**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY00383127) the facility did not ensure that all alleged violations involving abuse and mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to other officials (including to the State Survey Agency) for four (4) (Resident #1, #2, #3, and #4) of four (4) residents reviewed. Specifically, allegations of resident abuse were not reported within 2 hours to the New York State Department of Health and law enforcement agencies. The finding is: The policy and procedure titled Abuse dated 6/2024 documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients by anyone including but not limited to staff, family, friends, and residents of the facility. The Administrator and Director of Nursing are responsible for investigation and reporting. Report to the local law enforcement and appropriate State Agency(s) immediately (no later than two (2) hours after allegation/identification of allegation) by the Agency's designated process after identification of alleged/suspected incident. The local law enforcement authorities are to be notified of any instance of resident: abuse, exploitation, mistreatment, neglect, involuntary seclusion or misappropriation of personal property which is a criminal act. Resident #1 had diagnoses including generalized anxiety disorder, major depressive disorder, and selective mutism (a mental health condition where an individual was unable to speak in certain situations due to fear or anxiety). The Social Service Assessment and Documentation dated 5/23/25 documented Resident #1 was usually understood, usually understands and had moderate cognitive impairment. Resident #2 had diagnoses including morbid obesity, chronic kidney disease and hypothyroidism. The Minimum Data Set (a resident assessment tool) dated 4/1/2025 documented Resident #2 was always understood, always understands and was cognitively intact. Resident #3 had diagnoses including encephalopathy (a disease in which the functioning of the brain was affected), polyneuropathy (a disease process involving a number of nerves), and anemia. The Minimum Data Set, dated [DATE] documented Resident #3 was always understood, always understands and had severe cognitive impairment. Resident #4 had diagnoses including cerebral infarction (stroke), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body). The Minimum Data Set, dated [DATE] documented Resident #4 was usually understood, usually understands and had severe cognitive impairment. Review of the New York State Complaints/Incidents Tracking System Investigative Report received on 6/10/25 at 10:52 AM revealed photographs that were posted on social media sites by Certified Nurse Aide #1, as well as a text message that was sent to the Administrator. The photographs attached to the report revealed heavily soiled, incontinent residents in various stages of undress, with their buttocks and genitalia exposed. The social media post indicated the post was publicly shared 825 times. The report documented that the incident was not submitted by the facility. Review of the facility investigation dated 6/11/25 revealed on 6/9/25 social media posts alleged that Resident #1, Resident #2, and Resident #3 did not receive care on 5/25/25 to 5/26/25. The social media posts also showed photographs of facility residents in various states of care. The facility investigation documented the incident was reported to the Buffalo Police Department on 6/12/25, to the State Agency on 6/12/25 and the Office of Professions on 6/12/25. During a telephone interview on 6/12/25 at 9:00 AM, Certified Nurse Aide #1 stated they were a mandated reporter, and they were following the chain of command by reporting to the facility first. They stated they felt filing a complaint with the New York State Department of Health would not help so, they posted the pictures on social media sites of the facility and residents. The pictures had people in them but there were no faces, names or identification, so HIPAA (Health Insurance Portability and Accountability Act) was not broken. The pictures showed that the residents were laying in feces and the linens needed to be changed. Certified Nurse Aide #1 stated because there were no resident faces in any of the pictures there would be no issues related to HIPAA or dignity. During an interview on 6/12/25 at 9:42 AM, Certified Nurse Aide #2 stated the pictures posted on social media contained residents' exposed backside, including their buttocks. Certified Nurse Aide #2 stated Resident #4 was in one of the pictures that was shared on social media. During an interview on 6/12/25 at 9:48 AM, Certified Nurse Aide #3 stated they saw the social media post and Resident #4 was pictured in the post. They stated they knew it was Resident #4 because after taking care of someone so often, they were just able to tell it was Resident #4. During an interview on 6/12/25 at 1:25 PM, the Administrator stated they were aware within an hour of the post on social media that included allegations against the facility as well as pictures of residents laying in their beds. They began an investigation immediately but did not think about the possibility of abuse at the time. Allegations of suspected abuse should be reported within two (2) hours to the State Agency. Further interview at 3:30 PM, the Administrator stated they had not notified the State Agency or the local law enforcement agency at that time. During an observation and interview on 6/12/25 at 3:27 PM, the Director of Nursing was at their computer in their office and the Administrator was on their cell phone. The Administrator stated the Director of Nursing was filing an incident with the State Agency and they were on the phone with the Local Police Department. During an interview on 6/18/25 at 9:00 AM, Social Worker #1 stated if they were to see pictures of undressed residents including their buttocks and genitalia posted on social media, they would report it to the abuse coordinator immediately and file a report against the person who made the post. They stated that was something that could be humiliating and degrading for the residents involved. During an interview on 6/18/25 at 11:10 AM, the Director of Nursing stated the types of abuse include verbal, financial, sexual, physical, mental/emotional and neglect. An example of mental/emotional abuse would include making a resident feel humiliation shame, or embarrassment. The Director of Nursing stated that the social media incident was reported immediately after the recertification team brought it to their attention and questioned if it was abuse. Reporting allegations of suspected abuse was completed by the Director of Nursing, Administrator or Assistant Director of Nursing and should be reported to mitigate and maintain resident safety. Everyone in the facility has the responsibility to ensure the safety of the residents. During an interview on 6/18/25 at 11:35 AM, the Administrator stated the day that the incident happened was on 6/9/25, the incident was not seen as suspected abuse but was viewed a dignity concern and was investigated as a dignity concern. Any suspected abuse should be reported within two (2) hours to the State Agency. The incident on 6/9/25 was reported to the State Agency on 6/12/25. During an interview on 6/18/25 at 11:55 AM, the Director of Clinical Operations stated they expected the Director of Nursing or Administrator to report suspected abuse to the State Agency within two (2) hours. They stated that because the pictures that were posted on social media certainly could be humiliating and degrading, the incident should have been reported to the State Agency. 10NYCRR 415.4 (b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint investigation (#NY00383127), the facility did not ensure that all alleged violations of abuse and neglect were thoroughly investigated for four (4) (Resident #1, #2, #3, #4) of four (4) residents reviewed. Specifically, there was a lack of employee and resident interviews and statements to rule out abuse regarding a post on social media containing allegations against the facility and pictures of residents in the state of undress. The finding is: The policy and procedure titled Abuse dated 6/2024 documented allegations/reports of suspected abuse, neglect, mistreatment, distortion, injury of unknown etiology or misappropriation shall be promptly and thoroughly investigated by facility management. The Administrator and Director of Nursing are responsible for investigation and reporting. Initiate the investigative process. The investigation should be thorough with witness statements from staff, residents, visitors and family members who may be interview able and have information regarding the allegation. The policy and procedure titled Investigations, How to Conduct dated 11/2019 documented the aim is to complete the investigation as soon as possible from the day of the incident. The investigator conducts interviews in the following order: The resident(s) involved, obtain a statement (if possible) about what occurred from the resident and complete appropriate nursing assessments. Locate and arrange interviews with the people involved in, or who may have witnessed the incident (i.e. the person who found the resident/patient or to whom the incident was first reported, people who were near the incident scene, the staff member responsible for the care of the resident or patient, the nurse responsible for the unit. This may involve going back 24 hours and interviewing staff on previous shifts (or greater than 24 hours if alleged incident occurred earlier). Witnesses should be interviewed separately, and all provide written statements whenever possible. Collect information (evidence) that is related to the facts and circumstances of the incident being investigated. The information should include who, what, when, where, how and why. Resident #1 had diagnoses including generalized anxiety disorder, major depressive disorder, and selective mutism (a mental health condition where an individual was unable to speak in certain situations due to fear or anxiety). The Social Service Assessment and Documentation dated 5/23/25 documented Resident #1 was usually understood, usually understands and had moderate cognitive impairment. Resident #2 had diagnoses including morbid obesity, chronic kidney disease and hypothyroidism (thyroid disease). The Minimum Data Set (a resident assessment tool) dated 4/1/2025 documented Resident #2 was always understood, always understands and was cognitively intact. Resident #3 had diagnoses including encephalopathy (a disease in which the functioning of the brain was affected), polyneuropathy (a disease process involving a number of nerves), and anemia. The Minimum Data Set, dated [DATE] documented Resident #3 was always understood, always understands and had severe cognitive impairment. Resident #4 had diagnoses including cerebral infarction (stroke), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body). The Minimum Data Set, dated [DATE] documented Resident #4 was usually understood, usually understands and had severe cognitive impairment. Review of the Complaints/Incidents Tracking System Investigative Report received on 6/10/25 at 10:52 AM revealed photographs were posted on social media sites by Certified Nurse Aide #1, as well as a text message that was sent to the Administrator. The photographs attached to the report revealed heavily soiled, incontinent residents in various stages of undress, with their buttocks and genitalia exposed. The social media post indicated the post was publicly shared 825 times. The facility investigation dated 6/11/25 documented on 6/9/25 social media posts alleged that Resident #1, Resident #2, and Resident #3 did not receive care on 5/25/25 to 5/26/25. The social media posts also showed photographs of facility residents in various states of care. Multiple staff (more than ten (10)) reported the social media posts to the Administrator. The investigation included attestations of attempts to contact Certified Nurse Aide #1 for a witness statement, resident dignity interview worksheets, nursing progress notes, Certified Nurse Aide care documentation, and five (5) Certified Nurse Aide witness statements regarding care completed on 5/25/25. The investigation lacked staff witness statements regarding the social media post on 6/9/25. The investigation did not include Resident #4. Review of the Resident Dignity Interview Worksheets dated 6/9/25-6/12/25 documented residents were asked if staff treated them with kindness, spoke to them respectfully, knocked prior to entering their room, listened to them, provided personal care in private, if their belongings and space were treated with care, if they felt comfortable speaking up when something was wrong, and if they felt safe and well cared for. Resident #1 answered yes to all questions and signed the worksheet. There were no follow up notes documented. Resident #2 answered that Certified Nurse Aides sometimes treat them with kindness and that they did not feel safe or well cared for. Under the notes section it was documented care concerns - night shift without any further details. There were no further follow-up notes on the worksheet for Resident #2. Resident #3 answered all of the questions with yes with the exception that sometimes they were not sure staff were listening. There was no follow-up notes documented for Resident #3. There were no specific questions regarding concerns of abuse, use of cell phones, staff taking pictures, or social media on the worksheet. There was no Resident Dignity Interview Worksheet completed for Resident #4. Review of Resident #4's interdisciplinary progress notes dated 6/1/25-6/16/25 lacked documented evidence that Resident #4 or their responsible party was interviewed regarding the social media investigation. Review of the facility staffing sheet dated 5/25/25 documented during the 7 AM-3 PM shift, seven (7) Certified Nurse Aides, three (3) Licensed Practical Nurses, and one (1) Registered Nurse worked on Unit Two (2). During the 3 PM-11 PM shift, six (6) Certified Nurse Aides, three (3) Licensed Practical Nurses and one (1) Registered Nurse Supervisor worked on Unit Two (2). During the 11 PM-7 AM shift, three (3) Certified Nurse Aides and three (3) Licensed Practical Nurses worked on Unit Two (2). Review of the facility staffing sheet dated 6/9/25 documented during the 7 AM-3 PM shift four (4) Certified Nurse Aides, two (2) Licensed Practical Nurses, two (2) Registered Nurses, and two (2) Unit Managers worked on Unit Two (2). During the 3 PM-11 PM shift, seven (7) Certified Nurse Aides and three (3) Licensed Practical Nurses worked on Unit Two (2). During the 11 PM-7 AM shift one (1) Certified Nurse Aide, two (2) Licensed Practical Nurses, and one (1) Licensed Practical Nurse Supervisor worked on Unit Two (2). During an interview on 6/12/25 at 1:25 PM, the Administrator stated within an hour of the social media post, about eight (8) staff members in the facility had gone to their office to inform them of the social media post. There were other staff members that had texted or called them. The social media post had occurred on 6/9/25 around 3:00 PM and it was a former employee who was posting the pictures on social media and posting that they were from the facility. The Administrator stated at the time that the staff notified them of the social media post, they immediately started investigating by obtaining Certified Nurse Aide documentation and statements. The Director of Nursing had the investigation, and it was ongoing. The Administrator stated they did not ask the staff if they were able to identify the residents in the post because it was inappropriate and would feel uncomfortable with it. They stated they did not think of the pictures and social media post to be a form of abuse. During a telephone interview on 6/12/25 at 4:00 PM, Resident #4's Responsible Party stated they never received a phone call from the facility regarding pictures posted on social media. During an interview on 6/18/25 at 9:00 AM, Social Worker #1 stated they completed dignity rounds for all residents on Unit Two (2). During the dignity rounds they would go to each resident ask them if they felt comfortable or if they had any concerns with the facility. They used the Resident Dignity Interview Worksheet to complete the dignity rounds and only asked the questions that were on the worksheet. Social Worker #1 stated they had not personally asked any of the residents on the unit if they were ok with their pictures being taken or if they would be ok with their pictures being posted online. They stated they were not aware that the social media post on 6/9/25 contained any resident pictures. Any pictures taken of residents, even if it was just their face, consent needed to be obtained from the resident. They stated that they did not interview any of the families about their feelings at the facility or regarding any social media posts. During an interview on 6/18/25 at 11:10 AM, the Director of Nursing stated the investigation was focused on dignity because it was a dignity concern and not abuse. That included the social workers completing dignity rounds, reviewing Certified Nurse Aide documentation to see if residents received care, and nurses completed skin checks. The Director of Nursing stated they believed they received witness statements from all the Certified Nurse Aides they needed to because they looked at the assignment sheets and had the Certified Nurse Aides who were responsible for care of Resident #1, Resident #2, and Resident #3 on 5/25/25 write statements. The Director of Nursing stated they talked to other staff members about the social media post but never had them write any statements because she had a cheat sheet of who she talked to. When the Director of Nursing was asked what the conversation was between them and their staff regarding the cheat sheet no answer was given. The DON stated the statements from the staff were verbal and the incident was a dignity issue. During an interview on 6/18/25 at 11:35 AM, the Administrator stated because they did not know who the residents were in the pictures or when the pictures were taken, the investigation was general. Social work spoke with residents themselves and asked if there were any negative interactions with staff or if they felt cared for. The Director of Social Work was the one who reached out to the families and Social Worker #1 completed the Resident Dignity Interview Worksheet. They had looked for any previous grievances regarding resident care but were unable to find any grievances; they relied on the Social Workers' dignity audits. The Certified Nurse Aide Witness statements that were obtained were staff that had worked on the unit through various shifts and since the residents pictured could not be identified, they did not interview all of the Certified Nurse Aides on the unit. The Administrator stated they did not feel it would have been appropriate to interview all of the staff on the unit. They stated they had questioned the staff who had reported the social media post if they were able to identify the residents and they were unable to. The Administrator stated without specific identifiers, the incident was investigated the best they could and as a dignity and respect issue. During an interview on 6/18/25 at 11:55 AM, the Director of Clinical Operations stated their expectation was for the investigation to be done objectively and a full sweep of the unit should have been completed. They stated they thought that the Director of Nursing had spoken to everyone on the unit because they had a cheat sheet that they were working off of. The investigation to rule out abuse should have been started when the Administrator and Director of Nursing became aware of the social media post. During an interview on 6/18/25 at 12:30 PM, the Director of Social Work stated their part of the investigation was assisting in completing dignity rounds with the Resident Dignity Interview Worksheet. If a resident was unable to complete the worksheet, then the responsible party should have been called and it would have been documented in the progress notes. 10 NYCRR 415.4(b)(3)

Based on observation, interview, and record review conducted during an Abbreviated Partial Extended survey (Complaint #NY00383127) the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws and regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and the governing body is responsible and accountable for the Quality Assurance and Performance Improvement program. Specifically, the administration did not ensure implementation of abuse policies and recognize abuse when Certified Nurse Aide #1 took personal photographs of heavily soiled incontinent residents in various stages of undress without their consent, including some with their buttocks and genitalia exposed. The photographs were posted on social media along with text messages and descriptions of the lack of resident care. The findings are:REFER TO: F 600 - Free from Abuse and Neglect F 609 - Reporting Alleged ViolationsF 610 - Investigate/Prevent/Correct Alleged ViolationThe policy and procedure titled Abuse, dated 6/2024, documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients by anyone. The facility prohibits any exploitation of the mentally and physically disabled residents in the facility. Mental/emotional abuse is the use of verbal and/or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Mental abuse includes abuse that is facilitated or enabled using technology (smart phones, other personal electronic devices and cameras) that demeans or humiliates the resident, regardless of whether the resident provided consent or the resident's cognitive status. The policy and procedure titled Photography - Still and Video, dated 2/2020, documented in order to ensure resident privacy, to provide optimal resident care, and to foster mutual respect between and among the residents, family and staff, the facility will ban audio or visual recordings of resident encounters, activity of daily living (ADL) assistance, care or procedures by residents, visitors and staff, unless specifically allowed by the applicable procedures or required by state law. The policy and procedure titled Cell Phone Use, dated 10/2019, documented to maintain privacy and confidentiality rights of our residents; to be in compliance with Health Insurance Portability and Accountability Act (HIPAA), use of cellular telephones or any other electronic device is prohibited in resident areas. Protected Health Information should never be stored, shared or accessed on a personal device. Inappropriate use of a cellular device by an employee includes, but is not limited to, photographing or videorecording residents and sharing HIPAA (Health Insurance Portability and Accountability Act) protected information via unsecured networks. Review of a Counseling Memo dated 5/7/25 documented the Director of Nursing was provided counseling that all incidents must be thoroughly investigated to rule out abuse and all investigations must include factual data including witness statements and resident interviews to reach a reason able conclusion. The Counseling Memo was signed by the Director of Nursing. The Director of Clinical Operations signed as the instructor. During an interview on 6/12/25 at 1:25 PM, the Administrator stated they were aware within an hour of the post on social media that included allegations against the facility as well as pictures of residents laying in their beds. They began an investigation immediately but did not think about the possibility of abuse at the time, only dignity. During a telephone interview on 6/17/2025 at 10:14 AM, the Medical Director stated the facility was the residents' home and even though their physical safety was not affected, their mental safety was intruded on. During an interview on 6/18/25 at 11:10 AM, the Director of Nursing stated the incident that occurred was investigated focused on dignity because it was a dignity concern and not abuse. The Director of Nursing stated an example of mental/emotional abuse would include making a resident feel humiliation shame, or embarrassment. During an interview on 6/18/25 at 11:35 AM, the Administrator stated the day that the incident happened on 6/9/25, the incident was not seen as suspected abuse but was viewed a dignity concern and was investigated as a dignity concern. Any suspected abuse should be reported within two (2) hours to the State Agency. The incident on 6/9/25 was reported to the State Agency on 6/12/25. During an interview on 6/18/2025 at 9:00 AM, Social Worker #1 stated the pictures in the social media post were potentially humiliating and degrading for the residents involved. During an interview on 6/18/25 at 11:55 AM, the Director of Clinical Operations stated the pictures that were posted on social media certainly could be humiliating and degrading, the incident should have been reported to the State Agency.10 NYCRR 415.26

