024 documented the resident required assistance with activities of daily living. Interventions included extensive assistance with bathing, and personal hygiene. The resident's care instructions documented the resident preferred a shower. Shower was on Monday with no shift specification. During an observation and interview on 2/19/2025 at 1:56 PM, Resident #99 was sitting up in bed and had greasy hair. They stated they did not get their weekly shower like they were supposed to and there was not always a mechanical lift pad available so they could take a shower. They preferred a shower twice a week but when a shower was missed, they had to go two weeks between them. They were scheduled for a shower on 2/17/2024 but did not get it. The certified nurse aide asked them if they wanted a shower, they said yes, and then the certified nurse aide never returned to take them to the shower. The 2/17/2025 care log by Certified Nurse Aide #50 documented the resident did not get a shower. During a telephone interview on 2/25/2025 at 10:02 AM, Certified Nurse Aide #50 stated showers were highlighted in the assignment binder they looked at when they started their shift. On 2/17/2025 Resident #99 told them they wanted a shower around 8:00 PM. They did not get to it because they gave another resident their shower at that time. They had asked the other certified nurse aides working to give Resident #99 a shower, but that certified nurse aide did not get to it either. The resident liked to take showers. During a telephone interview on 2/25/2025 at 11:18 AM, Registered Nurse #30 stated the certified nurse aides were supposed to report to them if they did not give their scheduled showers. They were not told Resident #99 did not get their shower on 2/17/2025. They did not see the shower documentation in the electronic medical record, so they just had to rely on the certified nurse aides to tell them if they received them or not. During an interview on 2/25/2025 at 12:01 PM, Registered Nurse Unit Manager #13 stated Resident #99 was scheduled for showers on Mondays on the second shift. The resident liked showers, and it was important for good hygiene. They only got a shower once a week. If the resident did not get their shower, the certified nurse aide should have relayed that to the nurse and then it would be relayed to the oncoming shift. 10NYCRR 415.12(a)(3)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00370596, NY00368342, and NY00355972) surveys conducted 2/19/2025-2/25/2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 of 2 residents (Resident #99 and #236) reviewed. Specifically, for Resident #236 Licensed Practical Nurses #14 and #17 administered medications outside of acceptable time parameters, a tube feeding was not given and documented as administered, medications were signed as given prior to administration, signed as given on time when they were given late, and treatments were signed completed when they were not; Resident #99 had an order for a medicated shampoo weekly with showers, the medicated shampoo was left at the resident's bedside, and certified nurse aides administered the medicated shampoo instead of licensed staff. Additionally, the provider was not notified of late and missing medications and treatments. Findings include: The facility policy, Medication Administration, revised 11/2022, documented all medications were administered by a licensed professional nurse or a registered professional nurse and were documented in the electronic medical record. Medications were not left at the bedside. Medications were administered no more than one hour before and one hour after the ordered time. If medications were administered outside the one-hour time frame, the registered nurse/ Nurse Manager/ supervisor were notified. The Registered Nurse Supervisor evaluated the late medications and determined the course of action for the residents and medical staff notification. The nurse practitioner or physician were notified for any refusal of medications or missed dose of medications. The registered nurse completed an assessment as needed for a missed dose of medications. The facility policy, Charting Guidelines, revised 10/2024, documented an accurate record of care and treatment was provided. The resident's medical record was a legal document, and everything must be correct and legible. Medications were documented after they had been administered and treatments were documented upon completion. 1) Resident #236 had diagnoses including Guillain-Barre syndrome (a condition that affects the nerves), dysphagia (difficulty swallowing), and need for assistance with personal care. The 2/6/2025 Minimum Data Set assessment documented the resident had moderate cognitive impairment, had medically complex conditions, and received nutrition via tube feedings. The 7/17/2023 Comprehensive Care Plan, revised 11/14/2024, documented the resident received tube feedings, received nothing by mouth, and received all nutrition and medications via gastric tube. Nurse Practitioner #28 orders documented: - on 9/29/2023, may crush medications and administer together if not contraindicated. - on 2/13/2024 sertraline hydrochloride (an anti-depressant) 50 milligram tablet once daily via gastric tube. - on 7/24/2024, Jevity 1.5 calorie (tube feeding) oral liquid, full strength, bolus via pump 240 milliliters over an hour daily at 6:00 AM, 10:00 AM, 2:00 PM, and 6:00 PM; flush tube with 120 milliliters of water before and after each feeding; flush 60 milliliters of water before and after medication pass at 6:00 AM, 8:00 AM, 11:00 AM, 2:00 PM, 8:00 PM and 10:00 PM; flush 60 milliliters between medications; check residual every shift and if equal to or greater than 100 milliliters, hold feeding for one hour and recheck and notify physician if residual remains; check for proper tube placement prior to each feeding, flush, or medication; elevate head of bed 30 degrees during feeding and one hour after feeding; tube site care daily in the morning; check bowel sounds all quadrants daily; and provide mouth care daily. - on 8/21/2024, senna (stool softener) oral 8.6 milligram tablet two tablets twice daily at 8:00 AM and 8:00 PM via gastric tube. - on 12/5/2024, gabapentin (treats nerve pain) 600 milligrams one tablet three times a day via gastric tube. - on 1/14/2025, omeprazole (treats heartburn) delayed release 20 milligrams tablet via gastric tube daily at 8:00 AM; midodrine hydrochloride (treats low blood pressure) 2.5 milligram tablet via gastric tube one tablet twice daily, hold if systolic blood pressure greater than 120; and lactobacillus (a probiotic) extra strength oral capsule via gastric tube twice daily. - on 2/14/2025, nothing by mouth, tube feeding. The following observations of Resident #236 were made: - on 2/19/2025 at 12:46 PM and at 5:23 PM, lying in bed with the head of bed elevated 45 degrees. There was a full Jevity 1.2 calorie 1000 milliliter bottle hanging from the tube feeding pole, the tubing was in the pump, there was no cap on the end of the tubing, and the tubing was not connected to the resident. There were ten 240 milliliter Jevity 1.5 calorie boxes on the bedside table. - on 2/20/2025 at 2:48 PM, lying in bed with the head of the bed elevated 45 degrees. There was nothing hanging from the tube feeding pole and there were nine 240 milliliter Jevity 1.5 calorie boxes on the bedside table. - on 2/21/2025 at 9:50 AM, lying in bed with the head of the bed elevated 45 degrees. There was nothing hanging from the tube feed pole and there were eight 240 milliliter Jevity 1.5 calorie boxes on the bedside table. The following was observed during a continuous observation on 2/21/2025 from 10:06 AM through 1:57 PM: - from 10:06 AM through 11:30 AM, Licensed Practical Nurse #17 did not enter the resident's room. The 10:00 AM tube feeding, and water flushes were not signed off in the electronic medical record. - at 11:31 AM, the 10:00 AM tube feeding, and water flushes were signed off in the electronic chart by Licensed Practical Nurse #17. The nurse did not enter the resident's room. - at 11:34 AM, the 12:30 PM check tube placement and check bowel signs was signed off in the electronic chart by Licensed Practical Nurse #17. The nurse did not enter the resident's room. - at 12:38 PM, Licensed Practical Nurse #17 left the unit and returned at 1:00 PM. - at 1:07 PM, Licensed Practical Nurse #17 signed off the 2:00 PM tube feeding and water flushes. The nurse did not enter the resident's room. - at 1:12 PM, Licensed Practical Nurse #17 took medications into another resident's room. - at 1:14 PM, Licensed Practical Nurse #17 entered the resident's room with a bag of tube feeding that was initialed and dated 2/21/2025. They hung the bag on the pole and connected it to the resident. The pump on the pole was not utilized as ordered. There were seven Jevity 1.5 calorie boxes on the bedside table. - at 1:57 PM, the tube feed bag was empty and still connected to the resident. The following was observed during a continuous observation on 2/24/2025 from 8:44 AM through 1:43 PM: - at 8:44 AM, Licensed Practical Nurse #14 had not signed off any medications, tube feedings, or water flushes in the electronic medical record for their shift. - at 8:51 AM, the resident was lying in bed with the head of the bed elevated 45 degrees. An empty tube feeding bag dated 2/23/2025 was connected to the resident. There was nothing flowing through the tube feeding pump. There were no 1.5 calorie Jevity boxes on the bedside table. - at 10:23 AM, Licensed Practical Nurse #14 put on a gown and gloves and entered the resident's room. At 10:25 AM, the nurse exited the room and used alcohol-based hand rub from the hallway dispenser. - at 10:27 AM, the resident was lying in bed. There was no tube feeding connected to the resident and the bag and tubing were no longer hanging from the pole. - at 12:33 PM, Licensed Practical Nurse #14 took a blood pressure cuff into the room and closed the door. At 12:34 PM, the nurse exited the room with the blood pressure cuff. There were no medications, tube feedings, flushes, or other treatments signed off in the electronic medical chart by Licensed Practical Nurse #14. - at 1:15 PM, Licensed Practical Nurse #14 documented in the electronic medical record that water flushes, tube feedings, other treatments and medications were all given. This included the 10:00 AM and 2:00 PM tube feedings; the 120 milliliter water flushes for 8:00 AM and 11:00 AM; the 60 milliliter water flushes for 8:00 AM and 11:00 AM; the tube feeding residual check for 12:30 PM; the tube feeding placement check at 12:30 PM; the bowel sounds check for 12:30 PM; the tube feeding site care at 11:00 AM; the mouth care at 12:30 PM; the medications scheduled for 8:00 AM including 50 milligrams of sertraline, two 8.6 milligram tablets of senna, 20 milligrams of omeprazole, and 600 milligrams of gabapentin; the medications scheduled for 11:00 AM including lactobacillus extra strength capsule and 2.5 milligrams of midodrine; and the 2:30 PM scheduled dose of gabapentin 600 milligrams. The nurse did not enter the resident's room during the time frames documented as completed. - at 1:32 PM, during a tube feeding and medication administration observation with Licensed Practical Nurse #14, they entered the room with gloves on and was not wearing a gown. They had a plastic cup with cloudy water with flecks and a 60 milliliter syringe in their hand. The dressing to the gastric tube site on the abdomen was clean and intact, dated 2/23/2025. At 1:34 PM, the nurse put the plastic cup and the syringe down on the bedside table and left the room to get a Jevity 1.5 calorie box. At 1:36 PM, the nurse returned to the room and flushed the tube with 60 milliliters of water. The nurse did not check the placement of the tube, check residual, or check bowel sounds as previously charted. The nurse stated they were administering omeprazole, sertraline, senna, gabapentin, and a probiotic with 60 milliliters of water. At 1:38 PM, the nurse gave another 60 milliliters of water. At 1:40 PM, they put 240 milliliters of Jevity 1.5 calorie into a tube feed bag dated 2/24/2025, hung it from the pole and did not utilize the pump. The nurse did not provide tube site care or mouth care as charted. They stated that was the second feeding they gave on their shift and the resident received a feeding at 6:00 AM, 10:00 AM, 2:00 PM and 6:00 PM. They stated they were administering the 2:00 PM tube feeding and did not have a chance to give the 10:00 AM tube feeding because they came in late at 8:00 AM. They stated they had to prioritize their residents as they had another resident that was on comfort care and needed pain medications. They stated they had called a nurse practitioner about the missed feeding but did not know the name of the nurse practitioner. They stated it was important the resident received their ordered tube feedings and water flushes for nutrition and because they had a low blood pressure. Anytime they talked to a provider they documented in a note. The 2/24/2025 at 2:00 PM Licensed Practical Nurse #14 progress note documented Nurse Practitioner #28 was notified of gastric tube feed adjustments. During a telephone interview on 2/24/2025 at 4:41 PM, Nurse Practitioner #28 stated if any order was not completed, they should be notified, and the resident would be evaluated if warranted. They should be notified of missed tube feedings and Resident #236 needed the tube feedings as they were life sustaining treatments. Today was the first time they had been notified that the resident had missed a feeding. Licensed Practical Nurse #14 had called them after they started the 2:00 PM tube feeding and informed them the 10:00 AM tube feeding was not administered. They ordered a one-time 10:00 PM tube feed dose for today to make up for it. They were not made aware of medications given late or treatments not completed. During an interview on 2/25/2025 at 10:43 AM, Licensed Practical Nurse #17 stated she gave Resident #236 their 10:00 AM tube feeding after they came back from break on 2/21/2024. They stated they never missed an administration, and it was important the resident received the ordered feedings because it was their only source of nutrition. The provider should be notified of any missed doses. During an interview on 2/25/2025 at 12:01 PM, Registered Nurse Unit Manager #13 stated medications could be given one hour before or one hour after a scheduled administration and the provider should be notified of anything given outside that window. The nurse administering the medications should notify the provider. If the provider was notified, a nursing progress noted should be documented. Without a note, they would not know if a provider was notified. During an interview on 2/25/2025 at 1:22 PM, the Director of Nursing stated the provider should be updated on any medication given outside the ordered time frame so they could decide what actions needed to be taken, if changes needed to be made, or if an order for monitoring needed to be implemented. Orders were expected to be followed. 2) Resident #99 had diagnoses including atopic dermatitis (itchy, red, dry patches of skin), seborrheic dermatitis (itchy rash with flaky scales), and need for assistance with personal care. The 1/16/2025 Minimum Data Set assessment (a health status tool) documented the resident was cognitively intact, required substantial/ maximum assistance with bathing, had applications of ointments/ medications other than to feet, and did not reject care. The Comprehensive Care Plan for activities of daily living initiated 1/16/2025 documented showers were on Mondays (shift not specified) and the resident was dependent with transfer to the tub/ shower. It did not include the use of a medicated shampoo with showers. The 4/6/2023 physician order documented Ketoconazole shampoo 2 percent, applied to their scalp weekly on Mondays at 8:00 PM with shower for seborrheic dermatitis. The 1/29/2025 Nurse Practitioner #49 progress note documented the resident was seen for routine follow up. Seborrheic dermatitis was listed as an active medical problem. The plan was to monitor for worsening dry patches of the skin and refer to dermatology as needed. The 2/2025 Treatment Administration Record documented Ketoconazole Shampoo 2 percent was not administered as ordered on 2/17/2025 and 2/24/2025. During an observation and interview on 2/19/2025 at 1:56 PM, Resident #99 was sitting up in their bed, their hair was greasy. They stated they had a problem with their scalp, and they could scrape their skin off in patches. They were supposed to receive a medicated shampoo, but they did not always get their weekly shower which was not helping their scalp issue. Their Ketoconazole 2 percent shampoo was observed on their nightstand next to the bed. They stated during showers the certified nurse aides used that shampoo. During a telephone interview on 2/25/2025 at 10:12 AM, Certified Nurse Aide #50 stated they did not get a chance to give Resident #99 their scheduled shower on 2/17/2025. The resident handed them a special shampoo to use during the shower. During a telephone interview on 2/25/2025 at 11:18 AM, Registered Nurse #30 stated Resident #99 had an order for a medicated shampoo, but they never saw it. They did not think the resident ever received the shampoo because the facility did not have it on hand. They just signed the medicated shampoo off as not available but did not notify anyone. During an interview on 2/25/2025 at 12:01 PM, Registered Nurse Unit Manager #13 stated Resident #99 had a medicated shampoo used during showers. The certified nurse aide should communicate with the nurse when it was time for the shower so the medicated shampoo could be administered by the nurse. During an interview on 2/25/2025 at 1:22 PM, the Director of Nursing stated if a resident received a medicated shampoo, the certified nurse aide and the nurse needed to communicate. The certified nurse aides could not administer medications, so the nurse needed to administer the medicated shampoo. If the medicated shampoo was not given, the nurse should have notified the provider. During a telephone interview on 2/25/2025 at 2:24 PM, Nurse Practitioner #49 stated they expected to be notified of every dose of every missed medication. Resident #99 had the medicated Ketoconazole shampoo for seborrheic dermatitis. Without it, it could get worse. They were not notified of any missed doses of the shampoo. 10NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not ensure each resident who required colostomy (a surgical opening in the abdomen that allows waste to pass out of the body) services received such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #745) reviewed. Specifically, Resident #745 had a colostomy and there were no orders for ongoing monitoring, there was no order for the wafer of the 2 piece system, there was no care plan for the colostomy, no care instructions for the drainage pouch, and staff were unaware the resident had a colostomy. Additionally, the drainage bag was observed not in place and was not emptied timely when it was in place. Findings include: The facility policy, Colostomy/ Ileostomy Care, revised 3/2022, documented exposure of the resident's fecal matter to their skin should be prevented. The bag was emptied when it was one third full or at least every shift. The bag was changed every 2-4 days, and the wafer was changed at least weekly or more frequently if needed. The date and time care was provided was recorded in the resident's medical record. The supervisor was notified if the resident refused colostomy care. Resident #745 had diagnoses including colon cancer, muscle weakness, and need for assistance with personal care. The 2/18/2025 Minimum Data Set assessment (a health status assessment tool) documented the resident was cognitively intact, required supervision or touch assistance with toileting hygiene, had an ostomy appliance, and did not reject care. The 2/11/2025 hospital discharge summary/instructions documented Resident #745 had a colostomy to the left lower abdomen, a 2 piece appliance system that included a skin barrier (wafer) that stuck to the skin around the stoma of the colostomy and had a detachable pouch that collected stool. The discharge summary documented the pouch was changed on 2/9/2025. The 2/11/2025 Registered Nurse #9 admission assessment documented Resident #745 had a colostomy. The Comprehensive Care Plan, initiated 2/11/2025, documented the resident was continent of bowel. Interventions included assistance as needed for transfer on/off the toilet. There was no documentation related to a colostomy. The 2/12/2025 Nurse Practitioner #28 order documented ostomy care with soap and water and pouch ([NAME] 18193) was to be changed weekly on Thursday day shift. The order did not include any specific instructions related to the skin barrier wafer dressing. The 2/12/2025 Nurse Practitioner #28 History and Physical documented Resident #745's abdomen was soft, nontender, and bowel sounds were active. There was no documented evidence the Nurse Practitioner assessed the colostomy stoma or was aware the resident had a colostomy. The 2/2025 Treatment Administration Record documented ostomy care, soap and water, [NAME] 18193, 1.75 routine weekly on Thursday during the day shift, and change ostomy bag/pouch weekly on Thursday during day shift. Ostomy car was provided, and the pouch was changed on 2/13/2025 and 2/20/2025. The undated care instructions for toileting did not include documentation Resident #745 had a colostomy or instructions for how to care for the colostomy such as when and how often to empty and change the pouch. The 2/2025 certified nurse aide care documentation included: - No documented evidence of a bowel movement from 2/11/2025 through 2/18/2025. - On 2/19/2025 Registered Nurse Unit Manager #13 documented the resident was continent of bowel with no appliance. - On 2/19/2025, 2/20/2025, and 2/21/2025 Certified Nurse Aide #32 documented the resident was continent of bowel with no appliance. - On 2/22/2025 Certified Nurse Aide #33 documented the resident was continent of bowel with no appliance. Resident #745 was observed at the following times: - On 2/19/2025 at 2:13 PM, sitting up on the side of the bed in their room. There was a foul odor in the room and the left side of the resident's black t-shirt was soiled with a brown substance. The resident's family member was in the room and stated it was ridiculous the resident went the past 3 days without a colostomy bag in place. They just told the nurse the resident needed a bag and to be cleaned up. At 5:12 PM, the resident was sitting up in bed eating their dinner, there was a clear colostomy bag in place that contained brown liquid that filled approximately one third of the bag. - On 2/20/2025 at 2:58 PM, sitting up in the chair in the room. There was a clear plastic colostomy pouch filled to capacity with air and brown stool. The left side of the wafer covering the colostomy stoma was partially separated from the skin and brown liquid was seeping out down onto the resident's abdomen. Certified Nurse Aide #32 entered the room to ask if the resident if they needed anything, the resident declined, and the certified nurse aide exited. - On 2/21/2025 at 9:47 AM, sitting on the side of the bed, the colostomy drainage pouch had a tan colored fabric material that had the word [NAME] on it. The pouch was clean and intact. During a telephone interview on 2/25/2025 at 9:46 AM, Certified Nurse Aide #33 stated they did not know Resident #745 had a colostomy until one day the resident had feces on the floor and when they cleaned the resident up, they saw the opening and there was no pouch. The computer told them how to care for a resident and if it was not in the care plan, they would not know. During a telephone interview on 2/25/2025 at 10:57 AM, Certified Nurse Aide #32 stated Resident #745 had a colostomy, but they had not provided any care or emptied it. The resident had used foul language towards them, so they had not tried. They would have told the nurse if there had been a problem with the pouch or if the resident had refused care. They thought they had told Registered Nurse #30. During a telephone interview on 2/25/2025 at 11:18 AM, Registered Nurse #30 stated the certified nurse aides knew if a resident had a colostomy because they visualized it with care. If the bag was full it was emptied by the certified nurse aides. If the bag was dislodged, sometimes the certified nurse aides changed it and sometimes they were notified and changed the bag and the wafer. If the bag and the wafer was changed it was documented on the Treatment Administration Record. Sometimes they were out of bags or wafers on the unit but there were always supplies downstairs. Resident #745 had a colostomy but was not always compliant with the care of the bag. The resident had taken the bag off before and they saw the resident without a bag in place. Last night the bag was leaking but the certified nurse aides did not report that to them. They were not sure if the colostomy bag was included in the care plan or the care card but communication at shift change was key. During an interview on 2/25/2025 at 12:01 PM, Registered Nurse Unit Manager #13 stated they updated the care plans. The care card told the certified nurse aides the level of care the residents needed. If the resident had a colostomy, the toileting instructions indicated that. Resident #745 had a colostomy, and they thought it was included in the care plan and the care instructions, but it was not. 10NYCRR 415.12(k)(3)

Based on record review and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not ensure residents who required dialysis (a process that filters the blood during kidney failure) received such services consistent with professional standards of practice for 1 of 1 resident (Resident #257) reviewed. Specifically, the facility did not consistently assess Resident #257 vital signs (blood pressure, heart rate, respirations, temperature) prior to dialysis, review the dialysis communication book sheets upon return from dialysis, or notify the provider of incomplete and refused dialysis procedures. Findings include: The facility policy, Dialysis, revised 2/2023, documented residents received dialysis on an outpatient basis at a prearranged center and received quality nursing care. Nursing staff were to check the physician's orders, check the bruit and thrill (to ensure adequate blood flow) for residents with fistulas (a connection between an artery and a vein used for dialysis), send the resident with their communication binder to dialysis, observe the shunt site upon return from dialysis for any bleeding, observe and initial the communication book upon return from dialysis for instructions from the Dialysis Center, and inform the provider of any instructions and obtain orders. Resident #257 had diagnoses including chronic kidney disease. The 1/1/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition and received dialysis. The Comprehensive Care Plan, last reviewed 1/2/2025, documented the resident had end stage renal (kidney) disease with dialysis. Interventions included communicate with dialysis via the notebook, check for new orders each time the resident returned from dialysis, utilize the communication book with the dialysis unit, alert the medical provider of recommendations from the dialysis, and check the bruit and thrill every shift and as needed. The resident went to dialysis 3 times a week, the nurse was to send the dialysis communication book with the resident to each session, nurses were to monitor for bleeding from the dialysis shunt post dialysis treatment and monitor the resident for any adverse effects of dialysis. The 2/9/2025 Nurse Practitioner #12 order documented assess the arteriovenous fistula for bleeding, infection, bruit (abnormal sound of turbulent blood flow in an artery) and thrill (vibration caused by blood flow) every shift. Obtain vital signs three times a week on Monday, Wednesday, and Friday at 5:00 AM for pre-dialysis and at 10:00 AM for post-dialysis. The 1/2025 Medication Administration Record documented - assess access site for bleeding, infection, bruit/thrill, and patency every day, every shift, with a start date of 12/13/2025. There were no documented assessments of the arteriovenous fistula site on 1/2/2025 at 8:30 PM, 1/4/2025 at 8:30 PM, 1/5/2025 at 4:30 PM, 1/7/2025 at 4:30 PM, 1/8/2025 at 4:30 PM, 1/10/2025 at 8:30 PM, 1/11/2025 at 4:30 AM, 1/14/2025 at 12:30 PM, 1/17/2025 at 4:30 PM, 1/18/2025 at 12:30 PM, 1/20/2025 at 4:30 AM, and 1/29/2025 at 4:30 AM. - pre-dialysis vitals three times a week on Monday, Wednesday, and Friday at 5:00 AM, and post-dialysis vitals three times a week on Monday, Wednesday, and Friday at 10:00 AM. There was no documented evidence post dialysis vital signs were obtained on 1/4/2025, 1/11/2025, 1/14/2025, and 1/18/2025. The 2/2025 Medication Administration Record documented: - assess access site for bleeding, infection, bruit/thrill, and patency every day, every shift, with a start date of 1/25/2025. There were no documented assessments of the arteriovenous fistula site on 2/3/2025 at 4:30 AM, 2/12/2025 at 4:30 AM, and 2/15/2025 at 4:30 AM. - pre-dialysis vitals three times a week on Monday, Wednesday, and Friday at 5:00 AM, and post-dialysis vitals three times a week on Monday, Wednesday, and Friday at 10:00 AM. There was no documented evidence post dialysis vital signs were obtained on 2/7/2025 and 2/12/2025. The resident's Dialysis Communication Logs included three times a week communication sheets returned after dialysis from 11/21/2024 to 2/19/2025. There was no documented evidence the communication sheets were signed as reviewed by the facility nurse upon the resident's return from dialysis on Tuesday, Thursday, and Saturday 11/21/2024 to 1/24/2025 and on Monday, Wednesday, and Friday 1/25/2025 to 2/19/2025. There were no documented pre-dialysis vital signs on the dialysis communication sheets for 11/23/2024, 11/26/2024, 12/18/2024, 1/8/2025 and 2/17/2025. The Dialysis Communication Logs from the dialysis center documented: - on 12/18/2024 the resident did not receive their full dialysis treatment due to being late to dialysis. - on 1/22/2025 the resident did not receive their dialysis treatment due to feeling sick with nausea and being congested. - on 1/27/2025 the resident refused to go to dialysis. - on 2/7/2025 the resident's treatment ended early due to air in the dialysis system and clotting. There were no documented nursing progress notes or evidence the provider was notified of the resident's shortened or missing dialysis appointments. During a telephone interview on 2/25/2025 at 11:47 AM, Licensed Practical Nurse #37 stated when a resident returned from dialysis, nursing was supposed to get the resident's weight and vital signs. They stated they also looked at the access site and asked if the resident had pain. If they completed the vitals or the site check, it should be documented in the resident's medical record. They stated sometimes they peeked at the communication book, but did not always have to sign that it was reviewed. It was important to check the resident's dialysis site in the event there was swelling or bruising, signs of irritation, bleeding, or signs of infection. It was important the resident's vitals were taken before and after dialysis to ensure there were no drastic change with the resident's condition. During an interview on 2/25/2025 at 12:04 PM, Licensed Practical Nurse #38 stated they were responsible for checking the resident's vital signs when they returned from dialysis and for checking the bruit and thrill for the arteriovenous fistula. They stated they never checked the dialysis book as the dialysis center usually called if the issue was something pertinent. The dialysis center usually noted it in their own records if a resident did not finish treatment and had bleeding. They would only document a nursing note if dialysis was unable to treat the resident's concerns. During an interview on 2/25/2025 at 12:16 PM, Registered Nurse Unit Manager #39 stated the licensed practical nurses should check the dialysis access site, obtain vitals, and complete the communication form prior to the resident's dialysis. The regular nightshift nurse was the only one who consistently completed the forms. They stated the dayshift licensed practical nurse should review the communication book when the resident returned from dialysis and sign on the sheet they had reviewed it. They stated this had not occurred as the forms were not signed by a facility nurse. They were unaware Licensed Practical Nurse #38 never reviewed the communication book when the resident returned from dialysis. If a resident refused to go to dialysis there should be a nursing note regarding the refusal and the provider should be notified. They were unsure if the facility nurses or the dialysis nurses informed the provider of incomplete treatments. It was important for the nurses to review the communication binder from dialysis for continuity of care. During an interview on 2/25/2025 at 1:00 PM, Dialysis Registered Nurse #40 stated the dialysis communication books should be filled in completely by the facility when the resident came to dialysis, and this was not always the case. It was important the communication sheets were filled out, so the dialysis team had a full and complete picture of the resident prior to treatment. The comments the dialysis team wrote in the communication books were necessary for the resident's health. They expected the communication books were read by facility nursing staff when the resident returned from dialysis. If a resident did not finish their treatment, the dialysis nurses informed the dialysis provider. They may call the facility provider if the reason was urgent. They expected the facility nurses to pass the information to the proper channels if it was written in the book. It was important the communication book was reviewed by both parties, so the resident received consistent and proper care, and had no adverse events due to lack of communication. During an interview on 2/25/2025 at 1:49 PM, the Director of Nursing stated licensed nurses should fill out the communications sheets in their entirety. Licensed nurses should review and sign the communication book every time the resident came back from dialysis. It was important for the communication book to be filled out and reviewed so the dialysis center knew what medications the resident received and was what going on with the resident and the book should be reviewed when the resident came back so the nurses knew of any issues with treatment, how much fluid was taken off, and the resident's vitals. They expected the medical provider to be notified, and a nursing progress be written if a resident did not complete or refused a dialysis treatment. During a telephone interview on 2/25/2025 at 2:02 PM, Nurse Practitioner #12 stated they expected to be notified if a resident did not finish or refused their dialysis treatment. They stated it was important they were notified because if the resident did not finish treatment or go to a treatment, it could have a significant impact on the resident. The resident could have fluid overload, or their blood work could be outside normal limits and may need medical intervention. They stated they were not made aware the resident refused dialysis on 1/27/2025 or that they ended dialysis early on 2/7/2025. 10 NYCRR 415.12(K)

Based on observations, record review, and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 1 resident (Resident #153) reviewed. Specifically, Resident #153 had an extensive mental health history, did not have person-centered mental health interventions, and Preadmission Screening and Resident Review Level II recommendations were not implemented into the resident's plan of care. Additionally, Resident #153 hid butter knives under their mattress and there were no documented social services follow ups with the resident following their behavioral symptoms. Findings include: The facility policy, Care Planning/Care Conference, initiated 11/2022, documented a comprehensive person-centered care plan was developed for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs. Care plans included person-specific, measurable objectives and timeframes in order to evaluate the resident's progress towards their goals. The comprehensive care should include any specialized services or specialized rehabilitative services the nursing facility provided because of a [Pre-admission Screening and Record Review] recommendations. There was no documented evidence of a facility medically related social work policy. Resident #153 had diagnoses including bipolar disorder, adjustment disorder with depressed mood, and anxiety disorder. The 12/26/2024 Minimum Data Set documented the resident had moderately impaired cognition, had no behavioral symptoms, was independent or required set up assistance for all activities of daily living, and was on a routine antipsychotic medication. The 8/7/2024 Preadmission Screening and Resident Review Level II documented the resident had a diagnosis of bipolar disorder and adjustment disorder. They had a history of suicidal ideations, lashing out verbally and physically when upset, delusions, medication non-compliance, and extensive history of trauma. They preferred female staff and enjoyed reading, arts and crafts, crossword puzzles, listening to music and watching tv. They no longer needed acute inpatient psychiatric treatment but needed a psychiatric and medication evaluation by a psychiatric or medical provider within 45 days of being admitted to a skilled nursing facility, a written, person-centered psychiatric plan of care developed which included information about how they experienced mental illness such as past symptoms, mental health services they have received, what can make their symptoms worse, early signs that the resident was not doing well, and how to best support the resident if symptoms increase, a list of personalized coping skills and ongoing psychiatric consultations and medication management. It was also recommended the resident have grief counseling, participate in recreation and group activities and a have a written safety plan due to the history of thoughts of ending their life. The 12/27/2024 Comprehensive Care Plan documented: - the resident had a mood problem and there was a potential for activities of daily changes, anxiety and mood changes related to bipolar depression. Interventions included to invite to activities of choice, encourage rest periods, increase daytime activities, offer reassurance, monitor for signs and symptoms of depression, provide a calm, quiet atmosphere, and to keep the social worker updated as needed. - the resident had a potential for behavior problems related to inappropriate behaviors, verbal aggression, socially inappropriate behavior, disruptive behavior, a new environment, bipolar disorder, adjustment disorder with depressed mood, unspecified psychosis, and anxiety. Interventions included to provide a safe, quiet environment, approach in a calm, positive manner, allow to express themself in appropriate ways, provide one-to-one as needed, reapproach as needed, a psychiatric evaluation as needed, observe for signs of intent to harm themselves or others, and monitor the effectiveness of their medications. There was no documented evidence the resident's Preadmission Screening and Resident Review Level II care plan for serious mental illness was reviewed and incorporated in the facility Comprehensive Care Plan including a safety plan due to a history of thoughts of ending their life. The 11/16/2024 Licensed Practical Nurse #43 progress note documented the resident had behaviors of stealing a spray bottle with unknown liquid, three tubes of muscle rub, and taking things off the linen cart in the hallway. The 11/21/2024 Licensed Practical Nurse #38 progress note documented the resident was throwing their clothing and bathroom supplies on the floor and continued to lock the bathroom door on their roommate. They called other residents names, and the resident was hard to redirect. The 1/17/2025 Licensed Practical Nurse #47 note documented the resident refused to go their appointment despite multiple reapproaches, had verbal altercations with another