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on [DATE], the facility did not ensure that each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two (2) (Resident #20, #47) of six (6) reviewed for dignity. Specifically, flies were observed were observed crawling on the residents' (faces, arms, legs) and their bed linens. The finding is: The policy and procedure titled Quality of Life/Dignity last revised 5/2024 documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Your Rights as A Nursing Home Resident in New York State dated 2022 documented as a resident in this facility, you have rights guaranteed to you by state and federal laws. This facility is required to protect and promote your rights. Your rights strongly emphasize individual dignity and self-determination, promoting your independence and enhancing your quality of life. You have a right to be valued as an individual, to be treated with consideration, dignity and respect in full recognition of your self-worth. You have the right to a comfortable living environment. 1. Resident #20 had diagnoses including dementia, depression and diabetes. The Minimum Data Set (a resident assessment tool) dated [DATE] documented that Resident #20 had severe cognitive impairment, was sometimes understood and usually understands. The undated comprehensive care plan documented Resident #20 had impaired cognition, was able to answer yes and no questions and able to make their needs known. In addition, the comprehensive care plan documented bladder and bowel incontinence related to physical limitations. The Kardex Report (guide used by staff to provide care) with an as of date of [DATE] documented Resident #20 required the assistance of two staff for care related to physical limitations. During intermittent observations and interviews from [DATE] through [DATE] and from [DATE] through [DATE] between the hours of 8:30 AM to 3:00 PM the following was observed: -[DATE] at 8:48 AM three flies were crawling on Resident #20's bare arms, face, and sheets while they slept. Multiple flies were buzzing/flying about the room. Resident #20's roommate stated there was a fly issue and staff swatted and killed them. At 8:50 AM, Resident #20 swatted a fly as it landed on their right eye lid. Resident #20 shook their head yes when asked if the flies made them feel uncomfortable and were bothersome. During a telephone interview on [DATE] at 10:15 AM, Resident #20's family member stated the resident would have a problem with flies all over the room, and on their skin. Anyone would be uncomfortable with flies crawling on them, and deserved respect as this was their home. -[DATE] at 10:43 AM with Licensed Practical Nurse #5 present seven visible flies were counted in Resident #20's room. Five flies were crawling on the bed sheets as Resident #20 slept and two flies were on clean towels that were on the night stand next to the bed. Licensed Practical Nurse #5 stated it was undignified. Resident #20 was helpless and incapable of swatting the flies. -[DATE] at 11:37 AM Certified Nurse Aide #7 stated maintenance was aware of the fly problem and they would not want flies crawling on them while they slept. It would be uncomfortable, and stated it was a dignity concern. -[DATE] at 1:02 PM Resident #20 was seated in their Geri recliner in the dining room. In Resident #20's room three flies were crawling on their bed. -[DATE] at 11:35 AM in the presence of Housekeeper #2 there were five flies buzzing/flying around Resident #20's bare arms and face while they slept and they had their mouth open. Housekeeper #2 stated the flies could land in Resident #20's mouth while they slept. The flies were disgusting, dirty and gross and would not want that to be their parent lying there. Resident #20 deserved respect and this was undignified. Housekeeper #2 stated they notified maintenance a few weeks ago. They stated they frequently cleaned Resident #20's mattress, mopped the floor and under the bed but it was ineffective. -On [DATE] at 11:36 AM in the presence of the Maintenance Director five flies were crawling on Resident #20's arms and face as they were asleep in bed. The Maintenance Director stated they would not want to have flies crawling on them while they slept and the resident should not have too either, and stated it was undignified. -[DATE] at 11:44 AM in the presence of the Administrator Resident #20 was asleep in bed and the Administrator stated there were flies on Resident #20. They had a right to a clean and homelike environment. The number of flies crawling on Resident #20 was not a dignity concern, just not homelike. The Administrator believed the source of the flies were from a room across the hall and maintenance had been addressing the fly problem. During a telephone interview on [DATE] at 9:54 AM, Licensed Practical Nurse #6 stated flies were gross and potentially contributed to the risk of infection and spread bacteria. Licensed Practical Nurse #6 stated they felt discouraged and that Resident #20 should be able to sleep comfortably and have a good quality of life. During a telephone interview on [DATE] at 10:29 AM, the Medical Director stated during their visit with Resident #20 on [DATE] they had noticed increased fly activity. The facility should provide a healthy environment. There were flies everywhere and this was disrespectful toward Resident #20 and all the other residents in the facility. 2. Resident #47 had diagnoses including encephalopathy (disorder/disease of the brain), right femur fracture (thigh bone break), and non-Hodgkin lymphoma (form of cancer). The Minimum Data Set, dated [DATE] documented Resident #47 had severe cognitive impairment, was usually understood and usually understands. During intermittent observations from [DATE] through [DATE] between the hours of 7:46 AM to 12:27 PM Resident #47 was in bed and the following was observed: -[DATE] at 11:53 AM-12:08 PM multiple flies were buzzing/flying around the room, and 3-4 flies had landed on their bare arms and bed sheets. -[DATE] at 9:28 AM two flies landed/crawled on Resident #47's exposed right lower leg skin tear that had dried drainage present. -[DATE] at 9:37 AM multiple flies were buzzing/flying around the room and 3-4 flies landed/crawled on Resident #47's bare arms and bed sheets. -[DATE] at 7:46 AM and 11:59 AM Resident #47 was deceased and had multiple flies crawling on their bed sheets and two flies landed on the residents face near their mouth. During an interview on [DATE] at 11:59 AM, Resident #47's family member stated there had been flies present in Resident #47's room for a while and Resident #47 did not like them in their room. Resident #47's family member stated the flies were attracted to the uncleanliness and the fecal incontinence odor present. They stated no one should have to be around that. During an interview on [DATE] at 10:00 AM, Certified Nurse Aide #12 stated there were always flies in residents' rooms and there should not be. They stated flies were disgusting and unsanitary. Additionally, they stated maintenance was aware of fly issue on the second floor. During an interview on [DATE] at 10:38 AM, Housekeeper #1 stated flies carry bacteria, were not sanitary and should not be present in resident rooms. They stated they had reported concerns with flies on the second floor to the Housekeeping Director. During an interview on [DATE] at 10:48 AM, the Assistant Director of Nursing/Infection Preventionist stated flies should not be in resident care areas as they could spread bacteria. During an interview on [DATE] at 11:03 AM, the Director of Nursing stated flies were a concern for cleanliness. Residents had the right to be comfortable and stated they could not agree it was undignified, but it was unsanitary. 10NYCRR 415.3 (2)(f)(ii)

Based on observation, interview, and record review conducted during a Standard survey completed on 6/17/25, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (1) (Resident #14) of two (2) residents reviewed. Specifically, Resident #14 was observed with dirty long fingernails and unwanted/unkempt facial hair. The finding is: The policy and procedure titled Activities of Daily Living (ADL) Care and Support dated 2/28/25 documented the facility shall provide residents with activities of daily living care and support in accordance with current standards of practice, state and federal regulations and are based on the resident's assessed needs, personal preference and goals of care. Nail care should be provided as needed for the resident and facial hair will be groomed as per resident's preference and/or assessed needs. Resident #14 had diagnoses including dementia, encephalopathy (a condition that disrupts normal brain function) and rhabdomyolysis (a condition where one's muscles break down). The Minimum Data Set (a resident assessment tool) dated 4/18/25 documented Resident #14 was cognitively intact, was understood, and understands. The assessment tool documented Resident #14 had no behaviors or refusals of care. It was documented Resident #14 was a maximal assist for hygiene and bathing. The comprehensive care plan revised 3/20/25, documented Resident #14 required assist with self-care and mobility related to weakness. Interventions included the resident was a substantial assist of one for bathing and hygiene. Interventions included to engage the resident to participate in simple, structured activities. The Kardex (guide used by staff to provide care) dated 6/16/25 documented Resident #14 was a substantial assist of one staff member for bathing and hygiene. The Kardex documented to keep fingernails short to prevent the resident from scratching. Review of Progress Notes dated 6/1/25 - 6/12/25, Resident #14 had no refusal of care documented. Review of the Documentation Survey Report (certified nurse aide documentation) dated 6/13/25 documented Certified Nurse Aide #4 gave Resident #14 a shower on 6/11/25. It was documented that Resident #14 had no behavioral symptoms on 6/11/25. During observations on 6/10/25 at 11:45 AM, 6/12/25 at 3:44 PM and 6/13/25 at 8:42 AM, Resident #14 was observed to have long fingernails past their fingertips with brown debris under their nails and unkempt facial hair. During an interview on 6/12/25 at 3:45 PM, at the time of the observation, Resident #14 stated that they do not like their facial hair, and they wanted their beard shaved off. During an observation on 6/13/25 at 8:55 AM, Certified Nurse Aide #3, with the assistance of Certified Nurse Aide #2, provided AM (morning) care to Resident #14. Certified Nurse Aide #3 washed, rinsed and dried Resident #14's face, peri area and buttocks. While Certified Nurse Aide #3 was washing Resident #14's face they stated to the resident you're getting a beard, we will need to shave you soon. Resident #14 was placed in a new brief but remained in the same hospital gown. Certified Nurse Aide #3 and Certified Nurse Aide #2 stated that AM care was completed, and they would get Resident #14 out of bed later for therapy. During an observation at 1:00 PM, Certified Nurse Aide #3 along with Certified Nurse Aide #6 transferred Resident #14 out of bed via the mechanical lift into a Geri chair (reclining chair on wheels). Resident #14 was now dressed in day clothing but remained with the unkempt facial hair along with long fingernails with brown debris underneath the nails. During an interview on 6/13/25 at 9:35 AM, Certified Nurse Aide #4 stated they do not provide nail care or shaving on residents as much as they would like too, even on the resident's shower days because they were busy. They stated when there was a community aide on the schedule, the community aide would do those tasks. Certified Nurse Aide #4 stated on 6/11/25 they gave Resident #14 their scheduled shower. They stated they did not shave Resident #14 or complete nail care. They stated they were afraid to use a razor on any residents and were uncomfortable clipping their nails. During an interview on 6/13/25 at 1:13 PM, Certified Nurse Aide #3 stated they did not shave Resident #14 or provide nail care on 6/13/25. Certified Nurse Aide #3 stated the community aide would give the residents nail care or shave them but anyone could do it when needed. Certified Nurse Aide #3 stated they did not perform nail care on Resident #14 because they were scared' to do nail care. They stated they probably didn't shave Resident #14 because they were used to the community aide doing it but they absolutely should have shaven them. Certified Nurse Aide #3 stated it was a dignity issue not to shave a resident if the resident wanted to because the resident wants to look a certain way. They stated a resident's nails should be cut for safety of the resident. Certified Nurse Aide #3 stated for skin integrity reasons all areas of a resident's body should be washed. During an observation and interview on 6/13/25 at 3:45 PM, Licensed Practical Nurse Unit Manager #1, observed Resident #14 in the dining lounge as the resident was sleeping in their Geri chair. Resident #14 remained unkempt facial hair and long fingernail with brown debris underneath. After looking at the resident's nails, Licensed Practical Nurse #1 stated that Resident #14 was due for some nail care and Certified Nurse Aide #3 should have shaved Resident #14 with morning care. During an interview on 6/17/25 at 9:30 AM, Licensed Practical Nurse Unit Manager #1 stated removal of unwanted facial hair and nail care should be completed on showers days but continued to be monitored all week long and provide as needed. Licensed Practical Nurse Unit Manager #1 stated these were the normal duties of the assigned aide. Licensed Practical Nurse Unit Manager #1 stated at times the unit would have extra certified nurse aides scheduled, and they would be assigned the community aide role. They stated it was not necessarily the same staff member all time, and they would be expected to choose three extra residents of their choice on the unit and provided them extra activities of daily living care. Extra care would consist of showers, shaving and nail care, above the resident's weekly schedule shower for a boost and to make the resident feel better. Licensed Practical Nurse #1 stated Certified Nurse Aide #3 was assigned to Resident #14 on 6/13/25 and should have cleaned/ trimmed the resident's nails and shaved them. During an interview on 6/17/25 at 11:10 AM, the Director of Nursing stated they expected complete AM care for a resident to include oral hygiene, peri care, face washing, hair care and dressing and stated shaving and nail care should be completed as needed and mainly on shower days. They stated these duties were important so a resident can start their day clean and comfortable. 10NYCRR 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 6/17/25 the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for (3) three (Residents #47, #111, and #173) of five (5) residents reviewed. Specifically, weights were not obtained as recommended by the Registered Dietician and as ordered by the physician (#111 and #173). In addition, surgical staples were not removed as ordered by the physician (#47). The findings are: The policy titled Weight: Measuring, dated 3/1/24, documented weights will be obtained monthly and more frequently as clinically indicated. Staff will note the weight of the resident and document the weight in the resident's clinical record. The policy titled Wound Identification and Wound Rounds revised 11/6/2023 documented the facility will identify, assess, and manage residents with wounds in accordance with current standards of practice. 1 a. Resident #111 had diagnoses including dementia with behavioral disturbances, Wernicke's encephalopathy (a neurological condition), and abnormal weight loss. The Minimum Data Set (a resident assessment tool) dated 3/10/25, documented Resident #111 was severely cognitively impaired, rarely/never understood and rarely/never understands. They required supervision/touch assistance for meals, and they had a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and was not on a physician-prescribed weight-loss regimen. The comprehensive care plan updated 3/13/25, documented Resident #111 had the potential for altered nutrition/hydration secondary to diagnoses of Wernicke's encephalopathy, history of alcohol abuse, and a Body Mass Index (a calculation based on height and weight to determine healthy weight) of less than 24.9 (underweight). The plan included weekly weights, report significant weight changes to physician and team, encourage meal intake, supplements, and a sandwich in the evening. The Kardex (a guide used by staff to provide care) dated 6/11/25, documented Resident #111 required supervision/touch assist for meals, and to provide an early dinner tray. The Kardex did not address obtaining weights. The Order Listing Report for Resident #111 documented mild to moderate malnutrition - Upon signature of this order Medical Doctor acknowledges that resident qualifies for diagnosis of mild to moderate malnutrition (revised 6/13/25), Boost (nutritional supplement) two times a day, weekly weights X 4, every Wednesday day shift (revised 5/27/25). The Team Meeting note dated 4/5/25, documented the Interdisciplinary team met on 4/1/25 the High Risk Meeting Summary documented previous weight decrease noted, current weight pending, monitor weekly weight. The Dietary Note completed by Registered Dietitian #1 dated 5/29/25, documented weight 145 pounds reflects a significant decrease of 29 pounds (16.7%) in the past 180 days. Weight appears to be stabilizing in the past 3 weights. Weekly weight as ordered. Calorie/protein supplement had been increased to twice a day with acceptance. Increased feeding assistance at partial assist to maximize intake per Occupational Therapy. Monitor intake/weight/labs/skin. Encourage intake as needed. Follow up and adjust plan as needed. The Dietary Note completed by Registered Dietitian #1 dated 6/8/25, documented Resident #111 has a clinical indication for malnutrition The resident's acute malnutrition is moderate as evidenced by: Resident's recent intake compared to estimated requirements reported as a percentage over time has been less than 75% of needs for greater than 7 days. The resident has had a 7.5% weight loss from baseline in 3 months. The Dietary Progress Note completed by Diet Technician #1 dated 6/9/25, documented the most recent weight for Resident #111 was 5/9/25, at 145 pounds on a standing scale. The note documented the resident's weight was not stable, with a 16% weight loss in the past 90 days. Staff reported the resident walks while they eat, sandwiches and finger foods have been provided and accepted. Review of Resident #111 weight tracking records provided by the Registered Dietician revealed the following: December 2024, monthly weight 173.8 pounds February 2025, monthly weight - 172.8 pounds March 2025, weekly weights requested - monthly weight -140.28, reweight- 139.6 April 2025, weekly weights requested- monthly weight - 141.6- reweight- 141.8 May 2025, weekly weights requested- monthly weight- 137.4- reweight- 145 June 2025, weekly weights requested- monthly weight- 144.6 Review of the weight tracking records, and the Weights and Vital Summary revealed weekly weights were not obtained as ordered by the physician and requested by the Registered Dietitian from March through June 2025. During an observation on 6/11/25 at 2:40 PM, Resident #111 was ambulating in the hall on the 3rd floor eating a sandwich. Resident appeared thin, and they were non-verbal. Staff would interact and encourage resident frequently. During an interview on 6/13/25 at 8:34 AM, Licensed Practical Nurse #3 stated Resident #111 was being monitored for weight loss and they were ordered weekly weights. They stated Certified Nurse Aides knew which residents needed to be weighed by checking the weight book at the desk. The Certified Nurse Aides documented the weights in the book. If there was a discrepancy, they notified the nurse and they reweighed the resident. The dietitian reviewed the weight book and documented them in the computer. During a review of the weight book and an interview on 6/13/25 at 8:39 AM, the weight book on the 3rd floor revealed there was not page in the weekly weights tab for Resident #111, and the monthly weight for Resident #111 was blank. Unit Clerk #1 stated the dietitian may have taken the weekly weight page. During an interview on 6/13/25 at 8:44 AM, Licensed Practical Nurse Unit Manager #1 floor, stated the Certified Nurse Aides were responsible for obtaining resident weights, and they knew who needed to be weighed weekly by checking the weight book. They stated the dietitian collected the sheets and documented the weights in the computer. They did not know where the weekly weight sheet for June 2025 was, and they did not know why a monthly weight was not obtained for Resident #111. Licensed Practical Nurse Unit Manager #1 stated they attended the weekly Risk Management meetings. During interviews on 6/13/25 at 8:59 AM, and 12:23 PM, Registered Dietician #1 stated Residents with unstable weights were placed on weekly weights so they can more closely monitor if their interventions were successful. Resident #111 should have weekly weights because they had a large weight loss. The weekly weight sheet from the 3rd floor was reviewed with Registered Dietician #1 and the were no weights documented for Resident #111. They stated they had not been informed that Resident #111 refused to get on the scale. The last weight they had for Resident #111 was from 5/9/25. The Registered Dietitian stated that obtaining weights was consistently a problem in the facility and they stated that the unit managers were aware of the problem. During interview on 6/13/25 at 10:56 AM, Registered Dietician #1 stated the Director of Nursing, and the Unit Managers attended the weekly Risk Management meetings and were made aware the weights were not being obtained. During an interview on 6/13/25 at 9:12 AM, Certified Nurse Aide #9 stated that Resident #111 should be weighed weekly, and they did not refuse to get on the scale. They stated they usually did weights on Mondays and would write it on a scrap paper. They did not know why the weights did not get documented in the book. b. Resident #173 had diagnoses including intracerebral hemorrhage (bleeding in the brain), dysphagia (difficulty swallowing) and gastrostomy (surgical procedure for inserting a tube through the abdomen wall into the stomach) infection. The Minimum Data Set, dated [DATE] documented Resident #173 was severely cognitively impaired, understood and understands. They had no or unknown weight loss or weight gain. The assessment tool documented the resident had a feeding tube and was on a mechanically altered diet. The resident was not on a physician-prescribed weight-loss regimen. The comprehensive care plan updated 3/8/25, documented Resident #173 required a feeding tube. The interventions included to follow weights as ordered; regular consistency with thin liquid diet; report significant weight changes to physician and team; and individualize meal plan as needed to meet preference and needs. The Kardex dated 6/16/25, documented Resident #173 was to be encouraged to use dominant hand for drinking, provide assist and cueing with eating as needed. The Kardex did not address obtaining weights. The Order Summary Report documented the following physician orders: -2/21/25 admission weight then weekly every Wednesday for 4 weeks -4/9/25 Weekly weights every Wednesday for 4 weeks -4/22/25 Weekly weights every Wednesday for 4 weeks Review of the Dietary Progress notes for Resident #173 revealed the following: -2/22/25 at 7:33 AM the Registered Dietician #1 documented they requested an admission weight from nursing. -2/25/25 at 2:18 PM the Diet Technician #1 documented the resident's admission weight was pending. Review of the Comprehensive Nutrition Assessment signed on 3/8/25 by the Registered Dietician documented Resident #173 was to be monitor weekly for weights. Review of the Dietary Progress notes for Resident #173 revealed the following: -4/10/25 at 9:02 AM the Registered Dietician #1 documented the residents by mouth intakes varied and appeared suboptimal. They documented weekly weights were initiated to monitor tend and will recommend initiating 237 milliliters of Nurten 2.0 (enteral feed) via percutaneous endoscopic gastrostomy (PEG) tube for additional support. -5/28/25 at 10:33 AM the Diet Technician #1 documented the resident had a history of dysphagia and percutaneous endoscopic gastrostomy tube (PEG) was in place. They documented by mouth intake was variable and weight was requested and pending. Unit manager was made aware. -5/30/25 at 6:33 AM the Registered Dietician #1 documented they requested current weight to assess, and the nurse manager was made aware. Review of the Weights and Vital Summary dated 6/17/25, Resident #173 had the following weights documented: -2/26/25 184.8 pounds -4/7/25 178.8 pounds -6/10/25 173.2 pounds There were no other weights were documented on the summary. Review of Resident #173 weight tracking records provided by the Registered Dietician revealed the following: March 2025, there was no monthly or weekly weights documented April 2025, monthly weight 161.6 pounds, reweight 157.6 pounds and 3rd reweight requested with no re-weight documented. The record documented Weekly weights were then requested for 4/23/25 and 4/30/25 with no weights documented. Weekly weights were not obtained per the physician's orders dated 4/9/25 and 4/22/25. May 2025, there was no monthly was weight documented. Registered Dietician #1 documented weekly weights were requested for 5/14/25, 5/21/25 and 5/28/25 and no weights were documented. Review of the weight tracking records, and the Weights and Vital Summary revealed weekly weights were not obtained as ordered by the physician in February and April. In addition, weekly weights were not obtained as requested by Registered Dietician #1. Review of the Nursing Progress notes from 2/21/25-6/15/25 revealed there was no documented evidence that weights were obtained or the resident refused to be weighed. During interview on 6/13/25 at 10:56 AM, Registered Dietician #1 stated every resident was to be weighed by the 10th of each month. They stated if they identified any discrepancies, they would request a reweight, and if there still was a concern then they may request weekly weights for the resident. Registered Dietician #1 stated the weight tracking record that was kept in a weight book on the nursing units. They write reweight and highlight the box where the certified nurse aides were to document the weight. They stated a separate weight tracking record sheet was use for the residents who needed weekly weights. They write the specific date the certified nurse aides were to obtain the weight. Registered Dietician #1 stated it was the facilities policy to obtain an admission weight on all residents and then weekly for four weeks. Registered Dietician #1 stated they did not receive a monthly weight nor weekly weights for Resident #173 in March 2025. They stated they requested two reweights in April 2025 because of large weight loss and then a 3rd reweight that staff never completed. Registered Dietician #1 stated they then requested weekly weights for April and nursing staff never completed. In May 2025 Resident #173's monthly weight was not completed, so they again requested weekly weights that again were not completed. During an interview on 6/16/25 at 3:31 PM, Registered Dietitian #1 stated they would attend the facilities weekly risk management meetings to discuss any weight loss concerns and the residents that staff had not obtained weights as requested/ordered. Registered Dietician #1 stated the Administrator, Director of Nursing, Social Worker and Unit Mangers attended these weekly risk management meetings and were made aware weights were not being completed as requested/ordered. The Registered Dietician #1 stated they spoke about Resident #173 at these risk meetings. During an interview on 6/13/25 at 1:13 PM, Certified Nurse Aide #3 stated they were responsible for Resident #173 care for the past few a few months. They stated they would know if a resident needed a weight because they look in the weight book and it would indicate if a resident needed a weekly or monthly weight. They stated the nurses would also keep on top of us to get our weights. Certified Nurse Aide #3 stated that if Resident #173 did not have a weight documented on the weight record, then they probably did not realize a weight was needed. During an interview on 6/17/25 at 9:38 AM, Nurse Practitioner #2 stated they were aware of the weight discrepancies for Resident #173. They stated the weights that were obtained in April 2025 and/or the admission weight were mostly likely inaccurate but would expect staff to follow facility protocol for obtaining weights on a resident and follow the medical providers orders. During an interview on 6/17/25 at 9:14 AM, Licensed Practical Nurse Unit Manager #1 stated the certified nurse aides were responsible for obtaining resident weights. Licensed Practical Nurse #1 stated they did discuss Resident #173's weight discrepancies and the requests for reweights at the weekly risk management meetings. Licensed Practical Nurse Unit Manager #1 stated they were responsible to ensure the aides obtained Resident #173's weights and did not follow through to ensure the weights were obtained. At 1:50 PM, Licensed Practical Nurse #1 stated they could not locate any further weights for Resident #173. During an interview on 6/17/25 at 11:16 AM, the Director of Nursing stated they expected monthly and weekly weights to be completed within a day or two after Registered Dietician #1 requested them and per the medical provider ordered. The Director of Nursing stated Unit Managers should make staff aware of which residents needed weights, and the Unit Managers were responsible to follow up to ensure they were obtained. 2. Resident #47 had diagnoses including right femur fracture (thigh bone break), encephalopathy (disorder/disease of the brain), and non-Hodgkin lymphoma (form of cancer). The Minimum Data Set (a resident assessment tool) dated 5/13/25 documented that Resident #47 had severe cognitive impairment, was usually understood and usually understands. Resident #47 had skin conditions, surgical wound(s) and surgical wound care documented on the Minimum Data Set. The comprehensive care plan initiated 5/9/25 documented Resident #47 had fracture/joint replacement. Interventions included follow up with Orthopedic Surgeon as ordered, incision, wound, site care to prevent infection and promote healing. The Progress Notes completed by Registered Nurse Supervisor #1 dated 5/9/25 documented hip incision with two areas, top area 5 centimeters long with 6 staples and lower area 1 and ¾ with 4 staples. The hospital Discharge summary dated [DATE] documented Resident #47 had surgery to repair right femur fracture on 5/1/25. Ortho recommended staples to be removed on postop day 14 at the rehab facility. The Order Summary Report dated 6/16/25 documented an order dated 5/9/25 for the surgical site staples to be removed on postop day 14 (5/15/25). The Order status was documented as completed. Review of Treatment Administration Record dated 5/1/25-5/31/25 documented staples to be removed post op day 14. Treatment Administration Record designated and assigned the treatment to be completed on 5/15/25. Administration record documented that Licensed Practical Nurse #4 signed the record as treatment was completed. Review of Report of Consultation report completed 6/5/25 by Medical Doctor #2 (Orthopedic Specialist) documented the staples to Resident #47's right hip were removed in their office (post op day 35). During an interview on 6/10/25 at 11:59 AM, Resident #47's family member stated Resident #47's staples were not removed when they should have been at the rehab facility. The staples were not removed until they followed up with their orthopedic on 6/5/25. They did not know why the staples weren't removed sooner. During an interview on 6/16/25 at 11:08 AM, the Assistant Director of Nursing/Infection Preventionist stated they expected orders to be followed and that Resident #47's staples should have been removed as ordered. They stated it was important for staples to be removed as ordered so an infection does not occur and to prevent staples from embedding into the skin. During an interview on 6/16/25 at 2:45 PM, Licensed Practical Nurse #4 stated they can remove staples if there was an order and that they did not remove any staples from Resident #47. Licensed Practical Nurse #4 verified their initials on the treatment administration record for 5/15/25 as having signed for removal of Resident #47's staples. Licensed Practical Nurse #4 stated they must have signed off completing treatment by accident and that nobody brought it to their attention. They stated they should not have signed off they removed Resident #47's staples because they did not. During an interview on 6/16/25 at 2:58 PM, Licensed Practical Nurse #2 Unit Manger stated they expected physicians' orders to completed. If an order was unable to be completed they should be notified, and a progress note written. Licensed Practical Nurse #2 Unit Manager stated if a treatment was not completed it should not be signed out because it could post [NAME] care to the resident. During a telephone interview on 6/17/25 at 10:14 AM, Medical Director/Medical Doctor #1 stated they expected staff to follow orders and would expect to be notified if the staples were unable to be removed. Medical Doctor #1 stated they were not aware Resident #47's surgical staples were not removed as ordered. During a telephone interview on 6/17/25 at 10:45 AM, Medical Doctor #2 (Orthopedic Specialist) stated they would expect recommendations for staple removal to be followed. They stated they were not notified of any reason why they weren't removed as recommended. Medical Doctor #2 stated they removed the staples from Resident #47's right hip themselves on 6/5/25 during an office visit. Additionally, they stated it was scary that the staples were overlooked. 10NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 6/17/25, the facility did not ensure that residents who had an indwelling foley catheter (tube inserted into the bladder to drain urine) received appropriate care and services to manage catheters for two (2) (Residents #47 and Resident #382) of three (3) residents reviewed. Specifically, staff improperly emptied the urinary drainage bag (used to collect urine) (Resident #382); did not ensure the tubing and urinary catheter drainage bag remained off the floor and there was lack of monitoring urine output (Residents #47 and #382). Additionally, Resident #47 lacked an order for a urinary catheter. The findings are: The policy titled Catheter- Care revised 5/2019, documented the purpose of the procedure was to prevent catheter-associated urinary tract infections and provide required care of resident's who have an indwelling catheter. Personal protective equipment (gowns, gloves, mask, et cetera, as needed) will be necessary when performing this procedure. 1.Resident #382 had diagnoses including sepsis (life threatening response to an infection), urinary tract infection (bladder infection) and obstructive and reflux uropathy (urinary tract disorders). The Minimum Data Set had not yet been completed. The comprehensive care plan initiated on 6/2/25 documented Resident #382 had an indwelling catheter related to obstructive uropathy. Interventions to maintain privacy bag, monitor and document output were initiated on 6/11/25. The resident required substantial assist of one staff for toileting hygiene. Nursing admission Evaluation progress note dated 6/2/25 at 6:44 PM, documented Resident #382 had a urinary catheter. Review of Progress Notes revealed: -6/9/25 at 8:52 AM by Medical Doctor #1 documented Resident #382 pulled out their foley. Nursing was advised to monitor urine output and reinsert catheter if the resident did not urinate. -6/10/25 at 2:30 PM, the provider progress note documented Resident #382 continued with a foley catheter with straw yellow urine. -6/12/25 at 3:43 PM, provider progress note documented Resident #382 had a foley catheter in place, continue foley catheter and monitor urine output. Review of Resident #382's electronic medical record including nurse notes and certified nursing aide task documentation from 6/2/25-6/13/25, revealed no documented evidence that urinary output was being monitored or recorded. Facility staff were unable to provide any documented evidence of recorded outputs. During an observation and interview on 6/10/25 at 9:20 AM-9:30 AM, Resident #382 was lying in bed, their urinary catheter collection bag was swelled (distended) with urine and looked like a full balloon. There was yellow urine observed in the tubing above the collection bag. The catheter tubing and urine collection bag were lying directly on the floor. Certified Nurse Aide #10 entered the room and stated the resident did not have a urinary catheter. Certified Nurse Aide #10 was shown the swelled catheter bag, and they stated Oh, they must have put it back in. Certified Nurse Aide #10 then applied gloves, placed a urinal on floor, opened the spigot on the catheter bag, filled the 1000 milliliter urinal, clamped the spigot, and emptied the urinal into the toilet. The Certified Nurse Aide #10 emptied the urine collection bag into the urinal twice more to drain the remaining urine. Over 2000 milliliters of urine was emptied from the catheter bag. They did not wear a gown and did not sanitize the spigot on the catheter bag between or after draining the urine and re-clamping the spigot. During an interview on 6/10/25 at 10:27 AM, Certified Nurse Aide #10 stated it was not communicated to them that Resident #382 had a catheter. They stated catheter bags were supposed to be emptied every two to four hours and should not be on the floor for infection control. During an interview on 6/12/25 at 10:18 AM, Resident #382's emergency contact stated Resident #382's catheter got caught on their wheelchair and got pulled out since admission to the facility. They stated Resident #382's urinary leg bag was not checked, emptied and urine had been in the resident's shoes on 6/11/25. During an observation on 6/13/25 at 7:55 AM-8:25 AM, Resident #382 stated their urinary bag was full and needed to be emptied. Resident #382 had a catheter leg bag on that was positioned to their right upper thigh and appeared distended through the pants they were wearing. Certified Nurse Aide #10 wearing only gloves, lifted the resident's right pant leg, accessed the leg bag spigot, and emptied 525 milliliters of urine into a urinal. While emptying Resident #382's leg bag, urine spilled onto the floor. While wearing the same gloves, Certified Nurse Aide #10 wiped the urine off the floor with a towel, then wiped the spigot of the leg bag with an alcohol wipe. During an interview on 6/13/25 at 8:30 AM, Certified Nurse Aide #10 stated they should have worn a gown and sanitized the spigot with alcohol when emptying Resident #382's urinary catheter for infection control. They stated Resident #382's leg bag was full and should not have been because it could leak, cause blockage, or infections. They stated they usually knew when a resident had a urinary catheter by checking resident rooms, looking for a bag. They identify when a urinary bag needed to be emptied by checking the urinary bags, notice if the resident was uncomfortable or if the tubing is tugging. Certified Nurse Aide #10 stated they can check the residents plan of care but usually they just do visual checks for urinary catheters. During an interview on 6/13/25 at 12:05 PM, Licensed Practical Nurse #9 stated the urinary spigot should be disinfected after emptying urine from the urinary drainage bag to decrease the resident's exposure to outer contaminates that could lead to urinary tract infections. They stated urinary output should be measured to make sure residents are urinating and hydrated. During an interview on 6/13/25 at 12:41 PM, Licensed Practical Nurse #2 Unit Manager stated the nursing staff (nurses, aides) were responsible for maintaining urinary catheters. They stated urinary catheter outputs should be recorded in the residents' plan of care by the certified nurse aides to make sure residents are urinating. Licensed Practical Nurse #2 Unit Manager, stated when a catheter drainage bag was emptied, a barrier should be placed on the floor and the spigot should be wiped with alcohol for infection control purposes. They stated urinary catheter bags that were not emptied timely could cause pain, bladder distention, back flow and infection. 2. Resident #47 had diagnoses including right femur fracture (thigh bone break), encephalopathy (disorder/disease of the brain), and non-Hodgkin lymphoma (form of cancer). The Minimum Data Set (a resident assessment tool) dated 5/13/25 documented that Resident #47 had severe cognitive impairment, was usually understood and usually understands. The Minimum Data Set documented no indwelling catheter, and urinary continence was not completed. The comprehensive care plan initiated on 12/3/24, documented Resident #47 required assist with self-care and mobility and the resident was dependent on staff for toileting hygiene. On 6/11/25 Resident #47 was care planned as at risk for multidrug-resistant organisms (MDRO) colonization/infections related to an indwelling foley catheter. There was no active comprehensive care plan for the use of an indwelling catheter. Review of Hospital Discharge summary dated [DATE], documented a foley catheter was placed during Resident #47's hospitalization. Review of Order Summary Report dated 6/16/25 documented an order for an 18 French (measurement scale used to describe the dimension of medical device tubing) 10 cubic centimeter balloon indwelling catheter as needed, and catheter care every shift were ordered on 6/10/25. Orders to remove the urinary catheter and monitor voiding status were ordered on 6/11/25. There was no documented evidence that the resident had orders for an indwelling catheter from 5/7/25-6/10/25. Review of Documentation Survey Report, documented by certified nurse aides, dated May-25 (5/7/25-5/31/25), Resident #47's bladder continence was documented as a 3 (not rated due to indwelling catheter) for 38 out of 57 entries. For Jun-25 (6/1/25-6/11/25), their bladder continence was documented as a 3 (not rated due to indwelling catheter) for 14 out of 20 entries documented. During an observation on 6/10/25 at 11:59 AM, Resident #47 was lying in bed, their urinary catheter tubing was on the floor and the urinary catheter bag was on the floor under the bed frame with no urine present. During an observation on 6/11/25 at 9:28 AM, Resident #47 was lying in bed and holding onto their urinary catheter tubing, with yellow urine present, in their hand. The urinary catheter collection bag was resting on the floor. During an interview on 6/16/25 at 2:45 PM, Licensed Practical Nurse #4 stated they could not recall if Resident #47 had a urinary catheter prior to 6/10/25. They stated urinary catheter orders should have been part of Resident #47's readmission assessment/orders. They stated urinary catheter collection bags and tubing should never be on the floor; they should be kept off the ground for infection control. They stated an order was obtained to reinsert Resident #47's urinary catheter on 6/10/25, because there were no current orders for one. During an interview on 6/17/25 at 8:15 AM, Resident #47's family member stated the resident had a urinary catheter since their surgery, which was around 5/1/25. During an interview on 6/17/25 at 9:27 AM, Licensed Practical Nurse #10 stated they did not recall if Resident #47 had a urinary catheter upon readmission on [DATE]. They stated it would be important and they should have known if a urinary catheter was present so they could obtain orders, and it could be monitored. They stated orders were needed for catheter size, catheter care and urine output every shift. Licensed Practical Nurse #10 stated the certified nurse aides are supposed to let the nurses know what a resident's catheter output is to make sure a residents' kidneys were functioning. During an interview on 6/16/25 at 10:48 AM, the Assistant Director of Nursing/Infection Preventionist stated they expected nursing staff to wear gowns, and gloves when emptying or performing any catheter care. They stated a barrier should be placed on the floor between the urinal when emptying the catheter bag. An alcohol wipe should be used before and after accessing catheter bag spigot so germs, bacteria are not introduced into the resident's body. They stated urinary catheter bags and tubing should not be on the floor due to the potential for infection. The Assistant Director of Nursing/Infection Preventionist stated there should be orders for monitoring output so urinary retention, and decreased kidney function can be monitored. During an interview on 6/16/25 at 12:29 PM, the Director of Nursing stated foley catheters should be emptied at least every shift, so they do not get too full. They stated if a catheter bag is too full it could cause urine to back flow into bladder, and cause infection. They stated foley catheters bags and tubing should not be on the floor for infection control, prevent infections. They stated they expected orders to be in place for urinary catheters and urinary output. The Director of Nursing stated Resident #382 outputs were not being monitored until 6/13/25 when it was brought to their attention. They stated monitoring output was important to be tracked to note any changes in condition. During a telephone interview on 6/17/25 at 10:14 AM, Medical Doctor #1/Medical Director stated it was important for urinary catheter bags to be emptied timely to prevent hydronephrosis (excess fluid in kidney), acute kidney injury, bladder injury or rupture and urinary tract infections. They stated urinary catheter bags and tubing on the floor increased the risk for infection and should not be on the floor. They stated it was important to monitor for urinary output to ensure the urinary catheter was functioning and to monitor clinical situations. 10 NYCRR 415.12 (d)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on 6/17/25 the facility did not ensure that a resident who was fed by enteral means (method of feeding that uses the gastrointestinal (GI) tract to deliver part or all a person's caloric requirements) received the appropriate treatment and services to prevent possible complications for one (1) (Resident #381) of two (2) residents reviewed for feeding tubes. Specifically, the facility did not provide the tube feed as ordered. The finding is: The policy and procedure titled Enteral Nutrition reviewed 6/2023 documented Dietary-Nursing Nutritional support would be provided to residents unable to obtain nourishment orally and are receiving enteral feeding ordered by a physician. The feeding method will be determined to optimize resident's independence whenever possible (at night or during hours that do not interfere with the resident's ability to participate in facility activities). In the event that a resident does not receive the prescribed amount of enteral feeding, the licensed nurse would notify the physician. Resident #381 had diagnoses that included gastrostomy (opening into stomach to insert tube), bulbar palsy (motor neuron disorder), tracheostomy (opening into the trachea), and type 2 diabetes mellitus. The Minimum Data Set (a resident assessment tool) dated 5/29/25 was incomplete, but documented Resident #381 was cognitively intact, understood and understands. The comprehensive care plan initiated 5/16/25 documented Resident #381 required tube feeding. Interventions included to administer tube feeding and water flushes per Registered Dietitian/ Licensed Dietician recommendations and Medical Doctor orders. The comprehensive care plan documented on 6/9/25 the resident had potential for altered nutrition/hydration secondary to nothing by mouth status with alternate feeding as their primary nutrition/hydration and interventions included feeding/flushes as ordered. The Order Summary Report documented an order dated 6/10/25 for Novasource Renal (calorically dense nutritional formula) by enteral tube at a rate of 60 milliliters per hour to begin at 4:00 PM for a total volume of 1080 milliliters to be delivered. May use Glucerna 1.5 (calorically dense nutritional formula) if Novasource Renal was not available every day shift. Stop the tube feed when total volume of 1080 milliliters are infused. Verify with pump setting that total volume has been delivered. Document total volume infused. Verify infusion every shift. Review of Weights and Vitals Summary dated 6/17/25, revealed Resident #381's weight on 5/21/25 at 8:27 AM was 168 pounds (wheelchair) and on 6/13/25 at 2:59 PM was 163.4 pounds (wheelchair), a 2.74 percent weight loss in 23 days. During an interview on 6/11/25 at 10:25 AM, Resident #381 stated their enteral feed was supposed to be started at 4:00 PM every day, but that does not happen, and it angered them. Resident #381 stated they were hungry sometimes and they have watched other residents receive breakfast, lunch and they had not received anything. During an observation and interview on 6/13/25 at 7:59 AM, Resident #381's enteral feed bag was full with 1000 milliliters present. The enteral feed tubing from pump, connected to resident was not primed (no feed in tubing), and the pump was not on. The label on the feed bag was dated 6/12 at 4:00 PM. Resident #381 stated they never received any of their feed since last evening. They stated the pump was beeping and was shut off by the nurse. The resident's roommate was consuming breakfast at this time and Resident #381 stated they were hungry. During an interview on 6/13/25 at 12:05 PM, Licensed Practical Nurse #9 stated they walked in on the feeding pump issue with Resident #381 that morning. They stated they had not been notified during shift report of any concerns with Resident #381's feeding tube or pump and could not believe Resident #381 had not received their enteral feed as ordered. They stated all nurses were responsible for verifying the correct feed, rate and volume infused were accurate. They stated it was important to verify orders to ensure residents were not receiving over or under the feed amount. They stated not receiving proper volume of enteral feed could cause weight loss. During an interview on 6/13/25 at 12:41 PM, Licensed Practical Nurse #2 Unit Manager stated enteral feed orders should be verified every shift. Enteral feed bottles/bags should be labeled with resident's name, date/time when hung and rate per hour to be given. They stated the enteral feed tubing and pump should be primed, feeding tube placement and residual checked prior to connecting feed to resident. They stated they expected nurses to ask for assist, report issues/concerns with feed tubes, feeding pumps to them or a supervisor. Licensed Practical Nurse #2 Unit Manager stated they were not notified of any issues with Resident #381's feeding pump on 6/12/25. They stated they were notified by Licensed Practical Nurse #9 at 8:00 AM on 6/13/25 that Resident #381 had not received their enteral feed and that there was an issue with the feeding pump. They stated it was important for Resident #381 to receive their enteral feed as ordered to prevent weight loss and ensure proper nutrition. Licensed Practical Nurse #2 Unit Manager stated a medical provider should have been notified to get orders for a bolus feed (method of delivering feed without the use of a pump) or to hold Resident #381's feed. During a telephone interview on 6/13/25 at 3:54 PM, Licensed Practical Nurse #7 stated they were Resident #381's nurse on 6/12/25-6/13/25 from 5:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM. They state they hung Resident #381's feed on 6/12/25 around 5:00 PM. They stated when they initiated the feeding pump it was beeping, indicated clogged. They stated they disconnected the feed and reconnected Resident #381 back to the pump and the machine stated, technical error 22, call tech support. Licensed Practical Nurse #7 stated they notified Licensed Practical Nurse #8 Supervisor. They stated Licensed Practical Nurse #8 Supervisor played around with the pump, pressed some buttons but the pump kept beeping, and they thought Licensed Practical Nurse #8 Supervisor was looking for another pump. They stated for 8-9 hours the pump would not stay on no matter what they did, and they shut it off. Licensed Practical Nurse #7 stated it was very possible that Resident #381 did not receive any of their ordered feed and that it was important for nutritional value. They stated they did not notify a provider because they did not think Resident #381 would not be receiving their feed the whole time and should have. During an interview on 6/13/25 at 4:54 PM, Registered Nurse Supervisor #1 stated they worked as the supervisor on 6/12/25 and was not aware of Resident #381's feeding pump not working. They stated Licensed Practical Nurse #7 made them aware of a different resident's feeding pump not working. They stated the facility was short on pumps and they would have gotten an order from the medical doctor to do bolus feeds temporarily until a pump was available. They stated it was important for residents to receive their ordered enteral feeds for nutrition and so they did not starve. During an interview on 6/16/25 at 12:29 PM, the Director of Nursing stated they would expect nursing to alert a supervisor if there were an issue with a resident's enteral feed, so they can make sure the resident received the proper feed. They stated it was important for residents to receive their enteral feed as ordered to prevent weight loss and ensure adequate nutrition/hydration. The Director of Nursing stated a provider should have been notified, could have administered a bolus feed. During an observation and interview on 6/16/25 at 2:01 PM-2:21 PM, with the Registered Dietitian present, Resident #381 was not connected to their feeding pump and the feed bottle was noted with approximately 100 milliliters remaining in it. Resident #381 stated the nurse was supposed to reconnect them until the feed delivered was 1080 milliliters. Resident #381's feeding pump was observed, and it indicated only 970 milliliters were delivered. Registered Dietitian stated based on what appeared to them Resident #381 had not completed their feeding regime. They stated this was concerning that resident may not be receiving their nutritional needs. Registered Dietitian stated it was brought to their attention on 6/13/25 that Resident #381's enteral feed did not run 6/12/25-6/13/25 as ordered and the feeding had to be made up. They stated the enteral feed was Resident #381's primary source of nutrition. They stated Resident #381 had expressed concern over losing weight and that it was important for them to receive the enteral feed as ordered to meet their nutritional needs, maintain their skin integrity and weight. During an observation and interview on 6/16/25 at 2:33 PM, Licensed Practical Nurse #9 observed the feed hanging from the pump pole had approximately 100 milliliters of feed remaining and the feed pump that indicated only 970 milliliters feed was delivered and stated Resident #381 had not received their total volume of enteral feed, that there was still feed that needed to be delivered. They stated Resident #381 was disconnected from the pump for physical therapy and should have received total volume of 1080 milliliters of enteral feed. Licensed Practical Nurse #9 stated Resident #381 could lose weight if not given the total amount of feed ordered. During a telephone interview on 6/17/25 at 10:14 AM, the Medical Director/Medical Doctor #1 stated they would expect residents to receive their enteral feed as ordered for adequate nutrition and fluids. They stated they would expect a provider to be notified if orders could not be completed as ordered to figure out what else could be done, such as provide a bolus feed. 10 NYCRR 415.12(g)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Complaint investigation (Complaint #NY00378534) conducted during a Recertification survey completed 6/17/25, the facility did not ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) met the needs of each resident for two (2) (Resident #s 380 and #391) of two (2) residents reviewed. Specifically, Resident #380 was not administered doses of their antibiotic medication and there was a delay in acquiring, receiving, and administering Resident #391's medications upon admission. The findings are: The policy titled Physician Orders- Transcription revised 8/2018, documented a clinical nurse shall transcribe and review all physician orders in order to affect their implementation. The clinical nurse shall notify pharmacy per pharmacy policy by telephoning or faxing the order. The policy titled Pharmacy Services revised 4/2020, documented pharmaceutical services consists of the processes of receiving and interpreting prescriber's orders, acquiring, receiving, storing, reconciling, dispensing, packaging, labeling, distributing, administering of all medications, biologicals. Provide routine pharmacy service seven days a week and emergency pharmacy service 24 hours per day, seven days a week, deliver medications to the facility, and help ensure that all deliveries are correct and proper documentation related to delivery is provided. Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if a resident's medication is not available for administration. The policy titled Admission- readmission revised 9/2022, documented it is the philosophy of the facility to admit residents 24 hours per day, 7 days a week based upon the resident's needs and the ability to meet those needs. Prior to or at the time of admission, the facility must be provided with the following information for the immediate care of the resident, including medication orders. 