resident, and housekeeping found butterknives underneath the resident's mattress. It was reported to dietary, the physician's assistant, the Unit Manager, and the nursing staff on the unit. The resident was not to have knives on their trays. The resident's care instructions had no documentation regarding the resident's behaviors, interventions for the resident's behaviors, or not having knives on their meal trays. The 1/21/2025 Nurse Practitioner #52 progress note documented the resident was upset with intermittent crying and argumentative with staff. The resident had an appointment but got combative in the dining room and refused to go. The resident vocalized frustration with other residents. Interventions included to encourage increased activity and engagement in social activities and monitor for suicidal and homicidal ideations. The resident was found with butter knives in their room, and knives were avoided on their meal tray. There was a gradual dose reduction meeting resulting in no changes in medications due to a recent increase in behaviors. The behaviors included recent confrontations with other residents and staff, refusing appointments, and occasionally hitting staff. The 1/31/2025 Psychiatric Nurse Practitioner #53 progress note documented the resident had a history of multiple inpatient psychiatric hospitalization, multiple comprehensive psychiatric emergency program admissions, and was in several long-term care facilities. The resident had an outside caseworker involved in their care. Staff reported no concerns prior to the visit, the resident reported wanting to be discharged , and was no recent agitation, aggression, or outbursts. The 2/19/2025 lunch meal ticket documented the resident was not allowed to have a knife at meals. There were no documented social services progress notes after 11/13/2024 regarding follow up on behaviors or behavior interventions. Resident #153 was observed and interviewed: - on 2/19/2025 at 1:10 PM, their lunch meal ticket documented no knife. There was a knife on their tray next to their plate. The resident stated the facility staff provided them with the knife so they could cut their food. They stated they were not allowed a knife as staff found a knife in their room, but it was not theirs. They stated they were not a violent person but not being allowed to have a knife made them feel like one. - on 2/24/2025 at 9:01 AM in the dining room eating French toast and eggs. They stated staff had to cut their food because the facility did not allow them to have a knife. During an interview on 2/25/2025 at 9:53 AM, Social Worker #54 stated if a resident was admitted with a Preadmission Screening and Resident Review Level II, the Director of Social Work assisted them in review and care planning. They stated they were responsible for the social services related care plans for their assigned floors. They determined what was best to address the resident's behaviors by talking to the resident, the nursing staff, and the medical provider. They stated resident care plans were to be personalized to the resident. Resident #153's care plan was not personalized. Resident #153 had several activities that calmed them down when they were upset and those should be on their personalized care plan. They stated Resident #153 had a lot of issues when they first arrived at the facility, including the passing of their roommate shortly after their arrival. These issues exacerbated the resident's mental health. They were unaware the resident hid knives under their mattress. They should have been notified so they could address it with the resident and include it in their care plan. During an interview on 2/25/2025 at 10:53 AM, the Director of Social Work stated they reviewed the Preadmission Screening and Resident Review Level IIs for any recommendations that needed to be addressed upon admission. They stated every resident with a Level II had a care plan and they incorporated the recommendations into the behavioral care plan. Resident #153 should have a Preadmission Screening and Resident Review Level II care plan, and they did not. The resident did not have a written safety plan. Resident care plans should be personalized. They did not consider Resident #153's behavioral care plan to be person-centered. They stated it was important to have a personalized care plan because each person was unique, and the staff should know what worked to de-escalate the resident's behaviors prior to the point where medication interventions were needed. The staff on the unit knew how to manage a resident's behaviors through verbal report from the social worker assigned to that unit. They were unaware Resident #53 had been hiding butter knives and was no longer allowed to have them at meals. They were unaware the resident was upset about not being allowed to have butter knives. They stated the resident should have been evaluated on why they were hiding knives under their mattress, and it should be included in the care plan. During an interview on 2/25/2025 at 12:16 PM, Registered Nurse Unit Manager #39 stated resident specific interventions and triggers were generally communicated in staff meetings. They stated Resident #153 was sometimes hard to redirect and if redirection did not work, staff should make sure the resident and others were safe then leave the resident alone. They stated Resident #153 was hiding the butterknives from their tray under their mattress and they were found by housekeeping. They did not remember if their assigned social worker or the Director of Social Work was told but one of them was. They stated they were unaware the resident's care plan did not include they were not allowed knives. That care plan should be done by social work as it was a behavior. 10 NYCRR 483.40 (d)

Based on record review and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not ensure residents were free of any significant medication errors for 1 of 6 residents (Resident #744) reviewed Specifically, Resident #744 did not receive Abilify (an antipsychotic medication) for 4 consecutive days (10 doses). Findings include: The facility policy, Medication Administration, revised 11/2022, documented medications were administered in a way that ensured the resident's safety. If the medication was not available on the nursing unit and not in the Pyxis machine (a machine that dispenses certain medications), the Registered Nurse Supervisor was notified, and they notified the pharmacy and physician as necessary. The physician or nurse practitioner were notified of any missed doses and a registered nurse completed an assessment of the resident as needed for missed dose of medications. If the registered nurse had any problems with obtaining medication the Director of Nursing or designee was notified and ensured prompt delivery of medications. Resident #744 had diagnoses including schizoaffective disorder, bipolar type. The 2/14/2025 Minimum Data Set assessment documented the resident was cognitively intact and took antipsychotic medication daily. The 2/7/2025 physician order documented Abilify 10 milligrams twice a day at breakfast and lunch, and 5 milligrams once a day between 4:00 PM and 9:00 PM. The 2/2025 Medication Administration Record documented Abilify oral tablet 5 milligrams, one tablet by mouth every day between 4:00 PM and 9:00 PM; and Abilify oral tablet 5 milligrams, two tablets by mouth twice daily with breakfast and lunch for psychosis. The resident did not receive the following scheduled Abilify doses: - on 2/16/2025, the 12:00 PM dose. - on 2/17/2025, the 8:00 AM, 12:00 PM, and 8:00 PM doses. - on 2/18/2025, the 8:00 AM, 12:00 PM, and 8:00 PM doses. - on 2/19/2025, the 8:00 AM, 12:00 PM, and 8:00 PM doses. Nursing progress notes from 2/16/2025-2/19/2025 did include documentation of missed doses of Abilify or notification of the provider of missed doses. During an interview on 2/19/2025 at 12:05 PM, Resident #744 stated they were not getting their Abilify medication. The nurses told them the medication was unavailable They stated this medication was very important for their mental health, and they knew they should not miss any doses. During an interview on 2/24/2025 at 1:49 PM, Licensed Practical Nurse #14 stated pharmacy came three times a day and made stat (emergency) deliveries. If a medication needed to be reordered, it was done electronically. Every missed dose required a phone call to the physician and was documented in a progress note. Residents should never be out of a medication. It was important the resident's medication were ordered and received as it was part of their plan of care and important for them to get better. Resident #744 did not get their Abilify because of a backorder problem. Abilify was available in the Pyxis medication dispenser so there should not have been any missed doses. The physician should have been notified about any missed doses because they might have ordered a substitute. During an interview on 2/25/2025 at 10:43 AM, Licensed Practical Nurse #17 stated the physician should be notified of every missed dose of a medication. If they saw a medication was getting low, they ordered a refill on the computer. Resident #744 was out of Abilify last week, but they were unsure how long they had been without it. They entered a refill request but did not think they called the pharmacy or followed up on it. The physician should have been notified as it was a psychiatric medication, and they could have withdrawal effects. They stated the physician could have ordered an alternative medication. During an interview on 2/25/2025 at 12:01 PM Registered Nurse Unit Manager #13 stated the physician should be notified for every missed medication and it should be documented in a nursing note. They were unaware Resident #744 missed their Abilify doses. The resident should have received that medication because it was a psychiatric medication, they needed it, and they could have an adverse reaction without it. During an interview on 2/25/2025 at 1:22 PM, the Director of Nursing stated If a medication was not given, the nurse should have notified the physician. The physician should be notified of every missed medication in case they wanted to make changes or wanted a new order for monitoring. Physician orders were expected to be followed. During an interview on 2/25/2025 at 1:58 PM, Nurse Practitioner #12 stated they wanted to be notified for each missed medication dose. Resident #744 was on Abilify to manage their bipolar disorder. If they missed 4 days, they could have increased depression, increased restlessness, and their behaviors and mood could worsen. If there was a pharmacy or insurance issue, they wanted to know so they could look at alternatives. They should have been notified immediately after the first dose was missed and they were not. 10NYCRR 415.12(m)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews during the recertification survey conducted [DATE]-[DATE], the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 6 medication carts (2B East cart) reviewed. Specifically, the 2B East medication cart contained 4 opened undated insulin vials, 7 opened undated insulin pens, and one expired insulin vial. Additionally, 2 vials of vaccines (Prevnar, pneumococcal vaccine and Abrysvo, respiratory syncytial virus vaccine) were observed sitting on top of the medication cart unsecured and unattended. The facility policy, Insulin Orders, revised 11/2016, documented the pharmacy assigned a 28-day expiration date on all insulin pen delivery devices once removed from the refrigerator. The facility policy, Storage of Medications, revised 9/2019, documented medications and biologicals would be stored safely, securely, and properly; the medication supply would be accessible only to licensed nursing personnel, pharmacy personnel, or staff members authorized to administer medications; and outdated medications would immediately be removed from inventory, disposed of, and reordered from the pharmacy. The facility policy, Medication Administration, revised 11/2022, documented the facility would ensure medication was not outdated and was properly labeled. During an observation of the 2B medication cart on [DATE] at 2:28 PM, 2 bags, one containing a prefilled syringe of Prevnar vaccine and one containing a prefilled syringe of Abrysvo vaccine were sitting on top of the medication cart. Both medications had instructions to store in the refrigerator. The cart was unattended. During an interview on [DATE] at 2:36 PM, Licensed Practical Nurse #14 stated vaccines should be stored in the refrigerator. They stated they did not put the vaccines on the medication cart. They thought Registered Nurse Unit Manager #13 received the vaccines from the pharmacy when the 2:00 PM delivery was made. They stated Registered Nurse Unit Manager #13 gave them the vaccines and told them to administer the vaccines. During an interview on [DATE] at 2:37 PM, Registered Nurse Unit Manager #13 stated they did not receive a delivery from the pharmacy. The pharmacy did not deliver until after 3:00 PM. They did not put the bags containing the vaccines on the cart. Vaccines should be pulled from the refrigerator prior to administration and should not be stored on top of the medication cart unsecured. Unsecured vaccines were a safety concern if a resident took them. Vaccinations should be kept refrigerated until the time of administration. During an observation and interview on [DATE] at 10:21 AM with Licensed Practical Nurse #17, the 2B East medication cart contained one opened vial of aspart (short-acting) insulin dated [DATE]; one opened and undated vial of Humalog (short- acting) insulin that belonged to a discharged resident; two opened and undated vials of lispro (short- acting) insulin; one opened and undated vial of aspart (short-acting) insulin; four opened and undated Lantus (long-acting) insulin pens; two opened and undated glargine (long-acting) insulin pens; and one opened and undated lispro (short-acting) insulin pen. Licensed Practical Nurse #17 stated insulin should be labeled with the date it was opened and expired 30-31 days from that date. Before administering insulin, the expiration date should be verified and if there was not an expiration date they should be discarded. If insulin was expired, it might be less effective and not work properly. During an interview on [DATE] at 10:28 AM, Registered Nurse Unit Manager #13 stated insulin should be dated when opened. Nurses should check those dates before use to make sure it was not expired. If opened insulin was not dated, it should be discarded because it could be expired. Residents should not receive expired insulin because it could be less effective. During an interview on [DATE] at 1:22 PM, the Director of Nursing stated medications should not be left unattended on top of the medication carts as a resident could take them and it was a safety concern. Insulin should be dated when opened because insulin expired and without that date, there was no way to know if the insulin was still good. That date should be checked before administering insulin. All multidose vials and pens should be labeled with the expiration date when opened to ensure medications were still effective and discarded on or before the expiration date. 10 NYCRR 415.18(d)

Based on observations, record review, and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 residents (Residents #49 and #226) reviewed. Specifically, Resident #226 was on transmission-based precautions (enhanced barrier precautions) and Licensed practical nurse #1 performed gastrostomy tube (feeding tube) care without wearing required personal protective equipment. Resident #49 was on isolation precautions (contact precautions) and X-Ray Technician #10 obtained an abdominal X-ray without wearing required personal protective equipment and Certified Nurse Aide #9 provided Resident #49 their meal tray wearing gloves and did not perform hand hygiene after removing their gloves. Findings included: The facility's Enhanced Barrier Precautions policy dated 2/1/2023 documented Enhanced Barrier Precautions were an infection control intervention designed to reduce transmission of multidrug- resistant organisms in nursing homes. Enhanced barrier precautions involved gown and glove use during dressing, bathing/ showering, changing linens, transferring, providing hygiene, changing briefs or assisting with toileting, wound care, and care for or using an indwelling medical device such as feeding tube care and tracheostomy/ ventilator care. The facility policy, Clostridium Difficile (bacterium known for causing serious diarrheal infections), revised 2/2021, documented Clostridium Difficile was suspected in residents with acute, unexplained onset of diarrhea (three or more unformed stools within 24 hours). Residents with diarrhea and suspected clostridium difficile were placed on Contact Precautions. The facility's Enhanced Barrier Precautions signage documented everyone must clean their hands upon entering and exiting the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities; dressing, bathing/ showering, changing linens, transferring, providing hygiene, changing briefs or assisting with toileting, wound care, and care for indwelling medical devices such as feeding tubes and tracheostomy/ ventilator. The facility's Contact Precautions signage documented everyone must clean hands prior to entering the room and exiting the room. Providers and staff should put on gloves before room entry and discard gloves before exiting the room. Put on a gown prior to entering the room and remove prior to exiting the room and use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. 1) Resident #226 had diagnoses including adult failure to thrive and pneumonia. The 1/22/2025 Minimum Data Set assessment documented the resident had intact cognition, was dependent for most activities of daily living, received a tube feeding and respiratory treatments including oxygen, suctioning, tracheostomy care, and had an invasive mechanical ventilator (to assist with breathing). The 10/16/2024 Comprehensive Care Plan documented the resident had infection control precautions (enhanced barrier precautions) related to an indwelling medical device. Interventions included to post sign at door and explain precautions/ limitations to resident and visitors. The 2/10/2025 physician orders documented the resident was to receive nothing by mouth, tube feedings 4 times daily via the gastrostomy tube, and isolation precautions (enhanced barrier precautions) related to the tracheostomy and gastrostomy tube. The updated 2/10/2025 Comprehensive Care Plan documented the resident had a tracheostomy related to risk for cessation of breathing. Interventions included daily oxygen usage, have clear open-air way, and monitor for decreased pulse oximetry (lower than normal blood oxygen). The resident had infection control precautions (enhanced barrier precautions) related to indwelling medical device. The updated 2/11/2025 Comprehensive Care Plan documented the resident had a nutritional problem related to nothing by mouth status and received all nutrition and medications via a gastrostomy tube (a feeding tube). Interventions included to provide tube feeding as ordered. The undated care instructions documented the resident was on enhanced barrier precautions related to tracheostomy and tube feeding. During an observation on 2/24/2025 at 1:09 PM, Resident #226's room door had a sign posted documenting enhanced barrier precautions with a caddy on the door containing personal protective equipment. Licensed Practical Nurse #1 knocked on the door and entered the resident's room. They explained to the resident they were going to administer their tube feeding. They placed the carton of tube feeding formula on the resident's bedside table and retrieved a pair of gloves from the caddy on the door. Licensed Practical Nurse #1 administered the resident's tube feeding without wearing a gown. During an interview on 2/24/2025 at 1:20 PM Licensed Practical Nurse #1 stated the resident was on enhanced barrier precautions due to their tracheostomy and tube feeding. They stated they should wear personal protective equipment when completing care and administering tube feedings, but they did not when they administered Resident #226's tube feeding. It was important to wear personal protective equipment to prevent the spread of infections/ disease. During an interview on 2/25/25 at 12:45 PM the Infection Control Preventionist #5 stated enhanced barrier precautions were used when a resident had any artificial opening. If staff were administering a tube feeding, they should wear gown, and gloves. It was important to wear personal protective equipment to help prevent the spread of infections and disease. 