1.Resident #380 had diagnoses including pneumonia due to Methicillin Resistant Staphylococcus Aurous (MRSA - an antibiotic-resistant bacteria), chronic kidney disease and dependence on renal dialysis (a life sustaining treatment for people with kidney failure). The Minimum Data Set (a resident assessment tool) dated 4/2/25 documented that Resident #380 was cognitively intact, understood, understands and received antibiotic medication. The comprehensive care plan initiated 3/28/25 documented Resident #380 had an actual respiratory tract infection, Methicillin Resistant Staphylococcus Aurous. Interventions included to administer antimicrobials (substance that kills or inhibits growth of bacteria) as ordered, administer medications and treatments as ordered. Review of the Aspen Complaints/incidents Tracking System (ACTS) Complaint/Incident Investigation Report intake dated 4/21/25 at 2:43 PM, the complainant alleged Resident #380 did not receive medications upon return from dialysis. The Order Summary Report printed 6/13/25, documented an order dated 4/2/25 for Linezolid (antibiotic used to treat bacterial infection) tablet 600 milligrams, give 1 tablet by mouth every 12 hours for infection until 4/16/25. The Medication Administration Record dated 4/1/25-4/30/25, documented an order dated 4/2/25 for Linezolid Tablet 600 milligrams give 1 tablet by mouth every 12 hours for infection until 4/16/25. Doses scheduled 8:00 AM on 4/7/25 and 8:00 PM on 4/5/25, 4/6/25, and 4/7/25 were coded 5 (hold/see nurse notes) by Licensed Practical Nurse #6. On 4/14/25 the 8:00 PM dose was coded 3 (out of facility) and on 4/15/25 the 8:00 PM dose was coded 9 (other/see nurses notes). It was documented the resident received 22 out of 28 prescribed doses. Review of Progress Notes dated 4/6/25 at 8:32 PM and 4/7/25 at 9:17 AM, revealed Licensed Practical Nurse #6 documented waiting for pharmacy for the Linezolid. There were no Progress Notes regarding the missed doses on 4/5/25, 4/7/25 8:00 PM, and 4/15/25. During a telephone interview on 6/13/25 at 1:53 PM, Licensed Practical Nurse #6 stated if a medication was not available or unable to be located, they would not indicate the medication as being administered on the medication administration record. They stated they would code the medication administration record and document the medication was not available. Licensed Practical Nurse #6 stated they did not recall that they did not have Resident #380's antibiotic, but if they coded the medication administration record as not given and documented they were waiting for pharmacy, then they did not give the antibiotic (4/5/25 8:00PM, 4/6/25 8:00 PM, 4/7/25 8:00AM and 8:00PM doses). They stated they would document this to cover themselves. Licensed Practical Nurse #6 stated they would have notified the supervisor and checked the medication pyxis (medication dispensing system) to see if the medication was available. Licensed Practical Nurse #6 did not recall what supervisor they notified and stated the antibiotic was not available in the pyxis. They stated it was important for residents to receive their antibiotics as ordered to treat their condition. Licensed Practical Nurse #6 stated a medical provider was not notified and should have been to extend the doses. During an interview on 6/13/25 at 12:41 PM, Licensed Practical Nurse #2, Unit Manager stated if a medication was not available, they would expect nurses to call the pharmacy and contact the medical provider. They stated the medical provider could prescribe an alternate medication on hand in the pyxis or a hold order may be needed until the medication was available from the pharmacy. They stated residents should receive their medications as ordered because they needed them. They stated medications should be reordered timely and that any nurse can take the initiative to reorder medications to make sure they are on hand to be given as ordered. During an interview on 6/16/25 at 12:33 PM, the Director of Nursing stated they expected antibiotics to be given as ordered and for a medical provider to be notified of missed doses of antibiotics so the antibiotic can be extended to ensure a therapeutic benefit of the antibiotics. They stated they did not feel the nurse looked hard enough for the antibiotic and was confused on its location. During a telephone interview on 6/17/25 at 8:02 AM, the Pharmacist #1 stated a total of 20 doses/10 days of Linezolid Tablet 600 milligrams was filled and delivered to facility for Resident #380. They stated Linezolid Tablet 600 milligrams for Resident #380 was first filled on 3/28/25 for a quantity of 10 tablets for 5 days, twice a day. They stated on 4/2/25 there was a new order for Linezolid Tablet 600 milligrams received but the medication was indicated as on hand by the facility and was not refilled at that time. They stated a request to refill from the facility was received on 4/7/25 and the pharmacy provided a quantity of 10 tablets for 5 days, twice a day. The Pharmacist #1 was unable to determine when the facility received the refill order. They stated it was important for residents to receive prescribed antibiotics for effective treatment against infections. During a telephone interview on 6/17/25 at 10:14 AM, the Medical Director/Medical Doctor #1 stated it was important for residents to receive antibiotics as ordered to treat an infection correctly. They stated missed doses of antibiotics can cause a reoccurrence of infection. They stated they expected to be notified of missed antibiotic doses so the course of antibiotics could be extended to ensure full treatment was received. Medical Director/Medical Doctor #1 stated they were not aware of missed antibiotic doses for Resident #380. 2. Resident #391 had diagnoses that included heart failure, alcohol use, and diabetes mellitus. The Minimum Data Set (a resident assessment tool) was not completed yet. Baseline Care Plan effective 6/11/25, documented Resident #391 was admitted for disease/illness management for post-surgical care, substance abuse disorder, heart failure, pain, hypertension (high blood pressure), liver cirrhosis and weakness. Interventions included: administer treatments as ordered, monitor medications and provide care and comfort. The Admission/readmission Evaluation dated 6/11/25, signed by Registered Nurse Supervisor #1, documented Resident #391 was cognitively intact and was alert to person, place, time, and situation. Review of the Order Summary Report dated 6/13/25 documented acetaminophen 325 milligrams, give 2 tablets by mouth every 6 hours as needed for pain was the only by mouth medication pharmacy order entered for 6/11/25 at 5:32 PM upon Resident #391's admission to the facility. Review of the Hospital Discharge summary dated [DATE] documented Resident #391's discharge medications included multivitamin with folic acid (supplement) 400 micrograms by mouth every day; oxycodone 5 milligrams by mouth every 4 hours as needed; albuterol (bronchodilator) meter dose inhaler 90 micrograms, 2 puffs inhaled every 4 hours as needed; eliquis (blood thinner) 5 milligrams by mouth every 12 hours; bumex (diuretic) 0.5 milligrams by mouth every morning; Jardiance (enzyme inhibitor)10 milligrams by mouth every day; trelegy ellipta (bronchodilator) 200-62.5-25, 1 puff inhale daily; lisinopril (heart medication) 2.5 milligrams by mouth every day; magnesium oxide (supplement) 400 milligrams by mouth twice a day; melatonin (dietary supplement) 5 milligrams by mouth every night as needed for sleep; naltrexone 100 milligrams (opioid antagonist) by mouth every day; metoprolol succinate (heart medication) 150 milligrams by mouth every day; zoloft (antidepressant) 50 milligrams by mouth every day; aldactone (diuretic) 25 milligrams by mouth every day; and thiamine (vitamin B-1-vitamin supplement) 100 milligrams by mouth every day. During an observation and interview on 6/13/25 at 8:17 AM, Resident #391 stated they thought they were going through withdrawal during the night. They stated they were throwing up, and sweating. They stated they had not received any of their routine medications from the nurses since they were admitted to the facility on [DATE]. Resident #391 stated they just took their own medication brought from home. Resident #391 had a healthcare provider box present at their bedside with daily medication packets filled with scheduled medications separated by date and morning and bedtime packets. The packet labeled Monday bedtime, June 2, 2025, listed the medications Eliquis 5 milligrams, lisinopril 2.5milligrams, magnesium oxide 400 milligrams, melatonin 5milligrams quick dissolve, metoprolol succinate extended release 100 milligrams, metoprolol succinate extended release 50 milligrams, and Zoloft 50 milligrams on the package containing the medications. The packet of medications Resident #391 stated they took that morning was on top of the garbage next to their bed. The packet was dated 6/3/25, morning and listed bumex 0.5 milligrams, Eliquis 5 milligrams, Jardiance 10 milligrams, magnesium oxide 400 milligrams, naltrexone 50 milligrams, Aldactone 25 milligrams, vitamin B-1 100 milligrams. Resident #391 stated they also had their own inhalers with them. Resident #391 stated they had asked about their medications and the nurses just kept saying they were on order. Resident #391 stated the only medications they had received from the nursing staff at the facility was their pain pill, Oxycodone and melatonin. During an interview on 6/13/25 at 4:37 PM, Registered Nurse Supervisor #1 stated they were Resident #391 admitting nurse and they had problems with inputting their admission orders into the electronic medical record on 6/11/25. They stated Resident #391 was admitted around 6:00 PM. They stated they had tried four to five times to enter Resident #391's orders, based off their hospital discharge summary, into the electronic medical record but couldn't see them or find them after putting them in. They stated the orders were placed as verbal orders from the medical doctor but that they did not speak directly with anyone. They stated the batch orders for acetaminophen were present for Resident #391, but none of their other medications would appear. Registered Nurse Supervisor #1 stated they felt Resident #391 could wait until 6/12/25 to have their medication orders addressed. They stated they phoned and reported their inability to enter Resident #391's medications orders to the Assistant Director of Nursing between 4:00 AM and 5:00 AM on 6/12/25. They stated the medical provider must acknowledge medications in the electronic medical record, but they were not sure how. During an interview on 6/13/25 at 12:05 PM, Licensed Practical Nurse #9 stated the only medication Resident #391 had ordered on 6/12/25 during the day shift was oxycodone. They stated Resident #391 told them that they were missing some medications. Licensed Practical Nurse #9 stated they notified Licensed Practical Nurse #2 Unit Manager, and the Licensed Practical Nurse #2 Unit Manager, administered medication (oxycodone) to Resident #391 from the pyxis. Licensed Practical Nurse #9 stated Resident #391's admission medication orders from the hospital discharge summary should have completed by a Registered Nurse when they were admitted . They stated if a resident was looking for additional medications it was important to communicate this to the supervisor to make sure residents received the right medications. During an interview on 6/13/25 at 12:41 PM, Licensed Practical Nurse #2 Unit Manager stated a Licensed Practical Nurse/Registered Nurse supervisor completed admissions orders. They stated admission orders were taken off the hospital discharge summary and placed into the resident's electronic medical record orders and the Medical Doctor confirmed the orders. They stated nurses were supposed to obtain what medications they could from the pyxis until they arrived from the pharmacy or get an order from the Medical Doctor to start medications as soon as they were available. They stated admission orders should be ordered the day of the resident's admission so there was no delay in receiving medications from the pharmacy and administering medications to residents. They stated they were not aware that Resident #391's medication orders were not transcribed until 6/12/25. During an interview on 6/13/25 at 4:10 PM, Licensed Practical Nurse #7 stated they were Resident #391's assigned nurse on 6/11/25 evening shift and 6/12/25 into 6/13/25 evening/night shift. They stated Resident #391 complained that they did not receive their medication since being admitted , and they reported this to the nursing supervisor. They stated there was nothing entered into Resident #391's electronic medical record, on the medication administration record indicating that any medications were to be administered on 6/11/25 evening shift. Licensed Practical Nurse #7 stated the only medication they administered to Resident #391 on 6/12/25 evening shift was magnesium 400 milligrams that was available as a stock medication. They stated they did not administer prescribed Eliquis 5 milligrams, 8:00 PM dose because it was not available and did not have time to get it from the pyxis. They stated Resident #391's medications did not arrive until late evening on 6/12/25. Licensed Practical Nurse #7 stated they were not aware of Resident #391 having their own medications on hand. During an interview on 6/16/25 at 10:48 AM, the Assistant Director of Nursing stated they received a phone call from Registered Nurse Supervisor #1 on 6/12/25 at 5:30 AM regarding their inability to enter Resident #391's medications into their electronic medical record. The Assistant Director of Nursing stated they did not know why Registered Nurse Supervisor #1 did not notify them prior to that. The Assistant Director of Nursing stated medication orders were supposed to be entered by the nursing supervisor per the hospital discharge summary orders upon admission and a facility medical provider verified the orders the next day when they came into the facility. They stated if there was an issue or a question with the hospital discharge medications, then they would expect the nursing supervisor to call a medical provider for clarification. The Assistant Director of Nursing did not feel there was a delay in resident #391 receiving their medications. During an interview on 6/16/25 at 12:29 PM, the Director of Nursing stated the medical providers can see and review medication entered through the resident's electronic medical record. They stated depending on what time a resident was admitted to the facility, the medical providers may not sign off on admission orders that night. They stated Registered Nurse Supervisor #1 was proficient at writing orders and never had this issue before. The Director of Nursing stated Resident #391's medications should have been reviewed by a medical provider and ordered from the pharmacy on 6/11/25. During a telephone interview on 6/17/25 at 8:02 AM, the Pharmacist #1 stated the facility had two scheduled deliveries daily, one at 1:00 PM and the other at 10:00 PM. They stated medications needed by the 1:00 PM delivery time, needed to be ordered before 11:00 AM. Anything ordered from 11:00 AM to 7:00 PM would be on the facility's 10:00 PM delivery. They stated late admissions were STAT (immediately) sent out the next morning. They stated the pharmacy received electronic orders through their computer system and were filled pending signature from providers or orders that were entered by the nurses. The Pharmacist #1 stated the pharmacy did not receive orders for Resident #391 until 6/12/25 between 10:50 AM and 1:59 PM. They stated the only by mouth medication order they received on 6/11/25 was for acetaminophen. During a telephone interview on 6/17/25 at 10:14 AM, the Medical Director/Medical Doctor #1 stated new admission orders were being entered pretty late. They stated they were notified by nursing in the morning that they had admission orders to sign. They stated they signed orders electronically after they have been entered by nursing staff. They stated it was not fair for the residents to have to wait for their medication due to the time they were admitted and a delay in ordering from the pharmacy. The Medical Director/Medical Doctor #1 stated it was not acceptable that Resident #391's medications weren't entered until 6/12/25. 10NYCRR 415.18(a)

Based on interview and record review conducted during the Onsite Post Survey Revisit #1 completed on 09/04/2025, the facility did not ensure that the Quality Assurance Performance Improvement Program (QAPI) Committee developed and implemented appropriate plans of action to correct identified quality deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements. Specifically, the Quality Assurance Performance Improvement Program Committee could not provide evidence that all licensed nurses were reeducated regarding the enteral tube feed administration and the use of enteral feeding pump(s) (method of feeding that uses the gastrointestinal tract to deliver part or all a person's caloric requirements) as stated in their plan of correction. The findings are:Refer to: F693 Tube Feeding Management scope and severity = DThe policy and procedure titled Quality Assessment Performance Improvement Program revised 04/28/2025, documented it was the policy of the facility to establish and maintain an effective, ongoing, and data driven Quality Assurance and Performance Improvement (QAPI) Program that addresses the care and unique services the facility provides. The purpose of the QAPI (Quality Assurance and Performance Improvement Program) was to support the continuous evaluation of facility system with the objective of ensuring care delivery systems function consistently, accurately and incorporate current and evidence-based practice standards; prevent deviation from care process; identify issues and concerns with facility system, as well as identifying opportunities for improvement; and develop and implement plans to correct and/or improve identified areas. The facility documented documentation of the Quality Assurance and Performance Improvement Program would include evidence that demonstrates the operation of the facility's program performance improvement project that were being conducted; the reasons for conducting each project; measurable progress achieved during performance improvement projects; and outcomes. Review of Standard Survey Statement of Deficiencies (Form 2567) issued by the New York State Department of Health with an exit date of 06/17/2025 revealed the facility was cited for not providing residents with enteral tube feed as ordered by the medical provider. The Standard Survey Statement of Deficiencies documented, per interviews with the Licensed Practical Nurse and the Nursing Supervisor, that the enteral feeding pump read a technical error, and they could not get the feeding tube pump to work resulting in the resident not receiving their provider ordered nutrition. Form 2567 documented the facilities approved Plan of Correction corrective would include that all licensed nurses would be reeducated regarding enteral tube feed administration, how to utilize the feeding pump(s) and the protocol to follow if a tube feed pump was not functioning as expected. The facilities Plan of Correction documented the deficiency would be corrected by 08/06/2025. Review of the Quality Assurance and Performance Improvement (QAPI) Meeting Summary dated 07/27/2025 documented under the regulatory deficiencies section that multiple tags reviewed including F tag 693 and numerous corrective actions implemented: audits, education, progressive discipline, policy reinforcement.Review of the facilities educational slide presentation titled (name of the city) Plan of Correction dated July 2025, identified as the facility's education presentation by the Director of Clinical Operations, documented Licensed Nurse education included tube feeding. The tube feeding education slide included tube feeing were to be administered per the provider orders, the feeding must run until the prescribed volume was infused utilizing the pump, feeding pumps and poles were to be wiped down, and if feeding pump was not functional the nursing supervisor/designee should be contacted. The slide presentation did not address how to specifically work the feeding tube pump. During an interview on 09/02/2025 at 12:56 PM, Licensed Practical Nurse #1 stated they had not received any recent education or in-services specific to utilizing feeding pumps. During an interview on 09/03/2025 at 1:07 PM, Licensed Practical Nurse Unit Manager #3, stated they do not remember receiving any education regarding utilizing feeding pumps. During an interview on 09/03/2025 at 1:57 PM, Licensed Practical Nurse #5 stated they had not received any education specific to the use of feeding pumps. During an interview on 09/03/2025 at 3:25 PM, Licensed Practical Nurse #2 stated they had not received any education specific to utilizing feeding pump(s). They stated if they did not know something about a pump they would ask a fellow co-worker. During an interview on 09/04/2025 at 10:34 AM, the Director of Clinical Operations, with the presence of the Administrator stated the last Quality Assurance Performance Improvement Program meeting was held was in July 2025 with the former Administrator and they have not had held the August 2025 meeting yet with the current Administrator. They stated at the July 2025 meeting the committee reviewed all the cited deficiencies along with their plan of corrections. The Director of Clinical Operations stated the unit managers were to ensure that all tube feeding were being administer per provider order. They stated they think staff still had some confusion on how to properly document the volume of enteral feed that was administered to the resident each shift in the medication administration record. After review of the provided facility's education from the slide presentation, the Director of Clinical Operations stated the education did not specifically include how to operate the enteral feeding pump. During a telephone interview on 09/04/2025 at 12:20 PM, Licensed Practical Nurse #7 stated they did receive education on the facilities cited deficiencies in July, but it did not include specific education on how to utilize an enteral feed pump. A telephone interview was attempted with Former Nurse Educator on 09/04/2025 at 1:03 PM and Former Director of Nursing on 09/04/2025 at 1:05 PM without success. During an interview on 09/04/2025 at 1:45 PM, the Director of Clinical Operations stated they were unable to locate any documented evidence that all licensed nursing staff were educated specially on how to operate the enteral feeding tube pump, and the nurse medication competencies did not contain a competency for proper pump operation. The Director of Clinical Operations stated they should have been able to provide evidence that all licensed nursing staff were provide education and therefore the facility did not follow their plan of correction. 10NYCRR 415.27(c)(3)(iv)(v)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a complaint investigation (#NY00382491) conducted during a Recertification survey completed 6/17/25, the facility did not provide a safe, clean, comfortable and homelike environment for two (Second Floor and Third Floor) of three resident units. Specifically, there were dirty community shower room chairs and floors, dirty resident medical equipment (feeding poles); unlabeled and inappropriately stored personal hygiene products and care items in shower rooms and in resident rooms. In addition, offensive odors were noted in and outside of the soiled linen room. The findings are: The undated facility titled Your Rights as a Nursing Home Resident in New York State and Nursing Home Responsibilities documented the resident had a right to dignity, respect and a comfortable living environment. It was documented that the nursing home was responsible to provide the resident with a safe, clean and comfortable room and surroundings. The policy and procedure tilted Environmental Services dated 5/18 documented the cleaning of the shower room was to provide safe and sanitary environment for the purpose to prevent the development and transmission of disease and infection. The policy titled Infection Prevention and Control revised 2/19/2025 documented policies, procedures, and practices of Infection Prevention and Control in the facility are designated to maintain a safe, sanitary and comfortable environment for residents, staff, visitors and others who may visit the facility. Provide guidance for safe cleaning and disinfection of resident care equipment supplies, and the facility environment. The policy titled Standard Precautions revised 2/19/25 documented resident-care equipment soiled with blood, body fluids, secretions, and excretions are handled in a manner that prevents transfer of microorganisms to other residents and environments. Reusable equipment shall be cleaned and disinfected between each resident use and is not used for the care of more than one resident until it has been appropriately cleaned and disinfected. Single resident items are used only for a single resident. During an interview on 6/17/25 at 8:52 AM, the Director of Nursing and the Cooperate Registered Nurse stated the facility did not have a policy for storage/labeling of resident supplies as that is a standard of care and not a policy. Second Floor: Intermittent observations and interviews revealed the following: B Wing- Shower Room, and Soiled Linen Room: -6/10/25 at 8:50 AM, plastic (PVC - polyvinyl chloride tubing) wide shower chair was dirty with a brown substance noted on the seat of chair; 2-3 inch raised area of dark black substance on shower room floor near the drain. There were three unlabeled opened bottles of 8-ounce shampoo/body wash cleansers; two unlabeled 8-ounce spray body cleansers. -6/10/25 at 9:00 AM, the soiled linen room had a strong foul odor of urine and feces. There were four barrels within the room; three of the barrels were uncovered and contained garbage and soiled linens. Additionally, there was no soap, paper towels or alcohol-based hand sanitizer present. -6/11/25 at 8:45 AM, the plastic (PVC - polyvinyl chloride tubing) wide shower chair remained dirty with the brown substance on the seat; the unlabeled opened bottles shampoo/body wash cleansers; spray body cleansers remained as well as the dark black debris on shower floor near the drain. The other shower stall had black debris on floor, and an unlabeled hairbrush on floor. -6/11/25 at 8:49 AM, the soiled linen room had a strong odor of urine and feces. There was an uncovered grey plastic barrel with garbage and an uncovered blue barrel with soiled linen. Additionally, there was no soap, paper towels or alcohol-based hand sanitizer available within the room. -6/11/25 at 8:56 AM, Resident room [ROOM NUMBER] had a strong urine odor and there was a urine-soaked brief on floor. At 9:02 AM, Licensed Practical Nurse #11 entered room and removed soiled brief from room. During an interview on 6/11/25 at 9:03 AM, Licensed Practical Nurse #11 stated dirty briefs should not be placed on the floor for infection control purposes. They stated the resident that was in room [ROOM NUMBER] was sent out to the hospital last night and the room should have been cleaned up immediately. They stated any aide, nurse and housekeeper could pick up a soiled brief, See it. Pick it up. During an observation and interview on 6/11/25 at 10:14 AM, Certified Nurse Aide #5 stated they did not know what the black/brown debris were on the shower room floor. They stated it looked like someone pooped on the shower chair and it had not been cleaned. Certified Nurse Aide #5 stated the person giving the shower was responsible for picking up and cleaning the shower room after giving a shower. They stated residents go to the bathroom while in the shower; and the shower chair, floor can get messy. They stated the shower chair and floor should be rinsed, cleaned off for infection control. Additionally, they stated used shampoo/body wash cleansers, used hairbrushes shouldn't be left in the shower room, because they don't know who they belonged to and should not be used on another resident. -6/12/25 at 8:55 AM, the B hallway had a strong urine odor present, flies were noted in the area. -6/12/25 at 9:20 AM, Resident room [ROOM NUMBER] had linen and a soiled brief on the floor. -6/12/25 at 9:25 AM, the soiled linen room had a strong odor of urine and feces. There were uncovered garbage and linen barrels containing garbage and soiled linens. There was no soap, paper towels or alcohol-based hand sanitizer available within the room. Second floor C wing/Central Shower/Bath, shower room, and soiled linen room: Intermittent observations revealed the following: -6/10/25 at 11:22 AM, plastic (PVC - polyvinyl chloride tubing) shower chair was dirty with a dried/smeared substance on the seat; there was a dirty washcloth laying on shower floor; and a clump of brown substance on shower floor. -6/10/25 at 11:27 AM, soiled linen room with strong foul odor of urine and feces and flies were noted within the room. There were uncovered soiled linen (blue) and garbage (grey) barrels. -6/11/25 at 9:17 AM, soiled linen room with strong foul odor of urine and feces and brown substance on the floor. Garbage and linen barrels remained uncovered. Flies observed in the hallway outside soiled linen room. -6/11/25 at 9:19 AM, the plastic (PVC - polyvinyl chloride tubing) shower chair was dirty with smeared brown substance on the seat; a clump of brown/black debris on shower floor; two 8-ounce unlabeled opened bottles of shampoo/body wash cleansers stored on the railing in shower stall. During an observation and interview Certified Nurse Aide #11 stated the aides were responsible for cleaning up after themselves after utilizing the shower rooms and equipment, to prevent cross contamination; and so, it was clean for the next resident to use. They stated the brown substance on the shower chair and floor should have been cleaned after resident use and housekeeping should have sanitized for infection control. During an observation of C wing shower room and interview on 6/11/25 at 9:56 AM, Licensed Practical Nurse #11 stated the substance on floor and shower chair was feces. They stated the feces looked like it had been there for a while. They stated the shower stall and shower chairs should be cleaned and sanitized between every resident for infection control purposes. Additionally, they stated opened soaps should not be left or stored in the shower room. -6/12/25 at 9:58 AM, the soiled linen room had a strong foul odor of urine and feces. The garbage and soiled linen barrels within the room were uncovered. Additionally, there were no paper towels available at hand washing station and no alcohol-based hand sanitizer present. During an observation and interview on 6/12/25 at 10:00 AM, Certified Nurse Aide #12 was observed to open soiled linen room door and stated Oh come on. I should have worn a mask; it smells so bad. Certified Nurse Aide #12 stated the soiled linen room smelled like a sewer and had no idea why it smelled like that. They stated the linen and garbage barrels should be covered with lids but even when covered the odor was still present. They stated the odor was not homelike and unsanitary. Certified Nurse Aide #12 stated housekeepers were not supposed to pick up poop. They stated the aides and nurses were supposed to clean up after themselves then notify housekeeping to sanitize as needed. Additionally, Certified Nurse Aide #12 stated they never tried to wash their hands in soiled linen rooms, never paid it much attention, but they should be able to immediately wash their after getting rid of soiled linen and trash for infection control purposes. During an interview on 6/12/25 at 10:38 AM, Housekeeper #1 stated any bio, biohazards: urine, vomit, feces, blood must be removed by nursing. They stated linen must be picked up and placed in soiled linen room by nursing. They stated they were not allowed to pick up any linen and are not supposed to pick up garbage's with biohazards. They stated if there is bio in the shower rooms they must wait for an aide to remove it so they can then sanitize. They stated when they see biohazards on the floor and on equipment, they report it to the first aide they see. They stated sometimes staff don't see things. They stated it was important for the shower rooms to be clean and organized because that was where the residents were showered and for infection control purposes. During an interview on 6/13/25 at 1:10 PM, Licensed Practical Nurse Unit Manager #2 stated nurse aides should be picking up linen, cleaning shower rooms, and putting supplies away after each shower so housekeeping can come in and sanitize. They stated personal supplies, shampoo/body washes should not be left in shower rooms. Licensed Practical Nurse #2, Unit Manager, stated shower chairs should not be stored dirty. Shower chairs should be wiped down and sanitized between residents for infection control. During an interview on 6/16/25 at 12:29 PM, the Director of Nursing stated they expected shower chairs to be wiped down between each resident. They stated once the bulk of debris was cleaned, housekeeping should sanitize. They stated they expected the shower rooms to be cleaned before being used again. They stated supplies should be labeled with resident name if being used more than once for infection control purposes. Additionally, the Director of Nursing stated housekeeping staff can remove soiled linen if proper personal protective equipment was worn. During an observation and interview on 6/10/25 at 9:10 AM, Resident room [ROOM NUMBER] had a urine odor in the room. Noted in the garbage can near the bed was a urine-soaked brief. The resident in the room stated they no longer notice the offensive odors because their nose got used to the smell. They stated when their family member visits, they notice the foul odors right away, so they brought in air freshener. Aerosol air freshener spray was observed on the resident tray table. During observations on 6/10/25 at 10:00 AM and 6/12/25 at 9:13 AM, Resident room [ROOM NUMBER] the shared bathroom had an unlabeled wash basin on floor the under sink. During an interview on 6/10/25 at 10:00 AM, Resident #381 stated some housekeepers do their jobs, they clean and collect garbage; while other housekeepers just remain in the hallway and must ask for their garbage to be removed. During an observation on 6/10/25 at 9:42 AM of Resident room [ROOM NUMBER], there was a wash basin was on the floor of the bathroom. During an observation and interview on 6/10/25 at 12:09 PM, Resident room [ROOM NUMBER]'s private bathroom had a wash basin on floor under sink. Resident #388 stated there was a urine odor every day on unit. Resident #388 stated housekeeping needed to do a better job cleaning the rooms. They stated their room should be cleaned like it was their home. During observations on 6/12/25 at 9:13 AM, 12:20 PM and 6/16/25 at 11:27 AM, Resident #381's tube feeding pole (medical equipment) was dirty with a thick dried tan substance and floor near pole was sticky with tan liquid. 2. Third Floor: Observations: a. The following was observed on 6/10/25 at 2:19 PM, 6/11/25 at 9:09 AM and 6/12/25 at 3:50 PM in Resident room [ROOM NUMBER]: -upon entering the room, there was a gray basin on the floor to the right of the doorway that contained a yellow liquid (near the door side bed). To the right side of the door bed there were plastic totes stacked on top of each other. The totes had personal belongings and clothing piled on top. Noted at the top of the pile of was a large gray bedpan placed up-side down. - a second empty gray basin was on the floor at the head of next to the bed by the window. The resident in room (door bed) at the time of the observation stated the basin had been on floor for a while, and they did not like the basin being stored on the floor or the bedpan being placed and stored on their clothes. The resident stated they did not feel their room was homelike. During an observation and interview on 6/12/25 at 3:53 PM, Licensed Practical Nurse Unit Manager #1 entered the room with the surveyor and stated they were not sure why the bedpan was stored on top of the resident's belongings. They were was not sure why there were basins on the floor but that was not a good place to store them. They stated floors were dirty and basins, including bedpans, should be stored in the night stand or in the bathroom. They stated they were not sure why the resident by the door did not have a dresser. Licensed Practical Nurse Unit Manager #1 stated the liquid in the basin was the color of urine but had no odor and did not know what it was. They stated the storage of bedpans on top of a pile of personal belongings and basins on the floor was an infection control issue and did not provide a homelike environment. During an interview on 6/12/25 at 4:00 PM, Licensed Practical Nurse #13 stated they do not know why there were basins stored on the resident's floor and they should not be there because they could cause a fall. Licensed Practical Nurse #13 stated bedpans should be stored in the bathroom, not upside down on a pile of clothes. They stated the basins and bedpans had germs and could spread germs everywhere. b. Third Floor A Wing hallway Shower Room: Observations -6/10/25 at 10:23 AM, there was six open/unlabeled house stock body washes, two open/unlabeled house stock powders and one open/unlabeled house stock shaving gel stored on the handrail in the shower stall. -6/12/25 at 3:40 PM, there were seven open/unlabeled house stock body washes, two open/unlabeled house stock powders and one open/unlabeled house stock shaving gel stored on the handrail in the shower stall. During an observation and interview on 6/12/25 at 4:05 PM, Licensed Practical Nurse Unit Manager #1 entered the A wing shower room with the surveyor. Licensed Practical Nurse #1 stated there stock hygiene items in the shower stall that were open and not labeled with any resident's name. They stated the facility process was each resident was designated stock hygiene items that were to be labeled with their name. Licensed Practical Nurse #1 stated it was not appropriate for staff to leave used soaps in the community shower room because there was a potential for the product to be used on more than one resident causing an infection control hazard. During an interview on 6/17/25 at 10:28 AM, the Infection Preventionist/Assistant Director of Nursing stated they would expect the linen bins to be covered in any soiled utility room so there was no chance of spreading infection and it would be helpful prevent odors. They stated they would expect staff to perform hand hygiene after disposing of the soiled linens at the hand sanitizing station in the hallway or even in the shower room. The infection preventionist stated it would not be a bad idea to place a hand sanitizing station in the soiled utility rooms. The Infection preventionist stated basins should not be stored on residents' floor for infection control reasons. The Infection Preventionist stated that staff should not be leaving/storing stock personal care items in the shower rooms because of infection prevention purposes. The Infection Preventionist added cleanliness in the facility was something they needed to work on, and the environmental concerns were not considered home-like. During an interview on 6/17/25 at 11:22 AM, the Director of Nursing stated their expectation for storage of basins and bedpans would be stored in the resident's cupboard on top of a clean barrier. The Director of Nursing stated that housekeeping/laundry department should ensure lids were on the soiled laundry bins to mitigate odors. They stated staff should have the means to sanitize their hands inside of the soiled utility room and a hand hygiene station needed to be place inside of the soiled utility room. The Director of Nursing added that these issues would detract (diminish) from a home-like environment. 10NYCRR 415.5 (h)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a Standard survey completed 6/17/25, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and a comfortable environment, to help prevent the development and transmission of communicable diseases and infections for five (5) (Residents #165, #173, #381, #382 and #387) of seven (7) residents observed for Enhanced Barrier Precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities). Specifically, staff did not maintain enhanced barrier precautions and wear the appropriate personal protective equipment while providing direct care for residents with a feeding tube (#173, #381); urinary catheter (#382); a peripherally inserted central catheter (#387) and for a resident with a pressure ulcer requiring a dressing (#165). In addition, there was no Enhance Barrier Precautions sign posted outside Resident #165's door. The findings are but not limited to: The policy titled Enhanced Barrier Precautions last revised on 3/12/25, documented enhanced barrier precautions will be implemented and is applicable for residents with any of the following: infection or colonization with a Multiple Drug-Resistant Organisms, wounds (any type of wound requiring a dressing) and/or indwelling medical devices (central line, urinary catheter, feeding tube, etc.) regardless of Multiple Drug-Resistant Organisms colonization status. Enhanced Barrier Precaution requires wearing disposable gloves and an isolation gown prior to high contact activity. High contact resident care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care - any skin opening requiring a dressing. Signage is placed on the door or just outside the resident's room to indicate Enhanced Barrier Precautions are in place. Review of the Enhanced Barrier Precaution signage (a sign used by the facility that was posted outside a resident's door to indicate they required enhanced barrier precautions) documented that providers and staff must wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care (any skin opening requiring a dressing). 1. Resident #387 had diagnoses including septicemia (a severe blood stream infection), diabetes mellitus, and hypertension (high blood pressure). The Minimum Data Set (a resident assessment tool) dated 6/13/25 documented Resident #387 had intact cognition, was understood, and understands. The undated comprehensive care plan identified as current by Registered Nurse Unit Manager #1, documented the resident had a risk for Multiple Drug-Resistant Organisms, colonization/infections related to a peripherally inserted central catheter (PICC line). Interventions included enhanced barrier precautions which included wearing a gown and gloves when providing high contact activities at the bedside. The Kardex Report (a guide used by staff to provide care) dated 6/16/25/25 documented Resident #387 was dependent on two or more staff for transferring from the bed to the wheelchair using a mechanical lift device and was on enhanced barrier precautions. During an observation on 6/11/25 at 10:01 AM Registered Nurse Unit Manager #1 entered Resident #387's room, put on gloves and disconnected their intravenous antibiotic, and flushed the peripherally inserted central catheter (PICC line) without wearing a gown. There was an Enhanced Barrier sign posted on the wall next to the room's entrance that notified staff and visitors what personal protective equipment should be utilized when caring for the resident. Additionally, there was personal protective equipment available in the hallway. During an observation on 6/12/25 at 9:44 AM, Registered Nurse Unit Manager #1 while only wearing gloves, accessed the Intravenous tubing and intravenous bag, flushed the peripherally inserted central catheter (PICC line) and connected the intravenous antibiotic. Registered Nurse Unit Manager #1 did not wear a gown. During an interview on 6/16/25 at 10:45 AM, Registered Nurse Unit Manager #1 stated Resident #387 had a peripherally inserted central catheter which was covered with a dressing and was a closed system, therefore they thought enhanced barrier precautions were not required. After reviewing the posted Enhanced Barrier Precaution sign, Registered Nurse Unit Manager #1 stated they should have worn a gown and gloves when working with Resident #387's peripherally inserted central catheter (PICC line). During an observation on 6/16/25 at 10:49 AM Certified Nurse Aide #15 and Physical Therapist #1 transferred Resident #387 with the mechanical lift from their bed into a wheelchair. Certified Nurse Aide #15 wore a mask and gloves but did not wear a gown. Physical Therapist #1 wore gloves but did not wear a gown. During an interview on 6/16/25 at 10:56 AM, Certified Nurse Aide #15 stated they followed standard precautions for all residents but should have followed enhanced barrier precautions and worn a gown while transferring Resident #387. During an interview on 6/16/25 at 11:02 AM, Physical Therapist #1 stated they did not see the Enhanced Barrier Precaution Sign posted and was not aware Resident #387 had a peripherally inserted central catheter (PICC line). They stated in addition to the gloves they should have worn a gown while transferring Resident #387. Transferring was considered a high care activity. During an interview on 6/17/25 at 9:20 AM, the Assistant Director of Nursing/Infection Preventionist stated Resident #387 had a peripherally inserted central catheter and staff were expected to wear gloves, gowns, and masks when splashing could occur during high care activities. 2. Resident #173 had diagnoses including intracerebral hemorrhage (bleeding in the brain, stoke), dysphagia (difficulty swallowing) and gastrostomy (surgical procedure for inserting a tube through the abdomen wall into the stomach for the purposes of nutrition) infection. The Minimum Data Set, dated [DATE] documented Resident #173 was severely cognitively impaired, understood and understands. The assessment tool documented that resident had a feeding tube. The comprehensive care plan updated 3/8/25, documented Resident #173 was at risk for multiple drug resistance colonization/infection related to a percutaneous endoscopic gastrostomy tube (PEG tube/feeding tube). Interventions include to educate resident and visitors on enhanced barrier precautions and wear gown and gloves when providing high contact activities at the bedside. The Kardex dated 6/16/25, documented Resident #173 was on enhanced barrier precautions and to use gown, gloves and mask when performing high-contact activities. During intermitted observations on 6/11/25 at 10:17 AM, 6/12/25 at 3:38 PM, 6/13/25 at 8:41 AM and 6/13/25 at 1:40 PM, Resident #173 had an Enhance Barrier Precaution sign posted outside of their door that directed staff to wear gloves and gowns when providing care during high-contact resident care activities for device care: use of a feeding tube. During on enteral feed observation on 6/13/25 at 1:40 PM Licensed Practical Nurse #3 put on gloves and administered 500 milliliters of Nutren 2.0 enteral feed to gravity along with water flushes via Resident #173's percutaneous endoscopic gastrostomy (PEG) tube. Licensed Practical Nurse #3 did not wear a gown while providing care. During an interview on 6/13/25 at 3:57 PM, Licensed Practical Nurse #3 stated that Resident #173 was on enhance barrier precautions for an open area to their right ankle. They stated they should have worn a gown when they administered Resident #173 enteral feed. Licensed Practical Nurse #3 stated enhance barrier precautions were to be utilized when a resident had a percutaneous endoscopic gastrostomy (PEG) tube. During an interview on 6/17/25 at 9:14 AM, Licensed Practical Nurse Unit Manager #1 stated enhanced barrier precautions were to be used when a resident had a percutaneous endoscopic gastrostomy (PEG) tube and staff should be wearing gloves and gowns when they do any resident care. During an interview on 6/17/25 at 11:13 AM, the Director of Nursing stated that enhanced barrier precautions should be utilized on residents that have tubes going in/out of the body. 3. Resident #382 had diagnoses including sepsis (severe blood infection), urinary tract infection and obstructive and reflux uropathy (urinary tract disorders). The comprehensive care plan initiated 6/2/25 documented Resident #382 was at risk for multidrug-resistant organisms (MDRO) colonization/infections related to a urinary catheter (tube inserted into bladder to drain urine). Interventions included enhanced barrier precautions: wear personal protective equipment (PPE) (gown, gloves) when providing high contact activities at bedside including device care and/or use. May additionally wear face protection if there is a risk of splash or spray. Additionally, Resident #382 required assist with self-care and mobility. Interventions included substantial assist of one staff for toileting hygiene. During an observation on 6/10/25 at 9:20 AM Resident #382's room had an Enhanced Barrier Precaution sign posted outside the room above the name placard that directed staff of the appropriate protective equipment to be worn. Certified Nurse Aide #10 entered the room without personal protective equipment, applied gloves and emptied urinary catheter drainage bag into a urinal and then secured urinary catheter bag to side of bed. During an observation on 6/13/25 at 8:25 AM Certified Nurse Aide #10 wearing only gloves emptied Resident #382's urinary leg bag into urinal, spilling urine on floor. During an interview on 6/12/25 at 8:58 AM, Resident #382 stated nursing staff wear gloves when they provide urinary catheter care, but they do not wear gowns. During an interview on 6/13/25 at 8:30 AM, Certified Nurse Aide #10 stated personal protective equipment was supposed to be worn when residents were on enhanced barrier precautions, and they should have worn a gown when they emptied Resident #382's urinary catheter. During an interview on 6/13/25 at 12:05 PM, Licensed Practical Nurse #9 stated nursing staff should have on gloves, gown and face shield when completing urinary catheter care. During an interview on 6/13/25 at 12:41 PM, Licensed Practical Nurse Unit Manager #2, stated residents with urinary catheters were on enhanced barrier precautions and wearing gown and gloves were required. During an interview on 6/16/25 at 12:29 PM, the Director of Nursing stated they expected staff to pay attention to precaution signs posted and wear personal protective equipment according to the sign. 4. Resident #165 had diagnoses including metabolic encephalopathy, (a brain dysfunction leading to altered mental status) hypertension and pressure ulcer of the sacral area. The Minimum Data Set, dated [DATE] documented Resident #165 was severely cognitively impaired, understood and understands. The comprehensive care plan updated 4/22/25, documented Resident #165 had an actual stage 4 pressure ulcer to the coccyx (tailbone). Intervention included to apply treatments per order. The care plan did not address enhanced barrier precautions. The Kardex dated 6/13/25 The Kardex did not document the resident was on enhanced barrier precautions. The medication administration record date 6/1/25-6/30/25 documented Resident #165 had an order to cleanse their coccyx pressure ulcer with Vashe wound cleanser every day and as needed and cover with bordered foam. During an observation on 6/12/25 at 9:07 AM, Certified Nurse Aide #5 completed morning care for Resident #165. Resident #165's had a bandage to their coccyx area with serosanguinous drainage (drainage mixed with blood and serum). At 9:31 AM, Licensed Practical Nurse #4 entered the room and completed the pressure ulcer treatment to the resident's coccyx. Certified Nurse Aide #5 and Licensed Practical Nurse #4 did not wear a gown during the direct hands-on care. There was no Enhance Barrier Precautions sign posted outside of Resident #165's room. During an interview on 6/12/25 at 3:05 PM, Certified Nurse Aide #5 stated if a resident was on enhance barrier precautions there would be a precaution sign posted by or on their door. A resident with an open wound should be on enhanced barrier precautions. They stated they did not wear a gown because there was no sign posted and they did not know the resident had an open wound until it was too late. They stated they should have worn a gown while providing care. During an interview on 6/16/25 at 12:29 PM, Licensed Practical Nurse #4 stated when they completed the pressure ulcer treatment on 6/12/25 there was not an Enhanced Barrier Precaution sign posted by Resident #165's door, and they did not wear a gown because there was no sign. Licensed Practical Nurse #4 stated they should have because the resident had an open pressure ulcer. During an interview on 6/16/25 at 12:43 PM, Register Nurse Assistant Unit Manager #1 stated they initiated an Enhanced Barrier Precaution signage for Resident #165 upon their admission. They stated they were unsure why there was no sign posted at present but there should be. Registered Nurse #1 stated staff were to wear gloves and gowns while completing treatments and care to Resident #165 because they have an open pressure ulcer. During an interview on 6/17/25 at 10:20 AM, the Assistant Director of Nursing/Infection Preventions stated they were responsible for initiating the Enhanced Barrier Precaution signage, but any staff member could initiate one. They stated Resident #165's pressure ulcer was so small, less than a centimeter, and the drainage could be controlled so they did not feel the resident needed to be on enhance barrier precautions. During an interview on 6/17/25 at 11:13 AM, stated the Infection Preventionist was responsible for initiating enhance barrier precautions. The Director of Nursing stated Resident #165's wound was small but if there was drainage then Resident #165 should have been on enhanced barrier precautions. During an interview on 6/17/25 at 10:20 AM, the Assistant Director of Nursing/Infection Preventionist stated residents should be on enhanced barrier precautions for wounds that are bigger than what could be covered by a band-aid, intravenous line, dialysis ports, foley catheters, percutaneous endoscopic gastrostomy tubes (PEG) and residents that have colonized multi-resistant drug organisms. They stated staff were required to wear gowns, gloves and a mask if there was potential for fluid splashing. 