2) Resident #49 had diagnoses including clostridium difficile (bacterial infection causing diarrhea and colon inflammation). The 1/4/2024 Minimum Data Set assessment documented the resident's cognition was intact, was dependent on staff for toileting hygiene, and was always incontinent of bowel and bladder. On 2/18/2025 the Infection Control Preventionist #5 documented the resident had complained of loose stools. The resident would be tested for clostridium difficile and placed on precautions for suspected Clostridium difficile. The 2/18/2025 physician orders documented the resident was to be on isolation precautions (contact precautions) for diarrhea associated with clostridium difficile suspected and 1 capsule of 125 milligrams of Vancomycin HCl (oral antibiotic) every six hours until 3/4/2025. A 2/20/2025 Licensed Practical Nurse #35 progress note documented the resident remained on contact precautions due to suspected clostridium difficile and had 3 loose stools throughout the day. During an observation on 2/21/2025 at 1:18 PM, the Contact Precautions signage and personal protective equipment caddy was hanging on the resident's door. Certified Nurse Aide #9 put gloves on prior to entering the resident's room and did not put on a gown. At 1:23 PM, Certified Nurse Aide #9 exited the resident's room and removed their gloves. They walked down the hallway and retrieved a garbage bag, entered the resident's room, removed soiled linen out of the room, walked down the hallway to dispose of the soiled linen, they were not wearing gloves and did not perform hand hygiene. During an interview on 2/21/2025 at 1:23 PM, Certified Nurse Aide #9 stated they thought the signage hanging on the resident's door was old. If a resident was positive or had suspected clostridium difficile staff should wear gloves and a gown when caring for them. They should have followed the instructions on the sign, and they did not. It was important to follow the signage to prevent the spread of infections/ diseases. During an observation on 2/21/2025 at 1:47 PM, X-Ray Technician #10 entered the resident's room with an X-Ray machine. They did not put on personal protective equipment. After exiting the Resident's room X-Ray Technician #10 stated they completed an abdominal X-Ray of the resident. They did not see the signage on the resident's door and did not put on any personal protective equipment other than gloves and did not complete hand hygiene. They did not know why the resident was on contact precautions. A 2/22/2025 Licensed Practical Nurse #34 progress note documented they spoke to the laboratory and the resident's stool sample tested positive for clostridium difficile. During an interview on 2/25/2025 at 9:36 AM, Registered Nurse Unit Manager #11 stated they or the Infection Control Preventionist placed or removed any infection control signage outside of the resident's room. Anyone providing hands on care should follow the signage. If someone did not know what the signage meant or thought the signage was old and not needed any longer, they should ask for clarification. Resident #49 was positive for clostridium difficile and continued to have loose stools. Staff should wear gowns and gloves when providing care and wash their hands. It was important to wear personal protective equipment to prevent the spread of infection. During an interview on 2/25/2025 at 12:45 PM the Infection Control Preventionist stated staff was expected to follow the signage on the resident's room. Clostridium difficile was contagious and if staff did not wear the correct personal protective equipment it could spread to other residents, visitors, and staff. 10 NYCRR 415.19(a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification and abbreviated (NY00355972, NY00357410, NY00358321, and NY00367882) surveys conducted 2/19/2025-2/25/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for 3 of 8 resident units (Units 2 A, 3 A, and 4 A) reviewed. Specifically, Unit 2 A had a strong smell of urine, unclean bedrooms floors, a bathroom with brown splatter on the toilet, and an over bed table with food debris; Unit 3 A's dining room floor was unclean and sticky, there was debris on the base of the food carts, and brown material on a raised toilet seat in a resident room; and Unit 4 A had a continuously running sink in a resident room, unclean floors in multiple resident rooms, and food splatter on the floors and walls. Findings include: The facility policy, Resident Room Cleaning, revised 3/2020, documented resident rooms were cleaned daily to ensure optimal levels of cleanliness and sanitation, prohibit the spread of infection and bacteria, and maintain the outward appearance of the facility. Wastebaskets were cleaned and sanitized daily, surfaces were cleaned and dusted including over the bed tables, floormats, doors, walls, and floors were cleaned with a dust mop and damp mop. The facility's Strip and Wax binder documented the following room floors were stripped and waxed: - in August 2024 Rooms 341, 343, 347, 360, 361, 365, 366 and 367. - September 2024 Rooms 300, 301, 303, 304, 306, 307, 308, 309, 310, 311, 312, 314, 332, 340, 341, 350, 356, 357, 358, 353, and 441. - in October 2024 Rooms 262, 263, 320, 321, 322, 323, 324, 325, 327, 326, 329, 331, 347, 501, 503, 505, 506, 507, 510, 511, 512, 515, 520, 521, 522, 523, 524, 525, 526, 527, 528, 529, 530, 531, and 532. - in November 2024 Rooms 244, 242, 243, 245, 251, 252, 255, 256, 257, 258, 259, 261, 264, 265, 266, 267, 422, and 429. - in December 2024 Rooms 504, 514, 526, and 533. - in January 2025 rooms [ROOM NUMBER]. There was no documented evidence that floor areas other than resident rooms were stripped or waxed on the 2nd, 3rd, 4th, or 5th floor. The following observations were made on Unit 2 A: - on 2/19/2025 at 1:19 PM room [ROOM NUMBER] had old, dried food splatter and debris on the floor, concentrated to the left side of bed where the floor mat was and at the foot of bed. The bed side table base had dried splatter. The bathroom floor had debris on the floor, the toilet had brown splatter, and on the left handle of toilet frame there was dried brown debris. - on 2/19/2025 at 1:34 PM, room [ROOM NUMBER] had scattered food debris all over the floor. - on 2/19/2025 at 2:46 PM, room [ROOM NUMBER] had food debris on the side of the bed towards the door, the bathroom had dried debris on floors and walls, 1 cotton swab was on the floor, and the toilet had brown splatter on it. - on 2/19/2025 at 2:50 PM, room [ROOM NUMBER] had dried debris on the floor mat and liquid on the floor to the right side of the bed. The over the bed table was covered with dry splatter. - on 2/20/2025 at 10:10 AM, there was a strong smell of urine that permeated the entire unit. - on 2/20/2025 at 2:26 PM, room [ROOM NUMBER] had debris on the floor, the over the bed table had a large amount dried splatter on the top and the frame, and there was dust and debris in the corners of the room. - on 2/24/2025 at 12:43 PM, room [ROOM NUMBER] had 4 straws and 2 cartons of an oral nutrition supplement under the bed, and a large amount of debris covering the floor. - on 2/25/2025 at 8:51 AM, room [ROOM NUMBER] had 4 straws, 2 cartons of an oral nutrition supplement under the bed, and other debris on the floor. room [ROOM NUMBER] had a large amount food debris on the floors in both the bedroom and bathroom. room [ROOM NUMBER] A had food debris and splatter on the floor, on the floor mat, and the over the bed table. - on 2/25/2025 at 9:01 AM, room [ROOM NUMBER]'s over the bed table was covered with splatter and the floors in the room and bathroom were unclean. -Oo 2/25/2025 at 8:56 AM, room [ROOM NUMBER] A's floor had debris, and the bathroom had brown splatter on the floor and walls. The following observations were made on Unit 3A: - on 2/19/2025 at 11:59 AM, 3 food carts holding meals trays located outside room [ROOM NUMBER] had dried debris on the base of the carts. - on 2/19/2025 at 1:09 PM, the floor in the dining room was sticky and unclean. - on 2/24/2025 at 12:20 PM, the floor in the dining room was sticky and covered with several differed sized dry spots some as large as a grapefruit. During an interview and observation on 2/24/2025 at 12:31 PM, the resident in room [ROOM NUMBER]'s family member stated they were in at least weekly to visit, and the facility was unclean each time. On multiple visits there was stool on the toilet and the bathroom floor. Last week the bathroom was so dirty they told the nurse. When they opened the bathroom door, they it appeared it had not been cleaned from the previous week. There was dried brown debris covering the entire back of the raised toilet seat and the floor around the toilet had black dried debris on it. The resident in room [ROOM NUMBER] said their room was never cleaned and they thought the room was not homelike. The daily cleaning logs for Unit 3A documented feces was noted in room [ROOM NUMBER] on 2/14/2025 and one other undetermined date in 2/2025. During an observation on 2/25/2025 at 11:29 AM, the first floor entry to the A side building had a foul smell. Corporate Registered Dietitian Consultant #8 stated they believed the odor was coming from the rubbish chute in the area. The following observations were made on Unit 4 A: - on 2/19/2025 at 12:15 PM, the sink in room [ROOM NUMBER] B was continuously running. - on 2/19/2025 at 1:24 PM, there was food and crumbs on the floor in room [ROOM NUMBER] with red splatter under the television. - on 2/18/2025 at 1:59 PM, room [ROOM NUMBER] had spilled dried red liquid covering two floor tiles and brown stains under the over the bed table between the bed and the wall. - on 2/19/2025 at 2:33 PM, room [ROOM NUMBER]'s floor had multiple areas covered with food and dried debris. During an interview on 2/24/2025 at 11:56 AM, [NAME] #19 stated they were responsible for cleaning hallways, stairwells, elevators, pantries, and dining areas every day. They swept and mopped the floors, sprayed doorknobs, and sanitized handrails every day. If floors were sticky, dirty, stained, or covered with debris it was not homelike. During an interview on 2/25/2025 at 8:34 AM, Certified Nurse Aide #15 stated housekeepers were responsible for cleaning resident rooms except bodily fluids, nursing staff was responsible for cleaning bodily fluids. Housekeeping was then notified and completed a deep cleaning. It was an infection control issue if bodily fluids were left on a toilet in shared bathrooms. Sticky floors, floors covered with food and debris, and over the bed tables covered in debris was not homelike. During an interview on 2/25/2025 at 8:52 AM, Registered Nurse Unit Manager #16 stated nursing was responsible for cleaning bodily fluids, then housekeeping was notified and completed a deep cleaning. Housekeeping cleaned resident rooms and bathrooms. They did not expect to see sticky floors, floors covered with debris, and tables covered with debris. It was not homelike for residents to have dirty or sticky floors, brown debris on toilet seats, or debris on surfaces or walls. During an interview on 2/25/2025 at 9:20 AM, Housekeeper #18 stated their job duties included cleaning resident rooms every day. Room cleaning included changing and emptying trash, sweeping the floors, cleaning the bathroom, dusting all surfaces, sweeping, mopping, and sanitizing the rooms. They were not allowed to touch bodily fluids until they were cleaned by nursing. After nursing cleaned the fluids, they completed a deep cleaning. They stated if rooms had food and debris on the floors and other surfaces, brown debris on toilet seats, sticky floors, and dust it was not homelike. During an interview on 2/25/2025 at 11:37 AM, Assistant Director of Housekeeping #20 stated they were responsible for making sure units and resident bedrooms and bathrooms were clean. Porters were responsible for floor care in offices, dining rooms, hallways, and completed the floor stripping and buffing of their designated areas every three months. Resident rooms were completed as requested and documented in the waxing and buffing logs in a binder. Housekeepers were responsible for cleaning resident rooms and bathrooms. Housekeepers disinfected bathrooms, cleaned bed frames, windows, changed trash, swept and mop the floors, and dusted all surfaces including walls and over the bed tables. Daily room cleaning was documented in a log. They stated nursing was responsible for cleaning bodily fluids and after the initial cleaning notified housekeeping. It was not homelike to have walls with splatter or brown debris on toilet seats, and unclean floors. 10 NYCRR 415.29(j)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not ensure that each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 lunch meals (2/21/2025 and 2/24/2025 lunch meals) reviewed. Specifically, the 2/21/2025 and 2/24/2025 lunch meals were not served at palatable and appetizing temperatures and the 2/24/2025 lunch meal was not palatable or attractive. Additionally, 7 of 7 anonymous residents at the Resident Council meeting stated the food was not appetizing and not served at appropriate temperatures; and Residents #46, #47, and #210 stated the food was not served at appetizing temperatures. Finding included: The facility policy, Food Temperatures and Test Tray Audits, revised 4/5/2024, documented the minimum temperatures at the time of service for: - milk and milk products were less than 45 degrees Fahrenheit. - hot entrees was greater than 135 degrees Fahrenheit. - hot beverages was greater than 140 degrees Fahrenheit - cold beverages was less than 55 degrees Fahrenheit. During an interview on 2/19/25 at 12:35 PM, Resident #47 stated the milk was warm, the hot food was cold, and the food was not good. During an interview on 2/19/2025 at 1:00 PM Resident #46 stated the food was always cold and never hot. During an interview on 2/19/2025 at 1:38 PM, Resident #210 stated the food was not good, the chicken could not be cut, and if they ate in the dining room, they would get hot food but if they ate in the hallway they might not. During a resident group interview on 2/20/2025 at 10:35 AM, 7 anonymous residents stated the warm food was served cold, cold food was served warm, milk and juices were served warm, and the food was not appetizing. During a lunch meal observation on 2/21/2025 at 12:27 PM on Unit 3 A, a lunch tray was tested. The slice of fish measured at 125 degrees Fahrenheit and was bland, the baked potato was bland, the 2% milk measured at 53 degrees Fahrenheit, the apple juice measured at 58 degrees Fahrenheit, and the ginger ale measured at 53 degrees Fahrenheit. During a lunch meal observation on 2/24/2025 at 1:48 PM, Resident #210's lunch tray was tested, and a replacement was requested. The chicken had a pink center, the ends were brown, and it was difficult to cut. The cottage cheese had a ring of clear liquid surrounding it and was measured at 54.1 degrees Fahrenheit. The coffee measured at 133.9 degrees Fahrenheit, the peaches and mandarin oranges measured at 52.5 degrees Fahrenheit, and the chocolate milk measured at 53.2 degrees Fahrenheit. During a follow up interview on 2/24/2025 at 12:31 PM, Resident #47 stated the food was not good and their family member brought in food every time they visited. They lost weight because they were not eating. They did not eat the hot entree (chicken [NAME]) at lunch that day as it was not appetizing. During an interview on 2/25/2025 at 10:45 AM, Dietary Supervisor #26 stated cooked foods were checked for temperature when sent to the units where they were served from steam tables. Cold items should be 38 degrees Fahrenheit or less. Cottage cheese should not have a lot of liquid on top as that signified it was too warm and should have been discarded prior to serving. During an interview on 2/25/2025 at 11:10 AM, Dietary [NAME] #27 stated cold foods were kept below 40 degrees Fahrenheit and hot foods above 165 degrees Fahrenheit to prevent bacterial formation. Food temperatures were checked by a cook using a digital thermometer when coming out of the oven and before leaving the kitchen to go to the unit. All cooks were educated on this during orientation. The facility supplied new thermometers weekly to kitchen staff and they were calibrated prior to use. Food should not be difficult to cut as a residents could have a hard time chewing and eating the food. The cooks knew if a food item was cooked correctly when they took the temperature the food. The chicken should not be pink on the inside. If chicken was not fully cooked, bacteria could form, and a resident might get sick from it. During an interview on 2/25/2025 at 11:28 AM, the Food Service Director stated the pink in the chicken may have occurred if it was cut near the bone or vein and did not mean it was under cooked. Milk and milk products should be served at 45 degrees Fahrenheit or below for palatability reasons. Hot foods should be served at 135 degrees Fahrenheit or above. 10NYCRR 415.14(d)(1)(2)