10NYCRR 415.19(a)(2) (b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Complaint Investigation (Complaint #NY00381783) conducted during the Standard survey completed on 6/17/25, the facility did not maintain an effective pest control program so that the facility was free from insects. Specifically, three (3) (Second Floor, Third Floor, and Fourth Floor) of three (3) resident units had issues with many flies observed throughout the facility. The findings are: The policy titled, Pest Control, created 11/2022 documented the facility shall maintain an effective pest control program. The facility maintains an on-going pest control program to ensure the building is kept free of pests and pest control services are provided through contract with an approved pest control provider. The Licensed Exterminator's most recent Service Report, dated 6/6/25, documented the fourth floor was inspected for large flies. The Technician Notes documented resident room [ROOM NUMBER] seemed to be the source of the flies and large flies were observed in the hallway and other patients' rooms in a lesser proportion than in room [ROOM NUMBER]. The Technician Notes also suggested daily rubbish management, working insect light traps, additional glue board devices, and replace or install tight fitting insect screens on windows. A second Service Report, also dated 6/6/25, documented two insect light trap bulbs were repaired and a new insect light trap glue board was provided on the fourth floor. Also, a fly bait sticker, a new insect light trap, and four fly glue sticks were provided for resident room [ROOM NUMBER]. Review of Licensed Exterminator Service Reports from 3/4/25 to present revealed the two Service Reports dated 6/6/25 were the only ones to address flies. Observation on the fourth floor on 6/10/25 at 8:30 AM revealed one dead fly was in the freezer in the Nourishment Room. At the time of the observation, Certified Nurse Aide #1 stated the fly in the freezer was disgusting. During an interview on 6/11/25 at 12:00 PM, Resident #114 stated the flies go room to room on the third floor. They stated they had neither seen improvement or worsening of the flies recently. Resident #114 also stated the windows at the ends of the halls did not have screens on the top panes and people had been opening those windows without screens, which they believed to be the cause of the issue. During an interview on 6/11/25 at 12:20 PM, Resident #229 stated there were flies in their room and on their body. They also stated because they ate their meals in their room, the flies were around their food. Resident #229 stated, They try to get in your food, and that happened at lunch today. At the time of the interview, two live flies were observed on Resident #229's legs. During an interview on 6/11/25 at 12:35 PM, the Maintenance Director stated they had screwed shut the top panes of the windows at the ends of the hallways this week. They stated staff members were opening the windows from the top down and the bottom up, which could have let in flies due to no window screen at the top half. Observation on the second floor on 6/11/25 at 12:35 PM revealed a small plug-in style fly light, missing the glue paper, was plugged in inside resident room [ROOM NUMBER]. At the time of the observation, the Maintenance Director stated the facility did not provide this device. During an interview on 6/11/25 at 12:40 PM, Resident #51 stated flies were around and they were bothersome during meals. During an interview on 6/11/25 at 12:50 PM, Resident #386 was seated in a chair next to their bed and stated there were flies in their room. At this time, two live flies were observed on Resident #386's bed and pillow. During an interview on 6/11/25 at 1:48 PM, Resident #158 stated they hated flies and sometimes flies landed on their body. At this time, one live fly was flying back and forth inside Resident #158's room. Observation on the fourth floor on 6/11/25 at 2:02 PM, revealed a small plug-in style fly light, missing the glue paper, was plugged in inside resident room [ROOM NUMBER]. At the time of the observation, the Maintenance Director stated the facility did not provide this device. During an interview on 6/12/25 at 12:05 PM, the Maintenance Director stated they purchased and installed insect light traps in the corridors, and inside resident room [ROOM NUMBER] three to four months ago. They stated they maintained the insect light traps by replacing the glue papers about once every two weeks, or as needed. The Maintenance Director stated the fly issue had gotten worse over the last two to three weeks because of the warmer weather. They stated the files on the second and third floor had recently improved, and the flies on the fourth floor were under control, but not improving, so last week they asked the licensed exterminator to get involved. The Maintenance Director stated they did not know why the licensed exterminator identified resident room [ROOM NUMBER] as the source of the flies and the resident in that room refused to allow most people to enter their room. The Maintenance Director stated staff could communicate any pest sightings to them verbally, and they would add it to the Pest Control Log that was maintained between themselves and the licensed exterminator, or staff could write any pest concerns in the Maintenance Log binder that was kept at each Nurses' Station. Review of the Pest Control Log dated 1/13/25 to present revealed it contained no entries about flies. Review of the Maintenance Log binders located at the second, third, and fourth floor Nurses' Stations revealed they contained no recent entries about flies. During an interview on 6/12/25 at 12:20 PM, the Director of Housekeeping and Laundry stated flies in the facility had been an issue off and on, but not a constant problem. They stated the resident inside room [ROOM NUMBER] did not let most staff enter their room, but did allow one Housekeeper to enter for daily cleaning. They stated the Housekeeper removed the garbage and cleaned as much as they could on a daily basis, but the resident would not allow them to touch the area around or under their bed or their tray table. The Director of Housekeeping and Laundry also stated the resident inside room [ROOM NUMBER] had a habit of throwing food and drink, which made it difficult to maintain cleanliness. The Director of Housekeeping and Laundry stated the flies inside resident room [ROOM NUMBER] were unsanitary. Observation on 6/16/25 at 11:30 AM, revealed a yellow fly glue strip was hanging from the ceiling in the center of resident room [ROOM NUMBER], and there were at least 50 dead flies stuck to the strip. At this time, the Maintenance Director stated the facility provided the yellow fly glue strips, they were temporary, and they were more for function than for looks. The Maintenance Director also stated the fly glue strip in resident room [ROOM NUMBER] needed to be changed. 2. Observation on 6/10/25 at 9:42 AM in resident room [ROOM NUMBER] there were approximately five to six flies in the room and on the resident's bed. The resident stated, there are flies everywhere and that it bothered them. Observation on 6/10/25 at 9:52 AM in resident room [ROOM NUMBER] there were approximately three flies in the room and on the resident's body. Observation on 6/10/25 at 10:00 AM in resident room [ROOM NUMBER] there were flies in the room. The resident stated that the flies in the room bothered them. Observation on 6/10/25 at 10:12 AM in resident room [ROOM NUMBER] there was a fly strip hung from the ceiling with approximately 20 to 30 dead flies stuck to it. Observation on 6/10/25 at 11:00 AM on Unit 2 C hall numerous flies flying throughout the hallway. Observation on 6/11/25 at 8:48 AM, resident room [ROOM NUMBER] had 10 to 15 flies in the room and three flies landed on the resident. Observation on 6/12/25 at 12:15 PM in resident room [ROOM NUMBER] there were approximately 30 flies on the wall, bedside table, and resident's bed. During an interview on 6/11/25 at 8:21 AM Resident #19 stated that there were large, black house flies that landed on them, their face, and it bothered them. They stated that they told staff about the flies and staff stated they would tell maintenance. During an interview on 6/12/25 at 3:14 PM Resident #16 stated that the flies in the room bothered them. They stated that a fly strip did not bother them, but the flies bothered them. During an interview on 6/12/25 at 3:20 PM Certified Nurse Aide #14 stated that the flies have been bad since they started working there. They stated that the flies land on residents and they thought it was dirty. They stated that it was difficult for residents to brush flies away who can't do that for themselves. During an interview on 6/12/25 at 4:00 PM, Resident #33's representative, stated they asked staff to clean up the room to get rid of the flies. They stated that they knew that flies would bother Resident #33. During an interview on 6/17/25 at 9:03 AM with Licensed Practical Nurse Unit Manager #1 stated that they believed there were flies on the unit due to a resident urinating on the floor and on their mattress. During an interview on 6/17/25 at 11:35 AM, the Administrator stated that they were aware of the fly issue. They stated that they had been working with the pest control contractors who have been coming in weekly or twice weekly to control the flies. They stated that the pest control contractors brought in an entomologist (a scientist who specializes in the study of insects and their environment) for recommendations to control the flies. They stated that they had insect lights installed to take care of the flies, but it did not work as they needed complete darkness to work. They stated that the entomologist recommended another type of insect light that would work better in a nursing home environment. They stated that they believed this light worked better than the previous one. 10 NYCRR 415.29(j)(5)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Abbreviated Survey (Complaint #NY00364627), the facility did not ensure that each resident was treated with respect and dignity in an environment that promotes maintenance or enhancement of his or her quality of life; recognizing each resident's individuality and protect and promote the rights of the residents for three (3) (Resident #1, 2, & 3) of three (3) reviewed. Specifically, an altercation amongst staff occurred in front of residents, was recorded and posted on social media. The finding is: The policy and procedure titled Quality of Life/Dignity dated 5/2024 documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be always treated with respect and dignity. Residents private space shall be respected at all times. The policy and procedure titled Resident Rights dated 5/2024 documented all residents shall be treated with kindness, respect, and dignity. The policy and procedure titled Cell Phone Use dated 10/2019 documented to maintain privacy and confidentiality rights of our residents; to be in compliance with Health Insurance Portability and Accountability Act (HIPAA), cellular telephones or any other electronic device is prohibited in resident areas. HIPAA Protected Health Information (PHI) should never be stored, shared or accessed on a personal device. Inappropriate use of cellular device by an employee includes, but is not limited to, photographing or videoing residents, sharing HIPPA protected information via unsecured networks such as text messaging, or electronically sharing resident information that does not meet the minimum necessary standard on a personal device. Resident #1 had diagnoses including anxiety, multiple sclerosis, and diabetes. The Minimum Data Set (a resident assessment tool) dated 11/15/24 documented that Resident #1 had severe cognitive impairment, was sometimes understood and sometimes understands. Resident #2 had diagnoses including Alzheimer's disease, hypertension (high blood pressure), and diabetes. The Minimum Data Set, dated [DATE] documented Resident #2 had severe cognitive impairment, was sometimes understood and usually understands. Resident #3 had diagnoses including anxiety, depression, and diabetes. The Minimum Data Set, dated [DATE] documented that Resident #3 had moderate cognitive impairment, was understood and understands. Review of Complaints/Incidents Tracking System ACTS/ Investigative Report received on 12/13/24 at 12:36 PM documented a video was shared on social media that involved a fight amongst facility staff. During an observation on 4/10/25 at 10:21 AM of the video posted on social media from 12/10/24 at 7:07 PM revealed an altercation amongst staff members. Yelling and screaming was heard on the video. Licensed Practical Nurse #1 and Certified Nurse Aide #1 were seen throwing objects in a resident care area with residents present in the lounge area in front of the nurse's station. The facility investigation revealed a written/signed statement dated 12/12/24 by Licensed Practical Nurse #2's that they came up to the third floor and observed Licensed Practical Nurse #1 throw a nutritional supplement and a stapler at Certified Nurse Aide #1. Certified Nurse Aide #1 threw French fries and cranberry juice back at Licensed Practical Nurse #1. Licensed Practical Nurse #2 attempted to remove Licensed Practical Nurse #1 from the situation. Licensed Practical Nurse #1 was yelling at Certified Nurse Aide #1 and pushed Licensed Practical Nurse #2 in an attempt to get near Certified Nurse Aide #1. Licensed Practical Nurse #2 then called 911, checked on the residents in the lounge area, and ensured they were safe. The date and time of the fight was not documented on the statement. Review of a documented interview on 12/11/24 between Licensed Practical Nurse Unit Manager #3 and Resident #1 revealed that on 12/10/24 Resident #1 was in the lounge while the fight between staff occurred. Resident #1 stated to Licensed Practical Nurse Unit Manager #3 that Licensed Practical Nurse #1 and Certified Nurse Aide #1 were yelling at one another. Resident #1 stated they felt safe. During a telephone interview on 4/10/25 at 11:28 AM, Registered Nurse #1 stated the fight between Licensed Practical Nurse #1 and Certified Nurse Aide #1 occurred on 12/10/25 in the evening on the 3rd floor at the nurse's station. A video was posted on social media, and it was a HIPPA (privacy rights) violation as there were residents located and seen in the area and was against resident rights. They were unaware of who recorded the video. On 4/10/25 at 3:20 PM a telephone interview was attempted with Licensed Practical Nurse #1 without success. During a telephone interview on 4/10/25 at 3:42 PM, Certified Nurse Aide #1 stated they were involved in a fight on 12/10/25 at 7:00 PM with Licensed Practical Nurse #1. The incident occurred in front of residents, and it was inappropriate and disrespectful. We should not have been fighting in the resident's home. Resident's #1, 2, & 3, I'm sure were shocked and frightened. Certified Nurse Aide #2 had recorded the fight on their cell phone and they saw the incident posted on social media. During an interview on 4/10/25 at 4:10 PM, Certified Nurse Aide #3 stated there were so many staff members and the scene was chaotic. They stated they were sure the residents in the area were confused, scared and could have been injured. The whole thing was undignified, and should not have happened. During an interview on 4/11/25 at 8:30 AM, Licensed Practical Nurse #2 stated the fight between Licensed Practical Nurse #1 and Certified Nurse Aide #1 took place in front of Resident's #1, 2 & 3 after supper at 7:00 PM. The yelling and screaming made them feel scared, intimidated, and was undignified. We would not want to see that in our home, and the resident's should not have had to see that in their home. Resident's 1, 2, & 3 were posted in the social media post which was a breach in HIPPA (privacy rights) and a dignity concern. During an interview on 4/11/25 at 8:45 AM, Registered Nurse #2 stated cell phone use was prohibited and the social media video violated residents' privacy. During an interview on 4/11/25 at 9:00 AM, Certified Nurse Aide #2 denied video recording the fight and stated photographing and video recording of resident's was against HIPPA (privacy rights) and was disrespectful. This was their home. During an interview on 4/11/25 at 11:27 AM, Resident #1 had no recollection of the staff altercation on 12/10/24 and answered yes when asked if the staff treated them with respect and dignity. During an interview on 4/11/25 at 11:45 AM, Resident #2 stated they were treated well here in the facility. Resident #2 could not recall the staff altercation from 12/10/24. During an interview on 4/11/25 at 12:02 PM Resident #3 stated fighting would be horrible. There's a time and place for fighting. Resident #3 was unable to recall the staff altercation on 12/10/24. During an interview on 4/11/25 at 1:15 PM, the Director of Nursing stated the staff acted inappropriately in the resident's home. The fighting, yelling, and commotion was unprofessional and disrespectful to all residents. Licensed Practical Nurse #1 and Certified Nurse Aide #1 actions created an undignified environment. The social media post violated Resident #'1, 2 & 3's privacy rights. During a telephone interview on 4/11/25 at 1:37 PM, the Administrator stated the fight, video recording, and staffs' behavior must have made the residents feel uncomfortable. The social media post violated resident rights, was against facility policy, and was unacceptable. 10NYCRR 415.3 (c) (1) (i)

Based on interview and record review conducted during a Complaint (#NY00375418) investigation, it was determined the facility did not ensure that all violations of abuse are thoroughly investigated for one (1) (Resident #4) of three (3) residents reviewed. Specifically, Resident #4 had an injury of unknown origin that was not thoroughly investigated. The finding is: A policy and procedure titled Abuse dated 12/2022 documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility. The policy and procedure documented the facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. A policy and procedure titled Accidents - Incidents dated 7/2020 documented the facility would monitor and evaluate all occurrences of accidents or incidents or adverse events occurring on the facility's premises which is not consistent with the routine operation of the facility or care of a particular resident. These occurrences must be evaluated and investigated. A policy and procedure titled Investigations - Injury of Unknown Etiology dated 11/2019 documented an investigation of all injuries of unknown etiology including bruises, abrasions and injuries of unknown origin source, will be conducted by an individual appointed by the Administrator, to ensure that the safety of our residents has not been jeopardized, and to investigate any potential abuse or neglect. Resident #4 was admitted to the facility with Alzheimer's disease and dysphagia (difficulty in swallowing). The Minimum Data Set (a resident assessment tool) dated 3/25/2025 documented Resident #4 was severely, cognitively impaired, was sometimes understood by others and sometimes understood others. The resident had no upper body impairments and was dependent on others for mobility. The undated comprehensive care plan documented that Resident #4 had impaired cognition, required assistance with activities of daily living, had limited physical mobility related to pain and weakness. Interventions included to ask yes or no questions to determine the resident's needs. A progress noted dated 3/12/2025 at 7:15 PM completed by License Practical Nurse Unit Manager #7 documented that during rounds, Resident #4 was found leaning to their left side. When the staff repositioned the resident, they discovered bruising on Resident #4's left arm and shoulder. The Medical Director was notified with new orders to discontinue Eliquis (a blood thinning medication) and therapy to improve core strength. A progress note dated 3/13/2025 at 2:57 PM documented the Occupational Therapist performed range of motion (ROM, moving arms or legs to determine how far they can move) exercises on Resident #4. The noted documented that Resident #4 did not have pain during the exercises. An SBAR (situation, background, assessment, recommendation) Communication Form and Progress Note completed by Licensed Practical Nurse Supervisor #6 dated 3/15/25 at 7:10 AM documented that Resident #4 had decreased mobility and this sign/symptom, and condition had not occurred before. A late entry progress note dated 3/15/2025 at 9:53 AM documented that Licensed Practical Nurse Supervisor #4 went to see a bruised area on Resident #4 at 6:00 AM, assessed Resident #4 and noted a protrusion within a bruised area on Resident #4's left shoulder. The progress noted documented that Resident #4 flinched from pain. Resident #4 was medicated with acetaminophen (pain reliever) with no relief and then was transported to the hospital. A progress noted dated 3/15/2025 at 8:59 AM completed by Licensed Practical Nurse Supervisor #5 documented that Resident #4 was admitted to the hospital with a fractured clavicle (bone connecting shoulder blade to breastbone). During an interview on 4/10/2025 at 8:55 AM, Licensed Practical Nurse Supervisor #6 stated there wasn't an incident report or investigation completed because Resident #4 had a bruise there. They stated they probably should have started an investigation and called the Director of Nursing because a protrusion was noted and that was new. They also stated that a Registered Nurse did not assess the resident because there were no Registered Nurses on duty at that time. They stated that they texted pictures of the shoulder to Licensed Practical Nurse Unit Manager #7. During an interview on 4/10/2025 at 10:58 AM, Licensed Practical Nurse Unit Manager #7 stated that the resident had horrible posture and that that's what they assumed caused Resident #4's initial bruise from a few days ago. They stated that this incident with the bone protruding from the bruise should have been reported to the Director of Nursing and the Administrator. They stated that if there was an injury of unknown origin, an investigation would have been initiated; employees would provide statements, and they would go back 72 hours to obtain employee statements to determine how the injury happened. They stated they received a text from one of the nursing supervisors and they advised them to send Resident #4 to the emergency room. During an interview on 4/10/2025 at 12:29 PM, Licensed Practical Nurse Supervisor #5 stated that an investigation was not started because there was an investigation concerning the resident's bruise from a few days ago. They stated that they were not sure if a Registered Nurse was in the building at the time to do an assessment. During an interview on 4/10/2025 at 1:00 PM, the Medical Director stated they would expect an investigation completed for an injury of unknown origin. During an interview on 4/10/2025 at 1:38 PM, Certified Nurse Aide #4 stated they did not remember if they were asked for a witness statement or not. They stated that they get in-serviced on abuse during orientation and it was part of their annual education. They stated that if there was a bruise on a resident, they would report it to their nurse. During an interview on 4/10/2025 at 3:06 PM, the Director of Nursing stated that they did not get an x-ray for Resident #4's shoulder because the resident was not exhibiting any pain during the occupational therapy evaluation. They stated that a Registered Nurse assessment was not needed as they sent the resident to the hospital right away. They stated that the bump or protrusion on Resident #4's shoulder was part of the bruise that was previously investigated so they didn't initiate another investigation. They stated that they were on call and would have come into the facility if a resident needed a Registered Nurse assessment. During an interview on 4/11/2025 at 8:31 AM, the Occupational Therapist stated they saw Resident #4 for a therapy evaluation related to the resident's positioning and core strength. They performed range of motion exercises on Resident #4's left arm and shoulder on 3/13/2025. They stated that Resident #4 at that time did not complain of pain and showed non-verbal signs of pain (grimacing, wincing, or guarding motions). They stated that if they saw a bone protruding where the bruise was located, they would have told nursing right away. During an interview on 4/11/2025 at 9:18 AM, License Practical Nurse Supervisor #4 stated that they worked the overnight shift the morning it happened to Resident #4. They stated that when they saw Resident #4 there was a bump protruding between the front and back of the resident's shoulder area where they were bruised. They stated that the bump was closer to the resident's neck. They stated that an investigation was not initiated because of the bruise that was found there a few days ago. They stated there was not a Registered Nurse in the building to do an assessment, so they did the assessment. During an interview on 4/11/2025 at 1:31 PM, the Administrator stated that they did not do an investigation because Resident #4's bruise on their left shoulder was investigated before. They stated that they considered the bump or protrusion part of this bruise and so it did not need to be investigated. 10 NYCRR 415.4(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Standard survey completed on 5/7/24, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #63) of three residents reviewed for infection. Specifically, Resident #63 did not have weekly blood tests completed as recommended per the hospital discharge summary and the facility Medical Director. In addition, there was no care plan developed for the use of an intravenous midline catheter (tubing that is inserted into a vein for the delivery of medications and/or fluids). The findings are: The policy and procedure titled Physician Consultations dated 8/19 documented as appropriate, the attending physician would approve orders based on consultant recommendations and the attending physician would be responsible for following up on the effects of recommended medications and treatments. The policy and procedure titled Care Plans-Comprehensive with revised dated 10/19, documented the comprehensive person-centered care plan would include measurable objectives and time frames; describe services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; incorporate identified problem areas and risk factors; and reflect currently recognized standards of practice for problem areas and conditions. Resident #63 had diagnoses that included sepsis (infection in the blood), chronic pancreatitis (an inflammatory disorder of the pancreas) and dementia. The Minimum Data Set (a resident assessment tool) dated 4/2/24 documented the resident was understood, understands, and had severe cognitive impairment. The Minimum Data Set documented Resident #63 was administered intravenous medications during the assessment period. The Comprehensive Care Plan with date initiated 3/28/24, documented that Resident #63 had sepsis (a severe blood infection). Interventions included to administer medications and treatments as ordered, monitor for adverse reaction to medications, monitor for an increase in symptoms and obtain labs as ordered with results reported to the practitioner. The care plan did not include the use of an intravenous midline catheter. The hospital Discharge summary dated [DATE] documented Resident #63 was to have weekly laboratory values obtained (CRP) c-reactive protein test and (ESR)erythrocyte sedimentation rate (blood tests that measure the amount of inflammation in the body)). The results were to be faxed to the infection control clinic at the hospital. The facility medical providers progress notes documented the following: 3/28/24 at 9:19 AM, The Medical Director documented that Resident #63 was to have a weekly c-reactive protein test and erythrocyte sedimentation rate obtained and the results were to be faxed to the infectious disease clinic. 4/1/24 at 6:08 PM and 4/5/24 at 7:37 PM, Physician Assistant #1 documented that Resident #63 was to have a weekly c-reactive protein test and erythrocyte sedimentation rate obtained. 4/11/24 at 2:31 PM, The Medical Director documented that they were awaiting labs for Resident #63 and that a weekly c-reactive protein test and erythrocyte sedimentation rate would need to be faxed to the infectious disease clinic. 4/18/24 at 5:49 PM, The Medical Director documented that Resident #63 needed inflammatory markers drawn on a weekly basis and was unclear if they had been drawn recently. It was further documented that a weekly c-reactive protein test and erythrocyte sedimentation rate would need to be faxed to the infectious disease clinic. Review of the order recap report dated 3/27/24-5/31/24, revealed Resident #63 had an order on 3/27/24 for Meropenem (a broad-spectrum antibiotic medication) Intravenous (IV) solution, 1 gram mixed with 100 milliliters of normal saline, to be administered intravenously three times a day for 56 days. There were no orders to obtain the weekly c-reactive protein test and erythrocyte sedimentation rate as recommended and per the Medical Director until 5/5/24. Review of Resident #63's laboratory results from 3/27/24-5/4/24 revealed there was no documented evidence that a c-reactive protein test and erythrocyte sedimentation rate was obtained weekly. During an interview and record review on 5/7/24 at 8:37 AM, Unit Clerk #1 stated they were responsible for filing out the laboratory sheets for the residents that were new admissions and who had weekly blood draws. Unit Clerk #1 stated Licensed Practical Nurse #2 would notify them which residents were to have weekly blood draws. Unit Clerk #1 stated that they were never told that Resident #63 was to have a weekly c-reactive protein test and erythrocyte sedimentation rate. Review of untitled documents that Unit Clerk #1 identified as their weekly laboratory blood draw logs dated 3/29/24, 4/5/24, 4/22/24, 4/26/24 revealed Resident #63 was handwritten on the logs to have a complete blood count and basic metabolic panel. During an interview on 5/7/24 at 9:07 AM, the Medical Director stated the unit manager or nurse doing the admission orders was to transcribe recommended laboratory orders that were on a discharge summary into the electronic medical record and then they would sign off the orders. The Medical Director stated their expectation was that a nurse would have ordered the weekly c-reactive protein test and erythrocyte sedimentation rate and sent the results to the infectious disease clinic as recommended on the hospital discharge summary. The Medical Director stated they documented in their progress notes the resident was to have the weekly blood tests and the results were to be sent to the infectious disease clinic. The Medical Director stated that they could not be positive if they ever gave a verbal order for Resident #63 to have the weekly blood work completed. The Medical Director stated the reason for Resident #63 was to have an erythrocyte sedimentation rate and c-reactive protein test weekly was because the laboratory test was a nonspecific inflammatory blood test, and the Infectious Disease Doctor requested it. During an interview on 5/7/24 at 9:18 AM, Licensed Practical Nurse #2 stated they had entered Resident #63 admission orders into the electronic medical record and per the hospital discharge summary the resident should have had weekly erythrocyte sedimentation rates and c-reactive protein blood tests obtained. Licensed Practical Nurse #2 stated that the Medical Director may have mentioned it but could not recall. Licensed Practical Nurse #2 stated on 5/5/24 they realized they had erroneously omitted the blood work recommendation and contacted Physician Assistant #2. Licensed Practical Nurse #2 stated they were responsible for updating a resident's care plan and Resident #63 did not have an intravenous catheter care plan in place and should have. During an interview on 5/7/24 at 12:26 PM, the Director of Nursing stated they expected all recommendations on a resident's hospital discharge summary to be carried out unless the primary Medical Doctor disagrees. The Director of Nursing stated they could not locate any erythrocyte sedimentation rates (ESR) and c-reactive protein (CRP) blood test results for Resident #63. The Director of Nursing stated there should have been a care plan developed for the resident's intravenous catheter. 10 NYCRR 415.20