Based on observations, record review, and interviews during the recertification survey conducted 2/19/2025-2/25/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards in the main kitchen and on1 unit (Unit 2A). Specifically, the main kitchen had multiple unclean surfaces, there were stored food items past their expiration dates, and staff did not wear hair nets. Unit 2A had a steam table with dried food, discolored water, and debris: and there was debris and 3 mouse traps behind the unit ice machine. Findings include: The facility policy, Dining and Meal Service, revised 4/5/2024, documented the dining room would be cleaned promptly after every meal. The facility policy, Dining Services Department Traffic, revised 4/5/2024, documented anyone coming into the kitchen must have a hair net on. All employees were educated to comply with the procedure and reasoning for implementation (i.e. cross contamination). Hair nets would be placed in an area within entrance to the department. The facility policy, Food Storage- Refrigerators and Freezers, revised 4/5/2024 documented all foods prepared on-site were stored for a maximum of 3 days at 41 degrees Fahrenheit or lower before it should be discarded. That day count began the day the food was prepared, or a commercial can was opened. The refrigerator interior was kept clean. Food was kept 6 inches off the floor on an enclosed shelf. The facility policy, Food Storage Dry Goods, revised 4/5/2024, documented dry foods were stored 2 inches from the wall and 6 inches off the floor. Floors, walls, ceilings, and shelving were kept clean. The facility policy, General Kitchen Cleaning, revised 4/5/2024, documented staff would maintain the sanitation of the kitchen. Tasks would be assigned to specific staff positions. The policy did not specify a cleaning schedule. The following observations were made in the main kitchen on 2/19/2025 from11:24 AM-11:56 AM: - milk was stored on the floor in crates - 3 dietary staff were not wearing hair nets. - trays of 2% milk set up for the 5th floor were warm to touch. - Dietary Aide #21 was plating fruit plates without wearing a hair net. - there was debris on the floor and a strawberry behind the 3-bay sink behind the milk cooler. - there was a Dunkin coffee cup with coffee in a milk crate. - Dietary Aide #22 was making snack sandwiches and was not wearing a hair net. - Dietary Supervisor #23 was making sandwiches and was not wearing a hair net. - there were 15 crates of milk and a box of cantaloupe on the floor of a cooler. - there was debris on the floor. - there were pre-wrapped cookies stored on the floor under a food prep table. - there were 3 uncovered sheet pans in a cooler containing pork butt and turkey roasts dated 2/19. - there was debris and build-up under the 3-bay sink. - a dry storage door was propped open about 2 inches and there were fruit flies by the dishwashing machine. The following observations were made on Unit 2 A on 2/19/2025 at 11:40 AM: - the kitchenette steam table contained discolored water with food remnants. There was dried macaroni and cheese on the steam table and one of the shelves had dried food splatter. - there was a plate rack with dried food debris on the top. - the steam table cord was cut in several different areas. - there was a loaf of moldy bread in an upper cabinet in the kitchenette. - the kitchenette cabinet drawers had dried food splatters and crumbs. - there was food debris, bottle tops, and aluminum foil behind the ice machine. - there were 3 empty mouse traps behind the ice machine. During an interview on 2/19/2025 at 12:04 PM, Dietary Aide #24 stated the steam table cord was usually not plugged in. They stated they did not know why the areas were dirty or if a work order was placed for the steam table cord. The following observation were made in the main kitchen with the Food Service Director on 2/24/2025 at 12:55 PM: - the nourishment cooler had a temperature reading of 44 degrees Fahrenheit. - there was brown debris along the interior floor edges of the dairy cooler and a cellophane wrap ball under a rack on the rear of the cooler. - another cooler contained a tub of gravy dated 2/20, a pan of green beans dated 2/21, a pan of broccoli dated 2/21, and yellow cake dated 2/19. - in the freezer, there was a pan of frozen Beefaroni dated 2/17, a pan of frozen turkey tetrazzini dated 2/1, and turkeys were being rapid cooled uncovered on bare racks. The Food Service Director stated the gravy was made on the evening of 2/20 and was good until the end of 2/24/2025. The green beans, broccoli, and cake were good for 5 days as they were already cooked. During an interview on 2/25/2025 at 10:45 AM, Dietary Supervisor #26 stated all dietary staff should clean the kitchen and prep areas. They were assigned a specific area daily. Floors and counters should be cleaned daily and after each use. Floors were cleaned twice daily and as needed. The dish area was cleaned after every meal. The refrigerators and freezers were cleaned every 3 days, and all interior items were pulled out to clean under them. All spills and debris should be cleaned immediately as soon as staff saw it. Cooks were responsible for cleaning the oven areas. The dietary supervisors performed cleanliness audits daily. All dietary staff were educated on cleaning during monthly meetings and as needed. The freezer and cooler floors should be cleaned prior to inspection. All foods should be dated when made or opened and discarded after 3 days to prevent bacterial formation. Hair nets were to be worn at all times in the kitchen and put on when entering the kitchen area to prevent hair or hair products from getting into food items. Informal audits were done by the Food Service Director and supervisors. On the spot education was done for violations. All kitchen staff were aware of this. Food should not be stored on the floors to prevent contamination. Cooked foods were checked for temperature when sent to the units where they were served from steam tables. Cold items should be 38 degrees Fahrenheit or less. Cottage cheese should not have a lot of liquid on top as that meant it was too warm at one point and have been discarded prior to serving it. During an interview on 2/25/2025 at 11:10 AM, Dietary [NAME] #27 stated cooks were assigned to clean specific areas in the cooking, freezers, and oven areas. The coolers were swept and mopped daily and as needed. Freezers were generally cleaned weekly, and spills should be cleaned when noticed. None of the areas should have debris on the floors. All food should be discarded 3 days after making them due to possible bacterial contamination. This included the yellow cake. Cooked foods that were frozen were to be discarded after a week. Gravy should be made daily, so it was fresh for the residents. The gravy and cake should have been discarded and the cook did not know why they were not. Hair nets should be always worn in the kitchen area to prevent hair or hair products from getting into the food. All dietary staff were aware of this. Food should not be stored on the floor as they could be contaminated from the dirty floor. Cold foods were to be kept below 40 degrees Fahrenheit and hot foods above 165 degrees Fahrenheit to prevent bacterial formation. Food temperatures were checked by a cook using a digital thermometer when coming out of the oven and before leaving the kitchen to go to the unit. All cooks were educated on this during orientation. Freezer and cooler temperatures were checked by a cook first thing in the morning, about mid-day, and at the end of the day. The temperatures were documented on each piece of equipment's log. The facility supplied new thermometers weekly to kitchen staff and they were calibrated prior to being put in use. During an interview on 2/25/2025 at 11:28 AM, the Food Service Director stated the kitchen coolers were mopped twice a day. The kitchen freezers were swept nightly and deep cleaned on a weekly basis. Both were also cleaned as needed. The gravy was outdated and should be discarded. Milk should be served at 45 degrees Fahrenheit or below due to palatability. The milk was kept in the kitchen cooler prior to being sent to the unit for each meal. Hot foods should be served at 135 degrees Fahrenheit or above. The food was prepared in the kitchen and sent to the units to be served from team tables. They should not have been served below that temperature. The facility performed random test trays at least monthly. All staff should always wear hair nets in the kitchen area to prevent hair or hair products from coming into contact with food products. All staff were aware of this. They stated the green beans and broccoli with the dates of 2/21 were thawing and waiting to be cooked. 10NYCRR 415.14(h)

Based on observation, interview, and record review during the recertification and abbreviated (NY00302292) surveys conducted 3/21/23-3/28/23, the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance and enhancement of quality of life for 2 of 7 (Residents # 24 and 165) reviewed. Specifically, Resident #24 was not provided their bathing preference of a shower; and Resident #165's urinary catheter collection bag was uncovered with the contents visible. Findings include: The facility policy Quality of Life-Dignity revised 2/2022 documented each resident shall be cared for in a manner that promoted and enhanced his or her sense of well-being, level of satisfaction of life, feeling of self-worth, and self-esteem. The facility culture was one that supported and encouraged humanization and individualization of residents, and honored resident choices, preferences, values, and beliefs. Respect for choices and values included personal grooming in which residents were groomed as they wished to be groomed. Staff were expected to promote dignity and assist residents which included helping to keep their catheter bags covered. 1) Resident #24 was admitted to the facility with diagnoses of osteomyelitis of the vertebrae (infection in bones of the spine), right leg below the knee amputation, and cerebral palsy (a disorder that affects movement). The 1/4/23 Minimum Data Set (MDS) documented the resident had intact cognition, required extensive assistance of 2 for personal hygiene and bathing, did not reject care, and it was somewhat important to be able to choose between a tub bath, shower, bed bath, or sponge bath. The 12/28/22 comprehensive care plan (CCP) documented the resident had activities of daily living (ADL) deficits. Interventions included bed bath every Tuesday evening shift and one-person physical assistance for activities of daily living. The undated Kiosk (care instructions) documented the resident required physical assistance of 1 for bathing and was to receive a bed bath every Tuesday on the evening shift. The ADL care log documented the resident received a bed bath with extensive assistance of one on Tuesdays 3/7/23, 3/14/23, and 3/21/23. During an interview on 0/22/23 at 9:35 AM Resident #24 stated that they had not had a shower and would like a weekly shower. During an interview on 3/27/23 at 4:59 PM certified nurse aide (CNA) #32 stated that the resident's care information was found in the Kiosk in the electronic medical record (EMR). The CNA stated resident bathing was done per the resident's choice and the resident could ask when they would like a shower. They stated the bathing task showed up in the CNA Kiosk and should be offered three times. CNA #32 stated that the Kiosk for Resident #24 documented a bed bath on Tuesday evenings. They stated the bath sheet (shower list) documented the resident was to be offered a shower every Monday during the day shift. CNA #32 stated that the bathing task for a shower did not come up to be documented on as given or refused as the care card was wrong. During an interview on 3/28/23 at 2:07 PM registered nurse (RN) Unit Manager #7 stated that Community Life usually did rounds and completed a questionnaire for any requests for activities, bathing, food likes, and shopping. RN Unit Manager #7 stated that the residents knew their shower day and a resident could request a shower on any day. RN Unit Manager #7 stated the shower list was updated periodically by the charge nurse and they did not ask preferences prior to putting the resident on the shower list. They stated that if the preference was not communicated by staff the resident may not receive their choice of bathing. RN Unit Manager #7 stated there was no follow up after the admission assessment on a resident's specific bathing preference. They stated that it was important for the resident's choice to be honored. During an interview on 3/28/23 at 2:45 PM with the Assistant Director of Nursing (ADON), they stated that resident preferences were completed by the social worker on admission and quarterly. The ADON stated the admission nurse also asked about preferences for eating as well as bathing to include the type of bathing and time preferences. ADON stated that that the resident care cards are updated with resident choice by nursing. ADON stated that the staff provide care per the care card. They also stated that preferences should be reviewed upon re-admission, quarterly, annually, and with any changes. ADON stated that it important for a resident to have their preference honored. 2) Resident #165 was admitted to the facility with diagnoses including Down Syndrome (a genetic disorder) and neurogenic bladder (lack of bladder control). The 2/17/23 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance of 2 for toileting, transfers, and bed mobility, and had an indwelling urinary catheter (a tube in the bladder that drains urine into a bag). The Comprehensive care plan (CCP) initiated 3/2/23 documented the resident had an indwelling catheter related to a neurogenic bladder. Interventions included to keep the catheter bag below the level of the bladder and away from the entrance door, use a leg strap to secure the catheter tubing safely, and cover the drainage bag with a dignity bag. The undated Kiosk (care instructions) documented the resident was totally dependent on 2 for toileting, had a urinary catheter, and the urinary catheter was to be emptied each shift. The resident was observed: - on 3/21/23 at 11:53 AM and 3/22/23 at 9:23 AM and 3:09 PM lying in bed with their catheter bag on the side of the bed facing the door. The drainage bag was uncovered, contained urine, and was visible from the hall. - on 3/27/23 at 9:53 AM sitting in their wheelchair in the dining room with their catheter drainage bag uncovered, resting under their wheelchair, and visible to other residents, staff, and visitors. During an interview on 3/28/23 at 12:57 PM, certified nurse aide (CNA) #22 stated that resident #165 needed assistance with their catheter care, their catheter bag should be covered for privacy, and it was not dignified to leave it uncovered for others to see. During an interview on 3/28/23 at 1:07 PM licensed practical nurse (LPN) #11 stated Resident #165 required assistance with catheter care. LPN #11 stated anyone could cover the drainage bags and a drainage bag should always be covered for dignity issues. During an interview on 3/28/23 at 1:10 PM registered nurse (RN) #12 stated Resident #165 should have a leg bag (a collection bag attached to the resident's leg and under clothing) when out of bed and should have a privacy bag covering their urinary drainage bag when in bed. It was not dignified if the collection bag was visible. 10NYCRR415.3(c)(l)(i)

Based on observation, record review, and interview during the recertification survey conducted 3/21/23-3/28/23, the facility failed to ensure residents were free of any significant medication errors for 1 of 1 resident (Resident # 250) reviewed. Specifically, Resident #250 had physician orders to receive nothing by mouth (NPO) and had six medications ordered with a route of administration by mouth (PO). Findings include: The facility policy Medication Administration revised 11/2022 documented a registered nurse (RN) or a licensed practical nurse (LPN) must check all residents' orders carefully prior to administering medications. The basic rules of safe administration should be kept in mind and included the right drug, the right resident, the right time, the right dose, and the right route. If there was any doubt about a medication, the nurse should not administer it and should contact the nurse practitioner or physician for clarification and instruction. The facility policy Medication Therapy revised 5/2022 documented medication use should be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments. All decisions related to medications should include appropriate elements of the care process such as each resident's condition and prognosis. The Medical Director and Consultant Pharmacist shall collaborate to address issues of medication prescribing and monitoring with the practitioners and staff. Resident #250 was admitted to the facility with diagnoses including cerebral infarction (stroke), hemiplegia and hemiparesis (paralysis and weakness) affecting the left non-dominant side, and dysphagia (difficulty swallowing). The 10/4/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, was totally dependent for eating (included intake by tube feeding), did not have a swallowing disorder, and had a feeding tube. The 11/14/22 physician order, renewed 3/24/23, documented the resident was NPO (nothing by mouth) and received a tube feeding. The following orders were documented in the electronic medical record (EMR) with a route of administration by mouth: senna plus oral tablet (laxative) 8.6-50 milligram (mg) two tablets by mouth daily; polyethylene glycol (laxative) 3350 oral powder one packet by mouth daily; gabapentin (nerve pain medication) 100 mg, 4 capsules by mouth every day at 8:00 AM, 2:00 PM, and 8:00 PM; Coreg (treats high blood pressure/heart failure) oral tablet 12.5 mg, 1 tablet by mouth every day at 8:00 AM and 8:00 PM); oxycodone (opioid) 5 mg, 1 tablet by mouth at 8:00 AM and 8:00 PM; oxycodone 5 mg, 1 tablet every four hours as needed (prn); and lorazepam (anti-anxiety) 1 mg, 1 tablet by mouth prn. The comprehensive care plan dated 9/28/22 documented the resident received a tube feeding related to potential for aspiration related to dysphagia, was admitted NPO (nothing by mouth), and received all nutrition and medications via a gastrostomy tube (GT, feeding tube). The CCP was revised 3/23/23 with interventions to administer enteral feeding (tube feeding), flush tube with 90 milliliters (ml) fluid before and after medications, and 90 mls with medications (for 3 med passes), and the resident was NPO. The speech language pathologist (SLP) #24 evaluation dated 2/4/23 documented a referral was requested for justification for continued NPO status and tube feeding to meet nutritional needs. Medications intake method was via tube. The SLP recommended continued NPO and tube feeding due to high aspiration risk with PO (by mouth). A pharmacy review by pharmacy consultant #26 dated 12/16/22 documented the resident received medications via tube, however the following orders stated to administer by mouth, Coreg and gabapentin, and clarification was requested. A pharmacy review by pharmacy consultant #26 dated 2/9/23 documented the resident received medications via tube however several orders stated to administer by mouth and clarification was requested. There was no documented evidence the pharmacy consultant's requests for clarification were addressed by the medical provider. During a medication administration observation on 3/27/23 at 2:17 PM, registered nurse (RN) #25 administered all ordered medications via the gastrostomy tube (GT). During an interview with RN #25 on 3/27/23 at 2:30 PM, they stated they determined the route of administration by the physician's order. RN #25 stated the five rights of medication administration were the right route, the right resident, the right medication, the right time, and the right dose and should be done for every resident. They stated that if they saw an order that stated, by mouth and the resident was NPO they would ask for the order to be changed to via GT. RN #25 stated the Resident was NPO and the resident's order for gabapentin had a route of administration of by mouth (PO). They stated that they did not notice route of administration when passing the medication. RN #25 stated that there was a danger of aspiration (getting into the lungs) if a medication was given by mouth and the resident was NPO. The Medication Administration Record (MAR) documented the following medications had a route of administration by mouth and were administered to the resident on 3/27/23: Senna Plus oral tablet 8.6-50 milligram (mg) two tablets by mouth in the morning; polyethylene glycol 3350 oral powder one packet by mouth in the morning, gabapentin cap 100 mg four capsules by mouth every day at 8:00 AM, 2:00 PM, and 8:00 PM; Coreg 12.5 mg every day at 8:00 AM and 8:00 PM; oxycodone 5 mg by mouth at times 8:00 AM and 8:00 PM: and lorazepam (anti-anxiety) 1 mg by mouth as needed limit twice daily. During an interview on 3/28/23 at 1:46 PM LPN #27 stated that the route of administration was determined by the physician's order which was on the MAR. They stated that the five rights of medication administration were to check the dose, the order, the resident's name band, the route, and the time. They stated that these should be checked for every resident prior to every medication pass. LPN #27 stated that medications should not be given via GT if the order documented by mouth even if the nurse was aware the resident was NPO. LPN #27 stated they should call the provider to clarify the order. During an interview on 3/28/23 at 1:19 PM RN Unit Manager #28 stated that the medication nurses knew the route of administration by the physician's orders. They stated if an order documented the medication's route of administration was by mouth and the resident was NPO, the nurse should call the provider to clarify the order prior to administering any medications. RN #28 stated that the resident would be at risk for aspiration if they were given medications by mouth. RN #28 stated that it was a medication error if the order documented to administer a medication by mouth and the medication was given via GT. They stated that physician's orders were sometimes entered by the provider and would populate the MAR. For a verbal order, two nurses must sign off on the order for it to become active. RN #28 stated that the pharmacy recommendations go to their task bar in the EMR for review and they had not seen the pharmacy recommendations from December 2022 and February 2023. During an interview on 3/28/23 at 10:40 AM pharmacy consultant #26 stated when they reviewed orders for a resident on a tube feeding, they verified that all orders documented via GT instead of by mouth. They stated that all pharmacy recommendations were entered directly into the electronic medical record (EMR) which notified the provider and nursing staff in real time. They stated their recommendations must be responded to within 60 days by either the nursing staff or the provider. They stated that if the recommendation had not been responded to by the next month, they would send out a reminder to administration, and if the recommendation had not been responded to by the end of the second month, they would send out a second request recommendation. They stated when they made the recommendation for the order clarification of by mouth orders, they assumed it was an error in entering the order. They stated that their recommendation from December 2022 for order clarification for by mouth orders was not responded to or complete which is why the recommendation was repeated in February 2023. During an interview on 3/28/23 at 2:01 PM SLP #24 stated the resident was NPO and their medications must be administered through the resident's GT. They stated that receiving oral nutrition or medication when NPO puts the resident at risk for aspiration, choking, or death. During an interview on 3/28/23 at 1:32 PM nurse practitioner (NP) #29 stated they provided verbal orders to the staff and did not directly enter any orders. NP #29 stated that they did not give a route of administration when providing verbal orders to the nursing staff, but they would confirm the order in the EMR once it was entered and verified by two nurses. The NP stated the resident was NPO, and all their medications should be given via GT. They stated that if the route of administration on an order was by mouth, then the order was incorrect. If the order stated, the route of administration was by mouth and was given via GT it was a medication error. 10NYCRR 415.12(m)(2)

Based on observation, interview, and record review during the recertification survey conducted 3/21/23-3/28/23, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and included the expiration date when applicable for 2 of 6 medication carts (Units 4-A and 4-B) and 2 of 4 medication storage rooms (Units 2-A and 4-A) observed. Specifically, Units 2-A, 4-A, and 4-B had expired resident specific medications, stock medications and biologicals in the medication carts, medication room and/or the medication room refrigerators. The facility policy Insulin Administration via a Pen reviewed/revised 4/2019 documented pharmacy assigned a 28 day expiration date on all insulin pen delivery devices once removed from the refrigerator. Insulin pens were for single resident use only. The facility policy Storage of Medications reviewed/revised 9/2019 documented outdated medications were to be immediately removed from inventory and disposed of. The facility policy Vials and Ampules of Injectable Medications revised 8/2020 documented opening a vial triggered a shortened expiration date. The date opened and triggered expiration date were to be recorded on multi-dose vials. At a minimum, the opened date must be recorded. Multi-dose vials were to be discarded 28 days after opening. The reviewed/revised 7/2021 Discontinued Medications facility policy documented the nurse receiving the discontinue order was responsible for recording the information and notifying the pharmacy of the discontinuation. Discontinued medications must be destroyed or returned to the pharmacy. During a Unit 4-B medication cart storage observation on 3/22/23 at 2:24 PM with licensed practical nurse (LPN) #4, the following medications were in the top drawer of the medication cart and were expired: - an opened stock bottle of Vitamin D (vitamin supplement) 25 micrograms (mcg) with a manufacturer's expiration date of 2/2023; - an opened stock bottle of zinc (mineral supplement) 50 mg with a manufacturer's expiration date of 11/2022; - Resident #24's Lispro (insulin) pen with no opened date; - Resident #13's glargine (insulin) vial and Toujeo (insulin) with no opened dates; - Resident #265's Lispro opened vial that had a handwritten opened date of 1/31; - Resident #167's Aspart (insulin) opened vial with no opened date; and - an opened vial of Levemir (insulin) with no opened date. When interviewed, the LPN stated that the zinc was being given to the COVID-19 positive residents on the unit. The LPN stated expired medications may not be as potent or as effective. Insulin was to be dated when opened as it was only good for 28 days once opened. They stated the nurse opening the insulin should date it, and each nurse should check the opened date when administering the medication to ensure it was not expired. During a Unit 4-A North medication storage observation on 3/22/23 at 2:30 PM with LPN #5, the second drawer of the medication cart contained the following expired resident specific blister medication packs: - for Resident #47's Vitamin D-2 50,000 units containing 2 capsules with a pharmacy use by date of 7/6/22; ibuprofen (nonsteroidal anti-inflammatory, NSAID) 400 milligrams (mg) 1 tablet with a pharmacy use by date of 5/25/22, and atorvastatin (cholesterol reducer) 40 mg, 24 tablets with a pharmacy use by date of 1/6/23; and - for Resident #53 1 card of Clonidine HCL (blood pressure medication) 0.2 mg, 30 tablets with a pharmacy use by date of 3/5/23; 1 card of Clonidine HCL 0.2 mg, 30 tablets with a pharmacy use by date of 2/4/23; and a card of ondansetron (treats nausea) 4 mg, 10 tablets with a pharmacy use by date of 3/20/23. When interviewed on 3/22/23 at 2:35 PM, LPN #5 stated the medications for Residents #47 and 53 were discontinued, should have been removed from the cart, and discarded. The LPN was not sure why they were not. During a Unit 4-A medication room storage observation on 3/22/23 at 3:00 PM with LPN #5, there was a box of Renacidin (irrigation solution) 30 milliliter (ml) vials, the box was opened and had a manufacturer's expiration date of 2/10/23. When interviewed, the LPN stated the solution was used to irrigate Foley (indwelling urinary) catheters. The LPN stated they should have been discarded prior to the expiration date. During a Unit 2-A medication room storage observation on 3/22/23 at 3:38 PM with LPN #6 the medication room refrigerator contained an opened Afluria (influenza vaccine) vial with a handwritten opened date of 12/7. LPN #6 stated they assumed the vial was opened on 12/7/22 and opened vials were good for only 30 days. The vial should have been discarded. During an interview on 3/22/23 at 3:15 PM, registered nurse (RN) Unit Manager #7 stated medication expiration dates should be checked by all medication nurses prior to administering the medication and weekly by the Unit Manager. Expired medications may not work to their full potency. Insulin was good for 28 days after opening the pen or vial, and an opened date should be written on the pen or vial when they were opened. There would be no way to tell if the medication was expired if there was no opened date on it. All nurses received education on medications during orientation. During an interview on 3/22/23 at 3:44 PM, the Assistant Director of Nursing (ADON) #3 stated the medication nurse should date the vial when opening it as the medication was only good for 30 days once opened. Insulin was good for 28 days once opened. Discontinued medications should be removed from the medication carts by the nurse discontinuing the medication. Each unit's night shift nurse was responsible for checking the medication rooms and carts weekly for expired or discontinued medications. Those checks were not documented. Medications were to be discarded a day prior to expiration (if there was a specific date) and by the last day prior to the expiration date (if only month and year date). The medication room refrigerators were to be checked nightly by the night shift nurse and the Unit Manager was to check them every other day. Each medication nurse should check the expiration date prior to administering each medication. When interviewed on 3/28/23 at 2:22 PM, the Director of Nursing (DON) stated resident specific medications should be discarded the month prior to the expiration date and the use by date was considered the expiration date. Each medication nurse should check the expiration date prior to giving a medication. The unit night shift nurse was supposed to check both resident specific and stock medications in the medication carts, medication rooms, and medication refrigerators on a weekly basis. Unit managers were also supposed to check the medication carts, medication rooms, and medication refrigerators on their unit weekly. Stock medications should be discarded by the end of the month prior to the expiration date. Open vials were good for 30 days once opened the nurse who opened it should write an opened date on the vial or box. 10 NYCRR 415.18 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview during the recertification and abbreviated (NY00308658, NY00311004, and NY00298919) surveys conducted 3/12/23-3/16/23, the facility failed to provide a safe, clean, comfortable, and homelike environment for 15 resident rooms (resident rooms 520, 505, 504, 448, 432, 430, 425, 406, 405, 403, 361, 359, 346, 260, and 248); 10 resident common areas (fifth floor north hall shower room, fifth floor hall near the 5A emergency exit stairwell, fifth floor north hall bathroom, fourth floor north shower room, fourth floor north dining room, third floor south shower room, third floor south dining room, second floor hall near resident room [ROOM NUMBER], and second floor south training bathroom); and 1 resident device (resident chair in fifth floor hall). Specifically, resident rooms 520, 505, 504, 448, 432, 430, 425, 406, 405, 403, 361, 359, 346, 260, and 248; fifth floor north hall shower room, fifth floor hall near the 5A emergency exit stairwell, fifth floor north hall bathroom, fourth floor north shower room, fourth floor north dining room, third floor south shower room, third floor south dining room, second floor hall near resident room [ROOM NUMBER], second floor south training bathroom; and a resident chair in the fifth floor hall were unclean or in disrepair. Findings include: The Maintenance Department QA Weekly Status Report submitted by the Director of Housekeeping and Laundry on 3/10/23 and 3/17/23, documented that work orders were reviewed weekly. The following observations were made on the Fifth Floor: - on 3/21/23 at 10:14 AM and 3/22/23 at 3:49 PM, an unused chair in the hallway had ripped arms and torn cushions at the end of the arms. - on 3/21/23 at 10:23 AM and 3/22/23 at 3:53 PM, the north shower room had an unknown black substance on the wall by the tub; and a soap container and debris in the shower tub. - on 3/21/23 at 10:48 AM and 3/22/23 at 3:36 PM, the bathroom in resident room [ROOM NUMBER] had unclean/stained walls by the toilet and the raised toilet seat was soiled with an unknown material. - on 3/21/23 at 10:52 AM and 3/22/23 at 3:30 PM, the floor in resident room [ROOM NUMBER] had black marks on the floor tiles. - on 3/21/23 at 11:25 AM, the ceiling in the hall near the 5A stairwell door was unclean with a black substance and had an unsealed penetration. - on 3/21/23 at 11:35 AM, the north hall resident bathroom toilet had broken plastic grab bars on both sides and had no call bell cord. - on 3/23/23 at 10:23 AM, the bathroom in resident room [ROOM NUMBER] had a loose metal bracket sink countertop extender. The following observations were made on the Fourth Floor: - on 3/21/23 at 12:10 PM, there was a black substance on the north shower room wall behind the shower head and on the white caulk around the tiles - on 3/21/23 at 12:25 PM, resident room [ROOM NUMBER] had a damaged section of wall behind the window side bed. - on 3/21/23 at 11:42 AM and on 3/22/23 at 11:37 AM, the concrete ceiling in resident room [ROOM NUMBER] had stains and peeling paint. - on 3/21/23 at 2:30 PM and on 3/22/23 at 11:42 AM, resident room [ROOM NUMBER] had wallpaper peeling along a seam to right of the window and above the window. - on 3/21/23 at 3:06 PM and on 3/22/23 at 11:53 AM, the concrete section of the ceiling in resident room [ROOM NUMBER] was water stained. There was a box of seal wrap, a plastic bottle of mustard, and an individual serving size cracker container on the ground behind the B resident and C resident mini-refrigerators. - on 3/22/23 at 12:16 PM, two of the north dining room walls were damaged at the height level of wheelchairs. - on 3/22/23 at 4:20 PM, the wall by the window in resident room [ROOM NUMBER] was discolored and stained. The wall behind Resident 430 B bed had glue stains. - on 3/22/23 at 4:29 PM, resident room [ROOM NUMBER] had a three foot section of peeling wallpaper over the window. - on 3/23/23 at 10:44 AM, resident room [ROOM NUMBER] had a hole in the wall behind the resident bed. The following observations were made on the Third Floor: - on 3/21/23 at 10:29 AM and on 3/22/23 at 4:33 PM, the bathroom sink faucet in resident room [ROOM NUMBER] was loose and the plastic light cover over the sink was broken. - on 3/21/23 at 10:56 AM and on 3/22/23 at 10:49 AM, the concrete ceiling in resident room [ROOM NUMBER] was cracked and the bathroom toilet was loose. - on 3/21/23 at 11:08 AM and on 3/23/23 at 10:53 AM, resident room [ROOM NUMBER] had a broken light over the bed that was wrapped with duct tape. - on 3/21/23 at 1:00 PM, the south resident shower room had debris (curtain poles, a razor, a wall hook, etc.) on the floor behind and around the toilet. The inside of the shower area tub was unclean. - on 3/21/23 at 1:12 PM, all four of the south dining room walls were scratched and damaged. The following observations were made on the Second Floor: - on 3/21/23 at 2:00 PM, there was a stained ceiling tile in the hallway near resident room [ROOM NUMBER]. - on 3/21/23 at 2:05 PM, the south training bathroom had a loose toilet. - on 3/23/23 at 4:12 PM, resident room [ROOM NUMBER] had non-skid strip remnants on floor near the A side bed and it did not look homelike. - on 3/23/23 at 4:16 PM, the toilet in resident room [ROOM NUMBER] ran continuously and multiple walls were scraped in the resident room. The following observation was made on the First Floor: - on 3/23/23 at 10:21 AM, the north side elevator wall had an approximate 2 inch hole under the elevator up and down buttons. During an interview on 3/27/23 at 2:00 PM, the Housekeeping and Laundry Director stated that the housekeeping department was responsible for disinfecting resident rooms, bathrooms, shower rooms, hallways, and other surfaces within the facility. They stated that the resident shower rooms were cleaned daily and was not aware of the black substance on the walls in the 5th floor north and the 4A north shower rooms, and the miscellaneous debris on the floor in the 3B south shower room. The Housekeeping and Laundry Director stated that they were not aware of the loose toilets in the 2B south training bathroom and in resident room [ROOM NUMBER], the loose sink faucet in resident room [ROOM NUMBER] bathroom, or of the unclean walls and ceilings in the facility bathrooms. They stated they were not aware that the chair located in the hallway was damaged with exposed foam in the arms. The arms of the chair could not be disinfected if there was exposed foam, and a work order should have been made for the maintenance department to replace arms. The Housekeeping and Laundry Director stated that they were not aware of the food items found behind the mini-fridges in resident room [ROOM NUMBER], and that moving furniture was part of the cleaning process for the housekeeping staff. They stated that if an issue was seen, a work order should be made, directed to the right department (maintenance department, housekeeping department, etc.), and that all staff could enter information into the facility work order system. During an interview on 3/27/23 at 2:22 PM, the Maintenance Director stated that they were not aware of any of the observed floor, wall, and ceiling concerns. They stated they expected all staff to report loose and damaged sinks and toilets, as water could quickly spread. The Maintenance Director stated when a resident was discharged from the facility, maintenance staff would go their room and check to see if there were any hidden items of concern. They stated they were not sure when the floor in resident room [ROOM NUMBER] had last been stripped and waxed. The stripping and waxing task was completed by the Housekeeping Director. The Maintenance Director stated that all staff were able to submit work orders, and there were no work orders for these concerns. They stated during the weekly tours of the facility the walls, floors, ceiling tiles and other resident areas were checked, but was not documented on the facility comprehensive work order system. The Maintenance Director stated the facility did not have an official maintenance procedure and policy for the weekly tour of the facility. 10 NYCRR 415.29(j)(1)

Based on observation, record review and interview during the recertification and abbreviated (NY00304704) surveys conducted 3/21/23-3/28/23, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 staff members (certified nurse aide {CNA} #32, licensed practical nurse {LPN} #33, unit helper #34, and dietary supervisor #38 observed and for 1 of 7 residents (Resident #197) reviewed. Specifically, CNA #32 was not wearing a N95 mask as required, and LPN #33, unit helper #34, and dietary supervisor #38 were not wearing N95 masks correctly on a unit with COVID-19 positive residents; and infection control standards during wound care for Resident #197 were not maintained. Findings include: The facility policy Donning and Duffing of Personal Protective Equipment-COVID-19 reviewed/revised 11/2022 documented prior to working with COVID-19 residents, all employees must have received documented training and have demonstrated competency in donning/duffing proper PPE (personal protective equipment). PPE must be donned correctly in proper order before entry into the resident care area. N95 masks may be kept on, unless soiled. To put on N95 mask secure elastic bands at the middle of the head and neck, fit flexible band around the nose bridge, and fit snug to face and below the chin. The facility policy COVID-19 Action Plan revised 3/17/23 documented COVID-19 spreads when an infected person breathes out droplets and very small particles that contain the virus. These droplets could be breathed in by other people or land on their eyes, noses, or mouth. Symptoms may appear 2-14 days after exposure to the virus. Follow all recommended infection control prevention practices, including wearing well-fitting source control (including N95 mask). The safest approach was for everyone, regardless of vaccination status, to wear a face covering or mask while in communal areas of the facility. Health care providers must be medically cleared, trained, and fit tested for N95 use. The facility policy Aseptic Dressing Change revised 9/2018 documented to assemble the supplies and equipment as needed, and date and initial all jars and bottles upon opening. Adjust bedside stand to waist level, clean bedside stand, and establish a clean field. Place the clean equipment on the bedside stand. Disposable items such as bandages and applicators that are soiled must be placed in a plastic bag and removed from the room upon completion of the procedure. Put on clean gloves, cleanse the wound, remove, and dispose of gloves, wash, and dry hands thoroughly, put on clean gloves, apply the ordered treatment, discard disposable items, remove gloves, and wash and dry hands thoroughly. 