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 5/7/24, the facility did not ensure that the residents' environment remained as free from accident hazards as possible. Specifically, four (First Floor, Second Floor, Third Floor, Fourth Floor) of four resident use floors had issues with water temperatures that exceeded 120 degrees Fahrenheit. The findings are: The undated policy and procedure titled Hot Water Temperature Policy documented that hot water temperature was maintained between 105 and 120 degrees Fahrenheit. Water temperatures were regularly monitored and tested at various points of use in resident care areas and records were maintained. If water temperatures deviated from recommended ranges, immediate corrective actions were taken. Facilities Management or designated personnel should address issues promptly. During observations on 5/6/24 between 11:30 AM and 11:54 AM, the following hot water temperatures were obtained using digital stem-type thermometers: First Floor: Sink in Main Lobby Public Bathroom - 126.6 degrees Fahrenheit. Second Floor: Resident room [ROOM NUMBER] - 134.5 degrees Fahrenheit Resident room [ROOM NUMBER] - 134.6 degrees Fahrenheit Resident room [ROOM NUMBER] - 130.0 degrees Fahrenheit Resident room [ROOM NUMBER] - 134.4 degrees Fahrenheit Resident room [ROOM NUMBER] - 135.7 degrees Fahrenheit Resident room [ROOM NUMBER] - 131.7 degrees Fahrenheit Third Floor: Sink in 3D Shower Room - 132.0 degrees Fahrenheit. Shower head 3B Shower Room - 129.0 degrees Fahrenheit Shower head 3C Shower Room - 128.0 degrees Fahrenheit Resident room [ROOM NUMBER] - 134.6 degrees Fahrenheit Resident room [ROOM NUMBER] - 133.9 degrees Fahrenheit Resident room [ROOM NUMBER] - 134.1 degrees Fahrenheit Resident room [ROOM NUMBER] - 129.0 degrees Fahrenheit Resident room [ROOM NUMBER] - 134.3 degrees Fahrenheit Resident room [ROOM NUMBER] - 129.0 degrees Fahrenheit Resident room [ROOM NUMBER] - 133.6 degrees Fahrenheit Fourth Floor: Resident room [ROOM NUMBER] - 133.4 degrees Fahrenheit Resident room [ROOM NUMBER] - 135.0 degrees Fahrenheit Resident room [ROOM NUMBER] - 132.8 degrees Fahrenheit Resident room [ROOM NUMBER] - 132.5 degrees Fahrenheit Resident room [ROOM NUMBER] - 134.0 degrees Fahrenheit Resident room [ROOM NUMBER] - 134.0 degrees Fahrenheit During an interview on 5/6/24 at 11:40 AM, Resident #456's family member stated the water from the bathroom faucet felt hot. and needed to add cold water to adjust the temperature. During an interview on 5/6/24 at 11:43 AM, Resident #351 stated the water was too hot. and they had to add cold water to adjust the water temperature from being too hot. During an interview on 5/6/24 at 11:50 AM, Resident #99 stated they noticed the hot water was hotter than usual starting last night (5/5/24) and added cold water to adjust the temperature. During an interview on 5/6/24 at 11:58 AM, Resident #97 stated, You couldn't even touch the water the past few days, it would get so hot. Resident #97 stated the aides did not give showers due to the temperature of the hot water. During observations on 5/6/24 at 12:15 PM, hot water temperatures were obtained in the presence of the Maintenance Director, using the Surveyor's digital stem-type thermometer and the facility's infrared thermometer. To obtain the temperatures, the Surveyor's thermometer stem was placed in the hot water stream and the facility's infrared thermometer was pointed at the bottom of the sink with the hot water running. In the bathroom sink of Resident room [ROOM NUMBER], the digital stem-type thermometer read 132.6 degrees Fahrenheit, and the infrared thermometer read 132.0 degrees Fahrenheit. In the bathroom sink of Resident room [ROOM NUMBER], the digital stem-type thermometer read 132.0 degrees Fahrenheit, and the infrared thermometer read 130.8 degrees Fahrenheit. During an interview on 5/6/24 at 12:15 PM at the time of the observation, the Maintenance Director stated hot water should be between 110 and 115 degrees Fahrenheit and the water temperatures obtained from Resident rooms [ROOM NUMBERS] were too hot. They further stated about ten days ago, the facility replaced a pump, which improved the circulation of hot water, and they had been playing with the hot water system's thermostat since then. The Maintenance Director stated they usually checked the facility's hot water system thermostat and hot water holding tank first thing in the morning, and this morning around 8:00 AM. The thermometer on the hot water holding tank read 110 degrees Fahrenheit, which they thought was low, and they raised the thermostat. During an observation and interview inside the Boiler Room on 5/6/24 at 12:25 PM revealed the hot water system thermostat was set for 122 degrees Fahrenheit and the thermometer on the hot water holding tank read 132 degrees Fahrenheit. The Maintenance Director stated the facility had one single hot water system with no mixing valve. The Director stated they personally recorded the temperature of the hot water holding tank every day that they worked, and the last time they did it was on 4/30/24. The Maintenance Director stated they personally recorded temperatures of hot water at various points throughout the facility and the last time they did was on 4/29/24, which was the day the pump was replaced. The Maintenance Director stated they were out of town starting on 5/1/24 and did not think any of the Maintenance department staff would've checked hot water temperatures while they were out, and they had no documentation of any hot water temperatures recorded between 4/30/24 and present. During an interview on 5/6/24 at 1:14 PM, the Maintenance Director stated the hot water system consisted of two boilers that supplied water to the hot water holding tank and the pump heated the water between the boilers and the holding tank. If the water was too hot, lowering the thermostat would cut off heat to the water, but would not be able to add cold water into the tank. They further stated the thermometer they used to take hot water temperatures was the infrared thermometer, which was new about two months ago and had not been calibrated. At 2:40 PM, the Maintenance Director stated no one from the Maintenance department worked on the weekends and they were not contacted about any hot water concerns while they were out of town. During an interview on 5/6/24 at 12:45 PM, the Assistant Maintenance Director and the Maintenance Technician stated they did not take any hot water temperatures in the facility, and they did not touch the hot water system's thermostat. At this time, the Assistant Maintenance Director stated if the Maintenance Director was out of the building and someone had an issue with hot water, they would call an outside vendor for repairs and not attempt repairs by themselves. During an interview on 5/6/24 at 12:54 PM, Housekeeper #1 stated they noticed the water was hotter than usual today and they did not notify anyone. During an interview on 5/6/24 at 12:59 PM, Certified Nurse Aide #2 stated the hot water was hotter than usual today and they had to adjust the water temperature by adding more cold water. During an interview on 5/6/24 at 12:59 PM, Certified Nurse Aide #3 stated the hot water was hotter than usual today and they were still able to shower their residents by adjusting the temperature. During an interview on 5/6/24 at 1:02 PM, Certified Nurse Aide #1 stated the water was steaming hot last week and they notified Maintenance right away. They also stated that if the water was really hot, they would notify their manager or Maintenance right away. They stated they would mix it with cold water so a resident would not get scalded by hot water. During an interview on 5/6/24 at 1:04 PM, Licensed Practical Nurse Unit Manager #1 stated there was a group chat that indicated there was hot water temperatures in the building. They stated that they expected staff to report any hot water temperatures to themselves, the Administrator, and Maintenance right away. They also stated that they expect their staff not to use showers if the water was too hot, to mix the hot water with cold water, or to use wipes to clean residents instead of very hot water. During interview on 5/6/24 at 1:08 PM, Certified Nursing Assistant #3 stated they first noticed the hot water was hotter than usual and added cold water during the night shift from 5/5/24 - 5/6/24. During an interview on 5/6/24 at 1:12 PM, Licensed Practical Nurse #9 stated they noticed the hot water was too hot when they washed their hands at lunch time today (5/6/24). and they added cold water to adjust the temperature. Review of the maintenance log titled Facility Maintenance Daily AM Rounds revealed hot water temperatures were recorded each weekday from the two boilers and the hot water holding tank. Additionally, hot water temperatures were recorded from six resident rooms on most weekdays. The most recent entry was dated 4/30/24 and documented the hot water holding tank was at 120 degrees Fahrenheit. The most recent entry that included hot water temperatures inside resident rooms was dated 4/29/24 and it documented the hot water holding tank was at 90 degrees and the hot water in the resident rooms ranged from 72 to 81 degrees Fahrenheit. During an interview on 5/7/24 at 2:00 PM, the Administrator stated the expectation was that Maintenance department staff should check hot water temperatures daily if the Maintenance Director was not here. 10 NYCRR 415.12 (h)(1)

Based on observation, interview and record review conducted during the Standard survey completed on 5/7/24, the facility did not obtain the services of a licensed pharmacist that was involved with all aspects of the provision of pharmacy services in the facility; the facility did not establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; did not determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for one (discontinued narcotic storage closet) of three medication storage rooms and five (second floor A and B wings, third floor A and B wings, and fourth floor C wing) of eight narcotic reconciliation books reviewed. Specifically, the discontinued narcotic storage closet located in the Assistant Director of Nursing office did not have accountability records for narcotics awaiting destruction. Additionally, the narcotic reconciliation drug records on the second floor A and B wings, third floor A and B wings, and the fourth floor C wing shift to shift counts were not consistently signed off as completed. Furthermore, the Pharmacist Consultant stated they were not involved with the controlled substance processes in the facility. The finding is: 1.The policy and procedure titled Narcotic Destruction, revised 3/20 documented that the keys to the narcotic destruction cabinet would be held by two people and when they became aware of a medication being discontinued, they were both to go together to the unit and receive the discontinued medication from the responsible nurse on the unit. The key holders would both verify the count of the discontinued narcotic, sign the page, along with the responsible nurse, in the bound book that the medication had been removed from. The policy and procedure documented that the appropriate page from the book was to be copied, the two key holders would take the medication and together lock it up in the narcotic boxes for destruction. The policy and procedure documented that the copy of the narcotic book would be stored in a separate place from the narcotic cabinet. The policy and procedure documented that when the list was compiled to be submitted to the Bureau of Narcotic Enforcement for destruction, both key holders would complete the list together. The pages that correspond to each medication must be matched to the narcotics for destruction to help ensure that all the medications are accounted for. During an observation on 5/2/24 at 4:01 PM, in the presence of the Director of Nursing and the Assistant Director of Nursing, the discontinued narcotic medications were observed to be stored in the Assistant Director of Nursing's office closet. The closet door contained a double lock and upon opening there was noted to be an excessive number of narcotics stored. The following was observed inside the discontinued closet: - a locked safe approximately 4 feet by 3 feet with three shelves of narcotic blister packs (carded plastic packaging used to dispense individual doses of medication). There was a stack of individual narcotic count sheets along with some narcotic count sheets wrapped around the blister packs. -four cardboard medical supply boxes on top of the safe filled with liquid narcotics. Three of the boxes contained an account log that matched the narcotics in the box and one box had a log form that did not match the narcotics in the box. -One green colored bag filled with narcotic blister packs. There was no account log for the narcotics in the bag. -Eight banker sized boxes (heavy duty cardboard boxes the height and width of a file folder and approximately 24 inches long) filled with narcotics with no account log for what was in the boxes. -Stacks of narcotics in rubber bands on top of a metal filing cabinet that did not contain an account log. -A few random blister packs on the floor of the closet. During an interview at the time of observation on 5/2/24 at 4:01 PM, the Assistant Director of Nursing stated they started working at the facility in October of 2023. The Assistant Director of Nursing stated they had accepted the keys for the discontinued narcotic closet from the Director of Nursing and they were the only key holder. The Assistant Director of Nursing stated at that time of the key exchange they could not account for what was in the destruction closet. The Assistant Director of Nursing stated that the closet was full upon key exchange, and they continued to collect discontinued narcotics so that they did not pile up on the units. The Assistant Director of Nursing stated that the process they used for picking up discontinued narcotics was the unit nurse would bring down the narcotic to their office along with the narcotic reconciliation medication book. Both would verify the count, stamp the reconciliation sheet closed and sign and date the reconciliation sheet. The Assistant Director of Nursing stated they then placed the narcotic into the closet. The Assistant Director of Nursing stated that they did not copy any narcotic count sheets nor fill out a log when the narcotic was placed into the closet. During an interview at the time of observation on 5/2/24 at 4:01 PM, the Director of Nursing stated they received the discontinued narcotic keys from the Former Director of Nursing in April 2022 and that the discontinued narcotic closet was full of narcotics. The Director of Nursing stated there was no accountability for the narcotics that were in the closet at the time of the key exchange from the Former Director of Nursing. The Director of Nursing stated that they had performed one destruction since receiving the keys and emptied about 75% of the narcotics in the closet at that time. The Director of Nursing stated presently, there were narcotics that remained in the safe that were discontinued in 2021. The Director of Nursing stated that the facility started using the bonded narcotic reconciliation book in April of 2022 and prior to that there was no accountability for what was in the narcotic closet. They stated the process they used prior to the bonded narcotic reconciliation books was they would wrap the reconciliation sheet around the narcotic and then place it in the discontinued narcotic cabinet closet but did not have any accountability log for those narcotics. The Director of Nursing stated the purpose of keeping a log was it would help identify if narcotic diversion took place. The Director of Nursing reviewed the facility policy and procedure and stated they were not following the steps outlined in the policy and if they did follow the policy there would be accountability for the discontinued narcotics. During a telephone interview on 5/3/24 at 8:41 AM, the Former Director of Nursing stated that they would use the safe in the Assistant Director of Nursing office to store discontinued narcotics. They stated once the safe started to get filled and then had a double lock placed onto the closet door and then started to store the discontinued narcotics in boxes. The Former Director of Nursing stated the process they used to collect discontinued narcotics was that themselves along with another registered nurse reconciled the narcotic along with the count sheet, put it into the narcotic closet along with the reconciliation sheet and then log the narcotic on the Department of Health log sheets. The Former Director of Nursing stated the log forms were stored in a binder that was either in the Director of Nursing's office or Assistant Director of Nursing's office. The Former Director of Nursing stated they stopped working in the facility around March of 2022 and showed the current Director of Nursing where everything was. During a telephone interview on 5/3/24 at 3:53 PM, the Regional Director of Clinical Services from the facility's dispensing pharmacy, stated neither they or the pharmacy were involved with the facility's controlled substance destruction process, or the narcotic processes and that the facility's pharmacy consultant should be checking their processes frequently. Facility staff should be following their corporate policies. During a telephone interview on 5/3/24 at 4:07 PM, the Pharmacist Consultant stated that that they did not participate in the review or development of the narcotic storage or narcotic destruction policy at the facility. The Pharmacist Consultant stated that they have never observed the discontinued narcotic closet, the unit medication carts nor the narcotic cabinets on the units. The Pharmacist Consultant stated that there should be an inventory log for what was stored in the narcotic cabinets for accountability. 2. The policy and procedure titled Narcotic Count dated 8/18 documented that to ensure controlled substances are properly accounted for the on-coming and the off-going nurses assigned to the medication cart would be responsible for ensuring the accuracy of the controlled drug count. The two nurses would look at each medication, verify the number of the medication matches the number on the declining inventory on each identified page. The policy and procedure documented that once the nurse has accepted the count, signed off on the controlled medication count acknowledgement page in the back of the book and accepts the keys it is then the nurse's responsibility if the count was not correct at the next shift change. The policy and procedure documented in the event of a need to change the nurse assigned to the narcotic during times other than at routine shift change, two nurses will count using the above process. During an observation and interview with Licensed Practical Nurse #11 on 5/3/24 at 12:59 PM, the Third Floor B Wing narcotics reconciliation book Shift Count sheet revealed the 4/30/24 count at 3:00 PM going off duty was the last signature, identified as Licensed Practical Nurse #10. Licensed Practical Nurse #11 stated they counted the controlled substance medications for B Wing that morning (5/3/24) with the night shift nurse (Licensed Practical Nurse #10) at 7:15 AM and neither nurse signed the Shift Count sheet. Licensed Practical Nurse #11 stated each time the controlled substance control keys were exchanged between nurses the controlled medications should be counted and the Shift Count sheet should be signed by the nurse taking responsibility of the medications in the coming on duty column and the nurse going off duty should sign indicating they were no longer responsible for the controlled substances. During an observation and interview with Licensed Practical Nurse #12 on 5/3/24 at 1:31 PM, the Third Floor A Wing narcotics reconciliation book Shift Count sheet revealed multiple sporadic blanks for coming on duty and going off duty. Licensed Practical Nurse #12 stated they did not know why the other nurses were not signing the Shift Count sheet and they should be. They stated the purpose of the Shift Count sheet was to indicate who was responsible for the controlled medications for accountability and there should not be any blanks for past dates. They stated they had not reported the blanks to their Unit Manager, Assistant Director of Nursing or Director of Nursing and they should have. During an observation and interview on 5/3/24 at 2:06 PM, the Second Floor B wing narcotics reconciliation book had one blank space on the shift count sheet for the AM shift on 5/3/24. Licensed Practical Nurse #4 stated that the previous nurse must have left without signing. They stated they counted the narcotics that morning, but both forgot to sign the book. Licensed Practical Nurse #4 stated that the count should be done every shift and the book should have been signed. They stated that it was important to keep track of the narcotics between shifts in case something went missing, so they would know which person had the keys at the time the medication went missing. During an observation and interview on 5/3/24 at 2:06 PM, the Second Floor A wing shift count sheet was not signed in or signed out for the 7:00 AM-3:00 PM shift for 5/3/24. Licensed Practical Nurse #5 stated that at times they didn't sign the shift count sheet because they got interrupted, distracted, or were rushing. Licensed Practical Nurse #5 stated that they never left their shift without counting and if the oncoming nurse was not available, they would count with the supervisor. They stated the purpose of signing the shift count sheet was that they were accepting responsibility for the medications and everything that was in the cabinet. Review of the Shift Count (Narcotic Count Reconciliation Records) from 4/22/24-5/3/24, revealed the following lacked documented evidence that narcotic reconciliation was completed by the oncoming and outgoing nurses: -Second Floor A wing cart had 21 shifts -Second Floor B wing cart had 9 shifts -Third Floor A wing cart had 26 shifts -Third Floor B wing cart had 49 shifts -Fourth Floor C wing cart had 23 shifts During an interview on 5/6/24 at 7:50 AM Licensed Practical Nurse #10 stated they don't always sign the shift count sheet because they were busy, and they should always sign in the appropriate column to indicate if they were coming on duty or going off duty to indicate accountability for the controlled substances. Licensed Practical Nurse #10 stated they were not aware the last signature on the shift count sheet for Third Floor B wing book was theirs and dated 4/30/24. They stated the shift count sheet was to be signed each time the controlled substance keys were exchanged between nurses to indicate the controlled substance count was accurate and who was responsible for the controlled substances for that date/shift. During an interview on 5/7/24 at 7:22 AM, Licensed Practical Nurse #13 stated they often do not sign the shift count sheet because they were too busy. They stated the shift count sheet should be signed each time they counted the controlled medications with the other nurse upon coming on duty and going off duty to indicate the controlled substance count was accurate and who was responsible for the controlled substances for that date/shift. During a telephone interview on 5/7/24 at 8:18 AM, Licensed Practical Nurse #7 stated that at times they've had to do narcotic count by themselves because the off going nurse left their shift and the narcotic cabinet keys were left in the reconciliation book. Licensed Practical Nurse #7 stated that they have never left their shift without counting out the narcotics. Licensed Practical Nurse #7 stated they were usually pretty good at signing in/out for the narcotics but at times may have forgotten. Licensed Practical Nurse #7 stated by signing in/out of the shift count log they were taking responsibility for the narcotics and an accurate account for them. During an interview on 5/7/24 at 9:02 AM, Licensed Practical Nurse #2 (unit manager of the second floor) stated that the oncoming and off going nurses should be doing medication reconciliation narcotic count at shift change and signing at the back of the narcotic book for accountability. Licensed Practical Nurse #2 stated after it was brought to the facility's attention the process of signing for shift-to-shift narcotic count not always being completed they usually tried to do audits of the narcotic reconciliation book for signatures, but they must have missed them. Licensed Practical Nurse #2 stated that there were times they've had to count with a nurse when they were leaving their shift prior to the oncoming