1) During an observation on 3/22/23 at 3:14 PM, CNA #32 was observed wearing only a surgical mask on Unit 4-A, which was had COVID-19 positive residents on the unit. The CNA was not wearing a N95 mask. During an observation on 3/22/23 at 3:20 PM on Unit 2-A with COVID-19 positive residents, LPN #33 was standing at the nursing station with a surgical mask over a N95 mask. The elastic straps from the N95 mask were hanging free in front of their face and were not wrapped around the back of the head. The surgical mask was holding the N95 mask in place. The N95 mask did not form a proper seal against the face. Unit helper #34 was wearing a surgical mask directly against their face, a N95 over the surgical mask, and another surgical mask over the N95. The N95 mask did not have a proper seal against unit helper #34's face. During an interview on 3/22/23 at 3:22 PM, unit helper #34 stated they wore the surgical mask under the N95 mask to make it more comfortable. The unit helper stated the purpose of the N95 mask was to filter out more germs and to protect the wearer. The unit helper stated they were not fit tested (a test protocol conducted to verify that a N95 mask is both comfortable and provides protection including ensuring a proper seal). The unit helper stated LPN #35 showed them how to wear the masks to make them more comfortable. During an interview on 3/22/23 at 3:28 PM, LPN #33 stated they floated floor to floor and their last COVID-19 education was about 4 months ago That education included PPE and N95 mask wearing. The N95 was the best mask for protection against COVID-19. They stated they were not fit tested for the N95 and was not provided with instruction on how to put on a N95 mask. The LPN stated the straps of the N95 should be behind the head and tight to the face to ensure germs did not pass through the mask and the fit test was used to ensure the mask fit tightly against the face. LPN #33 stated staff were supposed to always wear a N95 inside the building and were allowed to wear a surgical mask over it. The N95 mask was to be changed every 4 hours and staff were able to get one from a box on the unit. The LPN stated they had a hard time breathing with the mask tight against their face, which is why the straps were hanging from the front and not around their head. They stated they wore a surgical mask over the N95 to keep the N95 up. When interviewed on 3/24/23 at 10:12 AM, LPN #35 stated staff were supposed to wear the N95 mask with the straps behind their head and neck, with a surgical mask over the N95. There was supposed to be a good seal between the face and the N95 to block out the COVID-19 germs. The LPN stated they had never told the unit helper to wear a surgical mask under the N95 to make it more comfortable. When interviewed on 3/24/23 at 9:03 AM, the registered nurse (RN) Infection Preventionist (IP) stated the facility infection control policies were reviewed at least once monthly during quality assurance and performance improvement (QAPI) meetings. Staff were expected to wear a N95 mask against the face and covered with a surgical mask on a unit that had COVID-19 positive residents. A KN95 mask was not an alternative to a N95 mask. PPE was stationed throughout each unit and could also be obtained from central supply. The N95 mask was to be worn with a good seal against the face, the straps should be around the back of the head and neck to ensure extra filtration by not allowing the airborne germs to seep around or get through the mask. Wearing the straps in front of the face or wearing a surgical mask under the N95 mask did not ensure a good seal. The IP stated inappropriate mask wearing could increase the chances of staff contracting COVID-19. PPE and mask audits were to be performed by the Unit Managers or Supervisor at the beginning and end of each shift. COVID-19 and infection control education were done by the facility each time there was a new COVID-19 outbreak in the facility and education had been provided with the most recent outbreak. The Unit Managers, the facility education department, and the IP provided education on mask wearing to those staff not in compliance. During an interview on 3/24/23 at 10:54 AM, the Assistant Director of Nursing (ADON) #3 stated that if over 8-10% of the unit census was COVID-19 positive, then the unit was closed off and staff were required to always wear a N95 mask on that unit. Unit 2-A had 42 residents currently on the unit and had been a closed unit since there were over 8% of residents that were COVID-19 positive. Staff on Unit 2-A were required to wear a N95 mask while on the unit. Education for N95 wear was done during orientation and via poster boards and quizzes during the entire month of March 2023 and was tracked via sign-in sheets in the auditorium. LPN #33 was an agency nurse and received education on masking during orientation to the facility. Unit helper #34 should have received education during facility orientation. The ADON expected staff to wear N95 masks covering their nose and mouth with a proper seal, one strap over the crown of the head, and one strap behind the neck and should not wear a surgical mask between their face and N95 mask. This would not allow for a proper seal which could allow droplet germs between the mask and the face. When interviewed on 3/24/23 at 2:25 PM, RN Educator #37 stated the facility taught PPE/COVID/IC education during orientation, which included the sequence of putting on and taking off PPE. Staff fit testing for N95s started about a month ago and was done by the Director of Respiratory Therapy. The RN educator expected N95 masks to be worn by staff on Units 2-A, 2-B, 4-A and 4-B at all times. The RN Educator stated they performed trainings during shift changes and off shifts. The N95 mask was to be worn over the mouth and nose, the straps behind the neck and crown, and have a tight seal to prevent bacteria from going through or around the N95 mask. During an observation on 3/24/23 at 1:01 PM, dietary supervisor #38 exited the elevator on Unit 2-A, retrieved a meal tray cart from down the hall, returned to the elevator and brought the cart onto the elevator. The dietary supervisor was wearing a surgical mask against their face and a N95 mask over the surgical mask. When interviewed on 3/24/23 at 1:46 PM, dietary supervisor #38 stated they received PPE and mask wear education in 1/2023. The supervisor stated that during PPE and mask wear education, they were taught to wear either a surgical mask or N95 mask but not both at same time. The supervisor stated they were not aware their masks were reversed. 2) Resident #197 was admitted to the facility with diagnoses including a right lower leg open wound and cellulitis (skin infection) of the left lower leg. The 3/10/23 Minimum Data Set (MDS) assessment documented the resident had intact cognition, a Stage 3 (full thickness tissue loss) pressure ulcer, 1 venous or arterial ulcer, and received application of nonsurgical dressings. The 2/23/23 comprehensive care plan (CCP) documented the resident was at risk for infection due to a wound and had open wounds on the right and left lower legs. Interventions included observe for signs and symptoms of infection, provide nutritional needs to promote healing, and maintain infection control. On 3/21/23 at 3:16 PM, a cardboard box with wound care supplies was observed on the Resident #197's room floor by the room heater. On 3/23/23 at 10:57 AM a wound care treatment was observed for Resident #197's bilateral lower legs with licensed practical nurse (LPN) #39. Dressing supplies including alginate dressings, 4 X 4 gauze, and gauze wrap were removed by LPN #39 from the cardboard box sitting on the floor in front of the room heater. A bottle of acetic acid without an opened date was on the floor next to the cardboard box (this was not used for the observed treatment). LPN #39 opened supplies and laid them on the resident's bed linen using the packaging as barriers and placed bandage scissors on the linen at the foot of the resident's bed. The LPN removed the old, saturated dressing from the right lower leg with gloved hands. The LPN removed the gloves and put on a new pair of gloves without performing hand hygiene. The Aquacel silver (alginate dressing) was trimmed to size using the bandage scissors that were on the bed. The rest of the treatment was completed, the LPN removed their gloves and washed their hands using soap and water. The unused dressing supplies were then placed back into the cardboard box on the floor. When interviewed after the completion of the treatment, LPN #39 stated the acetic acid was used for cleaning the wound 3 days a week and took about 2 weeks to use the contents of the bottle. They stated they did not need to use the acetic acid during the observed treatment. The LPN stated the scissors were disinfected before they entered the room, and they should have been placed on a clean barrier and not the bed linen. The box of supplies and acetic acid should not have been placed on the bare floor as the floor was considered a dirty surface. Glove changes were not a substitute for hand hygiene and hand hygiene should be performed with each glove change to prevent spreading germs. When interviewed on 3/23/23 at 11:43 AM, registered nurse (RN) Manager #7 stated the resident received wound care at least twice daily, the wound care supplies were stored in a box on the floor in the resident room, and the box should not be kept there due to the possibility of mold or bacteria growth on the box and supplies. They should be kept on the treatment cart or in a drawer in the room. A barrier should be used to place supplies and scissors on to prevent cross-contamination of germs. Hand hygiene should be performed between glove changes to prevent the spread of infection. When interviewed on 3/23/23 at 12:03 PM, Wound Care RN #40 stated wound care supplies should be stored in the treatment cart and removed when the treatment was done. The RN did not notice the box of supplies on the floor in the resident's room. The box should not be kept on the floor as the box could get wet, promote bacteria growth, and was an infection control risk. Bottles of wound cleansing solution should not be kept on the floor as it could be an infection control risk due to spread of dirty substances from the floor. Scissors should not be placed on bed linen as germs could be transferred from the bed to the scissors and then into the wound. Scissors should be placed on a barrier. Hand hygiene was to be performed between gloves changes to prevent cross-contamination of germs. Just changing gloves was not an alternative to hand hygiene. 10 NYCRR 415.19(a)(b)

Based on observation, interview, and record review during the recertification survey, the facility did not ensure residents had the right to a safe, clean, comfortable and homelike environment for 1 of 5 residents reviewed. Specifically, Resident #34's room contained a clock that was not functioning, and 2 outdated calendars were hung on the wall for 4 days of survey. Findings include: The facility's Quality of Life/Homelike Environment policy updated 1/2/20 documents: - Residents are provided with a safe, clean, homelike environment and encouraged to use their personal belongings to the extent possible. - Staff shall provide person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. Resident #34 had diagnoses including alcohol dependence with alcohol induced persisting dementia, abnormal gait and mobility, and need for assistance with personal care. The 6/24/20 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, no behavioral symptoms, required extensive assistance of one person for dressing and hygiene and it was very important to choose their own bedtime. The comprehensive care plan (CCP) updated 9/23/20 documented the resident had low participation in activity programs, was pleasant and socialized with staff. Interventions included placing a calendar in the resident's room, providing activity tools for independent activity, allowing the resident to choose programs to attend, and placing on a room visit schedule. During an observation on 9/28/20 at 12:22 PM in the resident's room, a clock was hung over the top part of a wall calendar on the wall opposite the resident's bed. The resident sat on the bed facing the direction of the clock and calendar eating lunch. The clock read 5:30 and the second hand was not moving. The calendar hung beneath the clock was on August 2019. A calendar on the other wall across from the resident's bed (in the resident's view if lying down) was on July 2018. The resident asked what day and time it was and pointed to their watch, asking if it was correct. The watch hands were on 9:00 and the second hand was not moving. The clock, calendars, and watched remained set on the incorrect times, month, and year when observed on 9/29/20 at 11:27 AM, 9/30/20 at 12:17 PM, and on 10/1/20 at 11:56 AM. During an interview on 10/1/20 at 12:03 PM, certified nurse aide (CNA) #4 stated the resident preferred to remain in their room, kept the door closed, and was confused at times. The resident was aware of days and times and often asked staff what the time or day was, as the resident liked to keep track of how long they had been at the facility. The resident wore a watch daily and if a battery was needed, nursing would obtain one from maintenance. The CNA had not noticed the incorrect calendar or clock on the wall and stated that anyone providing care should ensure they were correct. The CNA had not provided care recently and could not recall seeing the clock, watch, or calendars. She stated having a correct watch, clock, or calendar were important to residents to help orient them, especially when they often remained in their rooms. When interviewed on 10/1/20 at 12:20 PM, social worker #7 stated she was not aware of who should be checking clocks and calendars in resident rooms. It was important for residents to have correct clocks and calendars to ensure they were oriented to time and place. She stated the BIMS (Brief Interview for Mental Status) assessment was based on orientation to the day and year. Residents also could become confused as to mealtime or preferred activities if the calendar and clock were incorrect. During an interview with the Activities Director on 10/1/20 at 12:40 PM, she stated activity aide #5 was assigned to the resident's unit and saw the resident at least 2 times per day. She instructed all activities staff to note clocks and calendars in rooms and expected any wrong ones to be corrected or removed. The exception would be if the resident preferred an outdated calendar because of the pictures. She did not think Resident #34 had such a preference and stated his calendar and clock should be current and set to the right time. When interviewed on 10/2/20 at 11:23 AM, activities aide #5 stated he saw Resident #34 daily in their room where the resident preferred to remain. He had not noticed the incorrect clock or calendars and stated he didn't really think about things like that. He stated he thought it would be important for residents to know the correct day and time,4 so they did not get confused. 10NYCRR 415.5(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey, the facility did not develop and implement a comprehensive person-centered care plan that includes services that are to be furnished to attain or maintain the resident's highest practicable physical well-being for 1 of 3 (Resident #127) residents reviewed. Specifically, Resident #127 was care planned to have an Ethics Committee review related to treatment options and the committee did not meet to review the resident. Findings include: The facility Ethics Committee Policy and Procedure revised 1/2020, stated it is the policy of the facility to have an established interdisciplinary body that provides guidance and assistance, on a consultant basis, to residents, families and healthcare providers in making decisions related to life threatening medical decisions. Resident #127 had diagnoses including multiple myeloma not having achieved remission, traumatic subdural hemorrhage (brain bleed) and vascular dementia. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had severe cognitive impairment and required extensive assistance with activities of daily living. Medical Orders for Life Sustaining Treatment (MOLST) initiated 2/6/18 documented the resident had orders to Do Not Resuscitate (DNR, do not perform chest compressions if the heart stops beating) and included a verbal consent from the resident's son. The MOLST form did not include orders for treatment (comfort measures, limited medical interventions or no limitations on medical interventions). The form was last reviewed by the physician on 8/9/20. An incapacity determination documentation form dated 2/6/2018 documented the resident was indefinitely incapacitated due to delirium secondary to CVA (cerebral vascular accident, stroke). The form was signed by the attending physician on 2/6/18 and a concurring physician on 3/28/18. A hospital Discharge summary dated [DATE] documented the resident's CAT scan (computerized axial tomography, medical image) showed multiple lesions on the spine and pelvic bones with a differential diagnosis of multiple myeloma (a type of blood cancer), or osseous metastatic disease (cancer in the bone that had spread). The recommendation was for primary care follow up and workup of the lesions to determine the future course of treatment. The nurse practitioner (NP) readmission note dated 3/18/20 documented the resident only had a son who was not the resident's health care proxy (HCP) but the only family member. The son had not been able to be reached for months even with a certified letter. Ethics Committee was pending to consider the resident's plan of care given advanced age, comorbidities and frailty. Depending on Ethics Committee, the plan was to consider pursuing work up for multiple myeloma which would include blood work and possibly a consult with hematology/oncology. This would not be ordered pending the Ethics Committee recommendations. The NP discussed this with the social worker and pending any further aggressive or invasive workup or intervention and Ethics Committee, she recommended it be set up as soon as possible. Physician orders dated 7/6/20 documented an Ethics Committee consult ASAP (as soon as possible). This had been requested multiple times and the social worker was aware this needs to be done. During an interview on 10/1/20 at 2:54 PM with the Director of Social Work #15 she stated the Ethics Committee would meet, review information and decide on further care-planning and that typically the Ethics Committee would meet within one week of the request. She stated that the social worker would be responsible for setting up the meeting. She stated the team would be difficult to get together with the pandemic, but a virtual meeting could have been set up. She stated 6 months was too long to wait to set up a meeting that was requested in March. She stated the purpose of having the Ethics Committee meet for Resident #127 was because no family was involved, and the resident was not capable of making medical decisions. It had been difficult to contact the family member. There had been multiple calls and a registered letter had been sent with no response. The MOLST completed in 2018 was for a DNR but did not address additional directives including treatment, antibiotic use, tube feedings and hospitalizations. She stated the NP had spoken with her and requested a meeting be scheduled, she did not document the conversation but she added to the care plan that a meeting of the Ethics Committee was requested. She was not sure why she did not follow up on the request. During an interview with the former Administrator on 10/2/20 at 11:06 AM he stated the process for initiating an ethics meeting would begin when someone submitted a written request. The committee would convene usually within a week or two. The meetings were set up when needed and did not occur at a regular scheduled frequency. The ethics committee met in April 2020 to discuss future health care planning for two other residents that did not have family or a health care proxy. He stated he was not made aware a meeting had been requested for resident #127. The request for a meeting regarding resident #127 was not followed up on and had not been addressed. He stated it was not acceptable for 6 months to pass after an ethics meeting was requested. 10NYCRR 415.11(c)(1)

Based on observation, record review and interview during the recertification survey, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 (Resident # 212) reviewed. Specifically, Resident #212 had an order for sliding scale insulin before meals (amount of insulin given depends on blood glucose level), the resident was observed not eating a meal after insulin was administered and there was no documented evidence the nurse was aware of the resident's intake to observe for signs and symptoms of hypoglycemia (low blood glucose). Findings include: The facility policy Mealtime Guidelines revised 2/2020 documented all residents will be encouraged to feed themselves. If they are unable to do so, assistance will be provided as needed. Staff will make frequent rounds on the unit to monitor residents eating in their rooms. Meal consumption will be documented on the Hydration/Nutrition Output Log. Any change in appetite, refusing to eat or poor intake will be reported to the nurse for follow up. Resident #212 had diagnoses including Type 2 diabetes with hypoglycemia, dysphagia (difficulty swallowing), adult failure to thrive and legal blindness. The 9/4/20 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, required supervision with assistance of one for eating and received insulin injections. The 8/28/20 hospital admission history and physical documented the resident had a worsening alteration in mental status (AMS) and in route to the emergency department had a fingerstick glucose of 35 milligrams/deciliter (mg/dl) (normal 80-130 mg/dl). The comprehensive care plan (CCP) dated 9/2/20 documented the resident had diabetes and interventions included monitor closely for signs and symptoms of insulin shock and diabetic coma, provide diet per physician order, administer medications as ordered and fingerstick blood sugars as ordered with insulin coverage. The resident required supervision and encouragement at meals. The undated intervention form care plans (care instructions) documented the resident required supervision and encouragement at meals and the resident was legally blind. The eating assistance comment documented the resident needed to be fed. Physician orders dated 9/3/20 documented a diet of no concentrated sweets with mechanical soft consistency. Hypoglycemia protocol; initiate protocol if blood sugar is less than 60 mg/dl. Physician orders dated 9/11/20 documented metformin (an oral diabetes medication) 500 milligrams (mg) every day at 8:00 AM and 8:00 PM for diabetes. A nurse practitioner progress note dated 9/11/20 documented the resident was on Novolin insulin and fingersticks had been ranging 66-260 mg/dl. The resident had a blood glucose level of 22 on lab draw and nursing reported a fingerstick was taken with a result within normal limits. The plan was to stop insulin and switch to metformin 500 mg twice daily and continue to check blood sugars twice daily. Physician orders dated 9/23/20 documented Lantus (long-acting) insulin 10 units subcutaneously every day at 8:00 AM Physician orders dated 9/24/20 documented fingersticks every day at 8:00 AM, 12:00 PM, 5:00 PM and 8:00 PM with Novolog insulin (fast-acting insulin) sliding scale for fingerstick results of 151-200 give 2 units; 201-250 4 units; 251-300 5 units; 301-350 6 units; 351-400 8 units; 400 10 units; result 400 contact physician. Medication administration records documented on 9/30/20 the following fingersticks and insulin coverage; -at 8:00 AM the resident's fingerstick was 224 mg/dl and 4 units of Novolog insulin and 10 units of Lantus insulin were administered; -at 12:00 PM the resident's fingerstick was 231 mg/dl and 4 units of Novolog insulin was administered. During an observation on 9/30/20 at 12:17 PM Resident #212 was observed lying in bed, naked, calling out. A lunch tray was observed on the overbed table next to the bed. None of the items on the tray had been opened or consumed. At 12:19 PM an unidentified staff (wearing personal protective equipment including a gown, a surgical mask and a face shield) entered the resident's room and exited with an uneaten lunch tray and proceeded to place the tray in the cart holding other consumed lunch trays. At 12:26 PM the cart was removed from the unit. At 12:28 PM the resident remained in their bed naked and the tray on the overbed table was gone. Between 12:19 PM and 12:28 PM no staff were observed entering the resident's room. The eating/fluid report dated 9/30/20 documented the resident consumed 51-75% of the breakfast meal with supervision and setup help only. There was no documented evidence the resident consumed lunch or dinner. There was no documentation nursing was aware the resident had not consumed lunch after receiving insulin. During an interview with certified nursing assistant (CNA) #8 on 10/2/20 at 9:31 AM she stated she was assigned to Resident #212 on 9/30/20 and the other CNA was assigned to the hallway on the other side. There were only 2 CNAs assigned to the B unit. The resident was unable to feed them self and was blind. The resident did not like to eat but the CNA would encourage the resident to eat. She stated she would never just leave a tray in a room as the nurses would get on me if she did that. She stated she might leave a tray and then come back to feed the resident. If she went to collect trays and noticed the resident had not eaten anything, she would have helped the resident eat and would not just take the tray away. She stated she thought she fed the resident lunch on 9/30/20. She stated she would enter the amount the resident consumed in the computer after lunch and did not know why there was no lunch documented on 9/30/20. During an interview with CNA #10 on 10/2/20 at 10:06 PM she stated Resident #212 needed to be fed but she had not fed the resident as they were not on her assignment and she would not chart on the resident either. She stated if she went to collect a tray and the resident had not eaten, she would ask the resident if they wanted to eat, heat the food in the microwave and feed the resident. She would never take a tray from a resident without asking and had not removed Resident #212's lunch tray on 9/30/20. During an interview with graduate practical nurse (GPN) #11 on 10/2/20 at 10:12 AM she stated Resident #212 required feeding by staff and she would expect staff to be in the room to try to get the resident to eat. If the resident did not eat, she would expect the CNA to let her know because the resident was diabetic. The resident's meal consumption should be documented by the CNA or whoever fed them. She stated if a resident received insulin and did not eat their blood sugar could bottom out. Resident #212 had received insulin before lunch on 9/30/20 and if the resident did not eat, she would like to know so she could monitor the resident for hypoglycemia and take a fingerstick in a half hour or so. She did not know Resident #212 had not eaten lunch on 9/30/20. During an interview on 10/2/20 at 10:21 AM registered nurse (RN) #12 Unit Manager stated if a resident was totally dependent for feeding staff would feed them after passing all the trays. She stated Resident #212 required assistance with meals. She would expect intakes be documented for all residents at all meals. Whoever had delivered the tray to the resident would be responsible to ensure they were assisted. If the resident was sleepy, they should cover the tray and go back later. If the resident had not eaten when the tray was picked up the staff member should have asked the resident if they wanted to eat and document in the chart even if they had refused. The resident had received 4 units of insulin at 11:34 AM on 9/30/20 and should have been monitored for signs and symptoms of hypoglycemia if they did not eat. 10NYCRR 415.12

Based on observation, interview and record review during the recertification survey, the facility did not ensure a resident with limited range of motion (ROM) receives appropriate treatment and services to prevent further decrease in range of motion for 1 of 3 (Resident #179) residents reviewed. Specifically, Resident #179 had contractures of both hands and was observed without bilateral palm grips as care planned. Findings include: The facility policy Splint: Use, Care and Cleaning revised 2/2020 documented fabricated splints will be fabricated and monitored by the Therapy Department for application schedules and continued use. Nursing staff will ensure appropriate use and care of the splints under the direction of the therapy department. Application and removal of splints will be the responsibility of nursing staff. Special instruction for splint application and wearing times will be included on the resident care plan, and use will be documented accordingly on the resident treatment record. Splint use will be reflected on the profile care card and on the TAR (treatment administration record) and care plan. Resident #179 had diagnoses including quadriplegia (loss of movement in all 4 limbs), cerebral palsy and chronic respiratory failure with tracheostomy status. The 8/12/20 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, was dependent for all activities of daily living (ADLs) and had functional limitation in ROM for all 4 extremities. The rehab devices order dated 2/1/20 documented bilateral palm grip every day and night shift on at all times with exception of off for hygiene and skin checks every shift. The comprehensive care plan dated 2/13/20 documented the resident had a problem of ADL functioning and approaches included bilateral palm grips. Special information interventions from care plans included bilateral palm grips every day, remove only for hygiene and skin checks. The current care instructions for Resident #179 did not include instructions for placement of palm grips. The resident was observed in bed with severely contracted hands and without palm grips in place at the following times: -on 9/28/20 at 12:00 PM; -on 9/29/20 at 10:35 AM; -on 9/30/20 at 11:29 AM; -on 10/1/20 at 8:41 AM; and -on 10/2/20 at 9:51 AM. During an interview with certified nursing assistant (CNA) #9 on 10/2/20 at 9:43 AM she stated she was the CNA who worked on the vent unit where the resident resided. She stated she had not worked on the unit in 6 months and had just started back on the unit. She stated if a resident had an order for any type of special device it would be in the Kiosk and the CNA would be responsible for making sure the device was in place. She had provided care for Resident #179 that morning and had not seen instructions for palm grips. She stated the resident had hand contractures, she had cleaned the resident's hands during care and had not placed any devices after performing care. She could not recall if the resident had palm grips when she had cared for the resident months ago. During an interview with registered nurse (RN) #12 Unit Manager on 10/2/20 at 10:21 AM she stated Resident #179 had hand contractures and she was not sure if the resident required palm grips. She stated there was nothing on the care card for palm grips but there were instructions in the care plan for palm grips. If the care plan included palm grips, then the resident should have them. She was unsure why the resident did not have them in place. During an interview on 10/2/20 at 11:05 AM with physical therapist (PT) #13 Director of Rehabilitation, he stated when occupational therapy last saw the resident the resident's functional level had not changed and the resident had upper extremity contractures. When reviewing the medical record, he stated at that time palm grips were recommended for the resident to avoid worsening of the contractures, but the order had been discontinued for some reason and should not have been. He stated the resident went to the hospital and it looked like the order for the palm grips was discontinued at that time along with all the facility orders. The palm grips were not reordered when the resident returned from the hospital and should have been. At 12:37 PM PT #13 stated he had just returned from assessing the resident and the resident still required the palm grips. He brought the resident new splints and informed nursing and therapy staff. 10NYCRR 415.12 (e)(2)

Based on observation, record review, and interview during the recertification survey the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 of 4 (Resident #212) residents reviewed. Specifically, Resident #212 was not provided with needed meal assistance and had a significant weight loss. Findings include: The facility policy Weight Protocol revised 4/2019 documented any weight gain or loss of 5 pounds or more since the previous weight will trigger a reweighing within 72 hours for confirmation and will be communicated to the dietitian/diet tech. The facility policy Mealtime Guidelines revised 2/2020 documented all residents will be encouraged to feed themselves. If they are unable to do so, assistance will be provided as needed. Staff will make frequent rounds on the unit to monitor residents eating in their rooms. Meal consumption will be documented on the Hydration/Nutrition Output Log. Any change in appetite, refusing to eat or poor intake will be reported to the nurse for follow up. Resident #212 had diagnoses including Type 2 diabetes with hypoglycemia, dysphagia (difficulty swallowing), adult failure to thrive and legal blindness. The 9/4/20 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, required supervision with assistance of one for eating, had a swallowing disorder and a significant weight loss. The undated intervention form care plans (care instructions) documented the resident required supervision and encouragement at meals and the resident was legally blind. The eating assistance comment documented the resident needed to be fed. An 8/10/20 nutrition note documented the resident weighed 199.6 pounds (lb) on 8/7/20. Meal intakes averaged 75% based on available documentation. A 9/2/20 head to toe nursing readmission assessment documented the resident's weight prior to admission was 181 pounds, the resident required extensive assistance with eating, had a decrease in appetite and weight loss. A 9/3/20 physician order documented the resident was to receive a no concentrated sweets diet with mechanical soft consistency and be weighed weekly. A 9/3/20 nurse practitioner (NP) progress note documented the resident had been hospitalized 8/28-9/2/20 for sepsis. The hospital discharge summary documented the resident had a significant decline in mental status given poor nutritional status. A 9/9/20 nutrition progress note documented the resident weighed 184.5 lbs and weight had stabilized over the past 4 weeks after previous 15 lb weight loss since August. Meal intakes averaged 67%. The resident was receiving fortified potatoes in place of regular and in place of rice and an HS (hour of sleep) salad sandwich with 4 ounces of milk. The plan was to increase milk to 8 ounces with meals to help meet protein and fluid. A 9/23/20 nutrition note documented a consult was received due to low albumin. Weight was 184.5 lbs on 9/17/20 and had stabilized over the past 4 weeks. Meal intakes averaged 67%. The Eating/Fluid Report from 9/2-9/30/20 documented: -1 meal consumed per day for 16 days; -2 meals consumed per day for 4 days; -3 meals consumed per day for 3 days; -No meals consumed for 7 days. Multiple meals on multiple days did not have consumption documented. The Weight Report documented the following weights: 8/12/20 199.6 pounds (lb); 8/19/20 187 lb; 8/26/20 181.4 lb; 9/2/20 178.2 lb; 9/10/20 182.2 lb; 9/17/20 184.5 lb; 9/30/20 185.9 lb; During an observation on 9/30/20 at 12:17 PM Resident #212 was observed lying in bed, naked, calling out. A lunch tray was observed on the overbed table next to the bed. None of the items on the tray had been opened or consumed. At 12:19 PM an unidentified staff (wearing personal protective equipment including a gown, a surgical mask and a face shield) entered the resident's room and exited with an uneaten lunch tray and proceeded to place the tray in the cart holding other consumed lunch trays. At 12:26 PM the cart was removed from the unit. At 12:28 PM the resident remained in their bed naked and the tray on the overbed table was gone. Between 12:19 PM and 12:28 PM no staff were observed entering the resident's room. The Eating/Fluid report dated 9/30/20 documented the resident consumed 51-75% of the breakfast meal with supervision and setup help only. There was no documented evidence the resident consumed lunch or dinner On 10/2/20 a weight was requested by the surveyor. The resulting weight was 172.6 lbs at 10:12 AM. A second reweigh was requested with a verbally reported result of 176 lbs. During an interview with certified nursing assistant (CNA) #8 on 10/2/20 at 9:31 AM she stated she was assigned to Resident #212 on 9/30/20 and the other CNA was assigned to the hallway on the other side. There were only 2 CNAs assigned to the B unit. The resident was unable to feed them self and was blind. The resident did not like to eat but the CNA would encourage the resident to eat. She stated she would never just leave a tray in a room as the nurses would get on me if she did that. She stated she might leave a tray and then come back to feed the resident. If she went to collect trays and noticed the resident had not eaten anything, she would have helped the resident eat and would not just take the tray away. She stated she thought she fed the resident lunch on 9/30/20. She stated she would enter the amount the resident consumed in the computer after lunch and did not know why there was no lunch documented on 9/30/20. During an interview with CNA #10 on 10/2/20 at 10:06 PM she stated Resident #212 needed to be fed but she had not fed the resident as they were not on her assignment and she would not chart on the resident either. She stated if she went to collect a tray and the resident had not eaten, she would ask the resident if they wanted to eat, heat the food in the microwave and feed the resident. She would never take a tray from a resident without asking and had not removed Resident #212's lunch tray on 9/30/20. During an interview with graduate practical nurse (GPN) #11 on 10/2/20 at 10:12 AM she stated Resident #212 required feeding by staff and she would expect staff to be in the room to try to get the resident to eat. The resident was not a good eater and she stated she did not think the resident ever refused to eat. If the resident did not eat, she would expect the CNA to let her know because the resident was diabetic. The resident's meal consumption should be documented by the CNA or whoever fed them. She did not know Resident #212 had not eaten lunch on 9/30/20. During an interview on 10/2/20 at 10:21 AM registered nurse (RN) #12 Unit Manager stated if a resident was totally dependent for feeding staff would feed them after passing all the trays. She stated Resident #212 required assistance with meals. She would expect intakes be documented for all residents at all meals. Whoever had delivered the tray to the resident would be responsible to ensure they were assisted. If the resident was sleepy, they should cover the tray and go back later. If the resident had not eaten when the tray was picked up the staff member should have asked the resident if they wanted to eat and document in the chart even if they had refused. She stated the resident had just been weighed today and was 172.6 lbs. Upon request, she stated she would get a reweigh because there was no explanation for the resident's weight loss. She stated today's weight was wrong. If intake is not documented it does not mean they did not eat, staff just didn't write it down. She would expect staff to document all consumption. During an interview on 10/02/20 at 11:28 AM registered dietitian (RD) #14 stated the resident required feeding by staff. The resident received fortified potatoes in place of rice, and she added a sandwich at night with 4 oz milk and 8 oz milk at meals. The resident was on nutrition watch. She stated she had not heard that the resident was refusing meals or had a poor intake. The resident should not have a tray left at the bedside because the resident needs to be fed. When a resident has a weight loss, she would assess weekly weights on Wednesday and let them know if any reweights were needed. She stated when completing an assessment, she would base it on what intakes were available, if intakes were missing it would not be an accurate reflection of the resident's actual intake. 10 NYCRR 415.12(i)(1)(j)