nurse arriving at the building and sometimes they signed the shift count log but sometimes they got side-tracked and did not. Licensed Practical Nurse #8 stated that the importance of signing the shift count log was it verified the narcotic count was accurate and all accounted for. During a telephone interview on 5/7/24 at 9:49 AM, Licensed Practical Nurse #8 stated that the process for narcotic key exchange was the outgoing nurse, and the oncoming nurse reconciled the narcotics along with the narcotic logbook at the change of shift. Licensed Practical Nurse #8 stated that at times they had the narcotic cabinet keys left for them in the narcotic reconciliation book and then they would make a nursing supervisor count with them. Licensed Practical Nurse #8 stated if they did not have a nurse replacement when they needed to leave the building, they would have the nursing supervisor count with them. During an interview on 5/7/24 at 11:45 AM, the Regional Director of Clinical Services stated the process for collecting discontinued medications would be that either the Director of Nursing or the Assistant Director of Nursing would along with another nurse verify the count of the narcotic, place them into the discontinued closet and log then on the Bureau of Narcotic Enforcement log. They stated then the log was to be kept in a binder. The Regional Director of Clinical Services stated they were unable to locate the binder from the Former Director of Nursing to account for the narcotics that remained in the discontinued closet and therefore they could not ensure that diversion of narcotics did not take place. The Regional Director of Clinical Services stated the process for narcotic cabinet key exchange on the units would be that the oncoming nurse, along with the off going nurse counted the narcotics, ensured that the count was correct and signed the shift count log. They stated the purpose of signing count sheet logs was the key holder was ensuring the narcotic count was correct and that the last nurse to sign the book was responsible for all of the narcotics in the cabinet. During a telephone interview on 5/7/24 at 12:15 PM, the Pharmacist Consultant stated the purpose of the key exchange process was that the oncoming nurse and the off going nurse verified the narcotic count was reconciled. The Pharmacist Consultant stated they were unsure if a signature was needed at the time of key exchange, but some type of documentation of inventory was needed from one staff member to the other. The Pharmacist Consultant added they do not oversee the narcotic processes in the building. During further interview on 5/7/24 at 12:35 PM, the Director of Nursing stated that they were unable to locate any discontinued narcotic logs or a binder from the Former Director of Nursing. The Director of Nursing stated that when they took responsibility for the discontinued narcotic cabinet, they started some logs for the discontinued narcotics and then failed to follow through with the logging process. The Director of Nursing stated that the purpose of maintaining a log for the discontinued narcotics was to be able to identify what is in the cabinet and to also identify if narcotic diversion could have occurred. The Director of Nursing stated their expectation for narcotic cabinet key exchange on the units was that the oncoming nurse needs to perform a narcotic reconciliation with the outgoing nurse, and they exchanged the keys. The Director of Nursing stated that when a nurse must leave their shift early or leave the building then the unit manager or the nursing supervisor were expected receive the keys and ensure the count was correct. The Director of Nursing stated that with key exchange the shift count sheets needed to be signed by each nurse for narcotic accountability. The Director of Nursing stated they were unaware of any incidence where narcotic keys were left by any off going nurse. During an interview on 5/7/24 at 12:43 PM, the Administrator stated that they expected the Pharmacist Consultant to review the narcotic policies as they are part of the Quality Assurance and Performance Improvement Committee. The Administrator stated they expected that the narcotics were reconciled and signed for at key exchange. The Administrator stated they expected all staff to follow the policy and procedures for narcotics to ensure that all narcotics were kept safe and were there when they are needed for the resident. They expected the management team would oversee that the policies were being followed by staff. 10 NYCRR 415.18(a)(b)(1)(2)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during a complaint investigation (Complaint #NY00296367) completed during a Standard survey started 10/12/22 and completed on 10/18/22, the facility did not ensure that all alleged violations including abuse are reported immediately, but not later than 2-hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the appropriate officials (including the State Survey Agency). Specifically, two (Residents #49 and 46) of five residents reviewed for abuse were involved in a resident-to-resident altercation which was not reported timely to the Administrator and to the New York State (NYS) Department of Health (DOH) as required. The finding is: The facility policy and procedure (P&P) titled Abuse revised 9/21 documented the shift supervisor was responsible for investigation and reporting abuse, neglect and misappropriation of property. The shift supervisor would be responsible for immediate initiation of the reporting process upon receipt of the allegation. The P&P documented the shift supervisor was to be immediately notified if suspected abuse, neglect, mistreatment or misappropriation of property occurs and then they would report the incident to the Administrator and Director of Nursing (DON). Then the DON or designee would report the incident to the Regional Clinical Manager. The local law enforcement and appropriate State Agency will be notified immediately (no later than 2 hours after alleged/suspected incident). 1. Resident #49 had diagnoses including vascular dementia with behavioral disturbance, post-traumatic stress disorder and alcohol induced persisting dementia. The Minimum Data Set (MDS- a resident assessment tool) dated 4/26/22 documented Resident #49 was usually understood, sometimes understands and was severely cognitively impaired. Review of the Comprehensive Care Plan (CCP) dated 5/23/22 documented an actual resident-to-resident altercation where Resident #49 was the aggressor as evidenced by verbal aggression and throwing coffee on another resident. The plan included to administer medications as ordered, notify the medical doctor (MD) of inappropriate behavior, offer diversional activity, and refer to psychiatry. 2. Resident #46 had diagnoses including major depressive disorder, alcoholic hepatitis, and Wernicke's encephalopathy (a degenerative brain disorder caused by a lack of vitamin B1). The MDS dated [DATE] documented Resident #46 was understood, understands and was moderately cognitively impaired. Review of the CCP dated 5/23/22 documented Resident #46 had a resident-to-resident altercation as evidenced by verbal aggression and coffee was thrown at them. The plan included to administer medications as ordered; notify the MD of inappropriate behavior, refer to psychiatry and treatment per MD order. Review of the Investigation form signed and dated by the DON on 5/27/22 documented that Resident #49 and Resident #46 were heard having an argument in the hallway as Certified Nurse Aide (CNA) #4 was delivering a lunch tray in a resident's room. It was documented that CNA #4 immediately intervened and as a they were walking Resident #46 back into their room, Resident #49 threw the contents of their coffee cup at Resident #46. It was documented that Licensed Practical Nurse (LPN) #8 assisted Resident #46 to their room, changed their clothes and notified the supervisor, Registered Nurse (RN) #3. It was documented that RN #3 assessed the Resident #46 and they had redness to their neck and shoulder. Review of untitled and undated document signed by CNA #4, provided by the facility in the investigation packet, documented they heard Resident #49 and Resident #46 bickering. CNA #4 documented as they were guiding Resident #46 to their room, Resident #49 threw coffee at Resident #46. CNA #4 stated the nurse looked at Resident #46 skin in their room. CNA #4 documented in their statement that the incident happened on 5/22/22 at approximately 12:30 PM. Review of an untitled document dated 5/23/22 signed by LPN #8, provided by the facility in the investigation packet, documented that on 5/22/22 they heard arguing at the coffee cart. LPN #8 documented they observed Resident #49 throw coffee at Resident #46's right side as the CNA was escorting Resident #46 back to their room. LPN #8 documented they removed Resident #46 shirt and called the supervisor. LPN #8 documented that they told the supervisor in detail of the incident that occurred. Review of the Health Electronic Response Data System (HERDS) Nursing Home Incident Form revealed the Administrator reported the incident on 5/23/22 at 11:13 AM as any other reportable incident. During a telephone interview on 10/17/22 at 5:00 PM, Registered Nurse (RN) #3, stated they were the facility supervisor the day that Resident #49 spilled coffee onto Resident #46. RN #3 stated they assessed Resident #46 and they had blanchable redness without any blistering to the right side of their neck and chest. RN #3 stated that there was miscommunication on the day the incident occurred, and they were not aware that the incident was a resident-to resident altercation. RN #3 stated that they were educated prior to and after the incident that any resident-to-resident altercation needed to be reported to the DON immediately. During an interview on 10/18/22 at 8:49 AM, LPN #8 stated that they were standing at their medication cart when Resident #49 and Resident #46 got into an argument. LPN #8 stated that as the CNA started to separate the residents, Resident #49 threw their coffee at Resident #46. LPN #8 stated they finished walking Resident #46 to their room and called the supervisor, RN#3. LPN #8 stated they told RN #3 exactly what had taken place between Resident #49 and Resident #46. LPN #8 stated RN #3 assessed Resident #46 and contacted the MD for a new order to apply an antimicrobial cream for prophylaxis. During an interview on 10/18/22 at 9:17 AM, the DON stated the incident between Resident #46 and Resident #49 was investigated and discussed in an interdisciplinary team meeting to rule in or out abuse the day after the resident-to-resident altercation occurred. The DON stated they were not notified of the incident the day it occurred, and they should have been. The DON stated they would need to report a resident-to-resident altercation to the DOH within two hours of an incident. During an interview on 10/18/22 at 1:07 PM, the Administrator stated the DON and themselves were not made aware of the resident-to-resident altercation between Resident #49 and Resident #46 until the DON noted the situation in the morning meeting the day following the incident. The Administrator stated when they became aware of the incident the DON immediately started an investigation and it was reported to the DOH. The Administrator stated their expectation when a resident-to-resident altercation occurred was for the situation to be reported to the DON and themselves immediately and then it would need to be reported to the DOH within two hours. 415.4 (b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a Standard Survey started 10/12/22 and completed 10/18/22, the facility did not ensure that a resident who enters the facility with an indwelling catheter (Foley- tube inserted into the bladder to drain urine) or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary. Specifically, for one (Resident #195) of one resident the facility did not assess for removal of the catheter and did not have the resident follow up with Urology as recommended by the hospital and as ordered by the facility physician. The finding is: The facility policy titled Physician - Consultation revised 8/2019 documented; it is the policy of this organization to ensure all residents receive medical care in a timely manner. The facility policy titled Physician Orders undated documented it is the policy of this facility to secure physician orders for care and services for residents as required by state and federal law. 1. Resident #195 with diagnoses including diabetes mellitus type 1, chronic kidney disease, and obstructive uropathy, urinary retention secondary to benign prostatic hyperplasia (BPH, enlarged prostate). The Minimum Data Set (MDS, a resident assessment tool) dated 8/25/22 documented the resident was cognitively intact. The Comprehensive Care Plan (CCP) identified by Registered Nurse (RN) Unit Manager (UM) #2 as current documented Resident #195 has indwelling catheter, neuromuscular dysfunction of bladder created on 5/27/22. The CCP documented a goal that the resident will be assessed and have catheter removed if absence of qualifying condition for use of catheter. Review of the hospital Discharge summary dated [DATE] documented a plan for discharge included to Urology follow up as outpatient (resident had no prior urologist). Review of the hospital Discharge summary dated [DATE] documented urinary retention, history of benign prostatic hyperplasia (BPH) status post chronic foley placement with recommendations to follow up with Urology as outpatient (resident had no prior urologist). Review of physician Order Summary Report dated 10/17/22 documented documented an order dated 8/19/22 to schedule an appointment and follow up with urology. Review of the Progress Notes dated 8/18/22 through 10/17/22 revealed there no documented evidence Resident #195 had a voiding trial, attempt at removal of the foley or a Urology appointment as ordered. During an interview on 10/13/22 at 8:52 AM, Resident #195 stated, they had not had a catheter at home prior to being hospitalized and believed the foley catheter was placed at the hospital related to a urinary infection and inability to urinate. Resident #195 stated they want to be discharged to home after rehabilitation, and does not want the foley catheter. The resident stated they were not seen by a Urologist and the facility has not tried to remove the foley. During an interview on 10/17/22 at 12:57 PM, RN UM #2 stated they were unaware Resident #195 wanted the catheter removed, and had not offered a voiding trail to the resident. During an interview at 3:40 PM the RN UM #2 stated they had reviewed the medical record, was unaware there was a physician's order for a Urology consult, and an appointment was not set up for Resident #195. During an interview on 10/17/22 at 3:58 PM, the Medical Director stated the resident should have seen a Urologist as ordered. During an interview on 10/18/22 at 11:42 AM, the Administrator stated they would have expected Resident #195 to be seen by a Urologist as ordered. During an interview on 10/18/22 at 12:19 PM, the Director of Nursing (DON) stated they would have expected Resident #195 to be seen by the Urologist as ordered by the medical provider. 415.12(d)(1)

Based on observation, interview, and record review conducted during the Standard survey started on 10/12/22 and completed on 10/18/22, the facility did not ensure that a resident who is fed by enteral means (method of feeding that uses the gastrointestinal (GI) tract to deliver part or all a person's caloric requirements) receives the appropriate treatment and services to prevent possible complications for one (Resident #88) of two residents reviewed for feeding tubes. Specifically, the facility did not administer the tube feed formula as ordered by the physician. In addition, the nursing staff documented the formula was administered as ordered. The finding is: The facility policy and procedure (P&P) titled Enteral Feedings revised 4/2020 documented that the facility is to provide nutrition therapy to residents unable to obtain nutrition orally, when such therapy is ordered by the physician. Procedure: Verify physician order. 1. Resident #88 was admitted to the facility with diagnoses of diffuse traumatic brain injury (TBI), mild intellectual disabilities, and gastro-esophageal reflux disease (GERD). The Minimum Data Set (MDS- a resident assessment tool) dated 8/12/22 documented Resident #88 had severe cognitive impairment, sometimes understood, and rarely/never understands. Additionally, the MDS documented that the resident received 51% (percent) or more of total calories and 501 cc (cubic centimeter) per day or more fluid intake through tube feeding. The Comprehensive Care Plan (CCP) initiated 9/3/2020 documented Resident #88 has a percutaneous endoscopic gastrostomy tube (PEG tube) for nutrition/hydration. Interventions included the resident was to have nothing by mouth (NPO), provide feeds/flushes as ordered- Jevity 1.5 80ml (milliliters) per hour x 18 hours total volume 1440ml. Review of Order Summary Report printed 10/14/22 documented an active enteral order dated 8/19/22 to administer Jevity 1.5 continuously via PEG, rate of 80ml/hour x 18 hours every day (qd), start at 2:00 PM, stop when total volume 1440 ml has been infused. Verify infusion q (every) shift, keep head of bed elevated 35-45 degrees during feeding. Additionally, an active order dated 2/11/21, documented enteral feed every shift to ensure feed is running and hung as scheduled. Intermittent observation of Resident #88 revealed the following: - 10/12/22 at 4:38 PM, Resident #88 was lying in bed with the head of the bed (HOB) elevated and Glucerna with carbsteady 1.5 cal. was infusing via the resident's PEG tube at a flow rate of 80 mL/hr. Documented on the label was Resident #88's last name, and 10/12/22 with start time of 2:00 PM. - 10/14/22 at 8:30 AM, Resident #88 was lying in bed with the head of the bed (HOB) elevated and Glucerna with carbsteady 1.5 cal. was infusing via the resident's PEG tube at a flow rate of 80 mL/hr. Documented on the label was Resident #88's last name, and 10/13/22 with a start time of 9:30 PM. The total volume infused (TVI) was 1365 mL; approximately 200 ml of Glucerna remained. Additionally, an empty bottle of Glucerna 1.5 was observed in the garbage can at the resident's bedside, with a label that documented Resident #88's name, the date of 10/13/22 and was timed 6:00 AM. No initials were documented on label. -10/14/22 at 9:25 AM, Glucerna enteral feed was observed infusing via the resident's PEG with a TVI of 1438 ml. The screen on pump indicated 2 ml's remained to be delivered. -10/14/22 at 10:36 AM, Resident #88 lying in bed with HOB elevated. Resident #88 observed still connected to tube feeding and the feed pump was turned off. -10/14/22 at 10:43 AM Licensed Practical Nurse (LPN) #3 entered Resident #88's room to administer medications via the PEG tube. LPN #3 disconnected the tubing from the PEG tube to administer a water flush and medications. After medication administration, LPN #3 disconnected the tubing and empty Glucerna enteral feed from pump to discard. LPN #3 stated that the feed bottle disconnected was Glucerna, and the label stated 10/13/22 at 9:30 AM. -10/14/22 at 11:07 AM, LPN #3 was observed to report to LPN Supervisor #4 the wrong feed was administered to Resident #88. Review of the Medication Administration Record (MAR) dated 10/1/22 through 10/31/22 documented to administer Jevity 1.5 continuously via PEG, rate of 80 ml/hr. x18 hours qd, start at 2:00 PM, stop when total daily volume 1440 ml had been infused. Verify infusion every shift, keep HOB elevated 35-45 degrees during feeding. The MAR was initialed as administered as ordered on 10/12/22, 10/13/22, and 10/14/22. During an interview on 10/14/22 at 10:38 AM, Certified Nursing Assistant (CNA) #2 stated that it was the nurse's responsibility to connect and disconnect residents from feeding pumps. CNAs were responsible to report to nurse if TF (tube feed) was leaking, pump was sounding and to make sure residents were seated upright while the feed was infusing. During an interview on 10/14/22 at 10:50 AM, LPN #3 stated they were familiar with Resident #88, and the resident was supposed to receive Jevity 1.5 not Glucerna. Stating, I know exactly what Resident #88 gets. LPN #3 identified an additional unused feed bottle on nightstand and stated, this is Glucerna as well and that they didn't know why it was in Resident #88's room. LPN #3 stated nurses were to verify the rate and feed hung every shift and that was the first time getting to Resident #88 that morning. During an interview on 10/14/22 at 11:07 AM, LPN Supervisor #4 stated a medication error report and investigation would have to be completed due to Resident #88 receiving the wrong feed. LPNS #4 stated, there could be adverse effects from receiving the wrong feed and could cause harm to a resident. LPNS #4 stated they were going to notify the dietician, Director of Nursing (DON), and the Physician Assistant (PA) of error. During an interview on 10/14/22 at 1:03 PM, the Registered Dietician (RD) stated upon review of electronic medical record that Resident #88 was ordered Jevity 1.5 continuous feed for 18 hours at 80cc/hr. Additionally, the RD stated an order would need to have been obtained to substitute with a different enteral feed product. During a telephone interview on 10/14/22 at 4:14 PM, LPN #6 stated MD orders were on the MAR for enteral feedings. The MAR is signed to verify the type of feed, ml's per hour, start and stop times and volume to be infused. When doing rounds make sure there are no disruptions, and feed is infusing. LPN #6 stated they worked 7:00 AM to 7:00 PM on 10/13/22 and stopped Resident #88 feed at 10:00 AM after TVI reached 1440. LPN #6 stated they noted bottle timed for 6:00 AM, and that there was feed remaining in bottle, so not to waste feed restarted that bottle at approximately 3:15 PM. Additionally, LPN #6 stated they reported off to LPN #5 on 10/13/22. During a telephone interview on 10/14/22 at 4:29 PM, LPN #5 stated they started work at 7:00 PM on 10/13/22 and had been informed during report by nurse leaving that Resident #88 would need a new bottle of feed hung. LPN #5 stated they didn't recall exactly what they hung, but verified bottle hung with bottle that was already hanging. The bottle of feed utilized was already present in Resident #88's room. LPN #5 stated they just assumed that was the feed resident was ordered and should have verified with the order before replacing. Additionally, LPN #5 stated MD orders should always be verified to ensure right formula and dose are being delivered. During an interview on 10/17/22 at 10:31 AM, Registered Nurse Unit Manger (RNS #1), stated nurses need to follow physicians' orders. The formula (feed) was on the MAR, and nurses were responsible every shift to confirm feed and that it was running as ordered. Additionally, RNS #1 stated this is important to the resident health to maintain weight, blood sugars, and proper fluids. During an interview on 10/18/22 at 9:45 AM, LPN #2 stated they worked evening shift on 10/12/22. LPN #2 stated if the tube feed label wasn't facing them, they may not have verified the feed. Additionally, LPN #2 stated that physician orders should be always followed. During an interview on 10/18/22 at 1:56 PM, the Director of Nursing (DON) stated they would have expected the nurses to follow the physicians' orders and give Resident #88 the enteral feed that was ordered. 415.12(g)(2)

Based on observation, interview, and record review conducted during the Standard survey started 10/12/22 and completed 10/18/22, the facility did not ensure that drug records were in order; and that an account of all controlled drugs was maintained and periodically reconciled on one (Unit 4) of two units reviewed. Specifically, the facility did not ensure the control substance book included a control count sheet for Lorazepam (Ativan, anti-anxiety medication) injectable solution to validate the correct count since 4/19/22. This involved Resident #4. The finding is: The facility policy and procedure (P&P) titled Controlled Substances revised 10/2018 documented the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together; they must document and report any discrepancies to the Director of Nursing Services (DONS). The DONS shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify responsibility parties, and shall give the Administrator a written report of such findings. During a medication storage observation of Unit 4's medication room (with Licensed Practical Nurse (LPN) #1 present) on 10/14/22 at 1:40 PM, there were three vials of Ativan 2 mg/ml injectable solution for Resident #4 stored in a locked refrigerator box. Review of the control substance record book identified by (LPN) #1 as current revealed there was no evidence of a corresponding control substance verification count sheet for the three vials of Ativan. Review of the previous control substance record book revealed a medication control sheet documenting Lorazepam injectable sloution 2 mg/ml with a count of three vials remaining for Resident #4. During an interview on 10/14/22 at 1:45 PM, LPN #1 stated they had not counted the three vials of Ativan for Resident #4 because they didn't know there was any controlled substance in the refrigerator locked box, and there was no control sheet. LPN #1 stated if there would have been a control sheet in the book for the three vials of Ativan sloution, they would have looked in the refrigerator and counted those vials. LPN #1 stated the current control substance book started April 19, 2022. The three vials of Ativan for Resident #4 were not carried over; therefore, the medication had not been reconciled since April 19, 2022. During an interview on 10/14/22 at 1:50 PM, LPN #2 stated they were filling in as the Unit Manager and recalled the Ativan being counted a long time ago and didn't realize the medication was in the refrigerator locked box. LPN #2 stated they have worked as a medication nurse recently, had not counted and reconciled the medication, and should have. LPN #2 stated every control medication should have a control substance record and should be counted between every shift by the nurses. During an interview on 10/14/22 at 1:56 PM, the DON stated the previous control substance record book was no longer in use, and the current control substance book was initiated April 19, 2022. The current control substance record should have had a control sheet to identify the Ativan for Resident #4. The DON stated when the new control substance book was initiated in April 2022, it was the UM responsibility to ensure each control substance was logged into the current book and the nurses should have been verifying the count every shift. During an interview on 10/18/22 at 11:37 AM, the Administrator stated the UM should have ensured all the control medication(s) information was transferred to the current control substance book in April 2022 and the nurses should have been counting the medication every shift to verify the accuracy of the count. 415.18 (a)(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey started on 10/12/22 and completed on 10/18/22, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director and the Director of Nursing (DON), and that these reports were acted upon for two (Resident #10 and #27) of six residents reviewed for drug regimen reviews. Specifically, for Resident #10 recommendations made on 4/13/22 and Resident #27 recommendations made on 5/23/22, were not addressed by the Physician and the Pharmacist did not follow up on the recommendations. The findings are: The facility policy and procedure (P&P) titled Pharmacy Consultant Med Review revised 3/20, documented the purpose of the review is to assist the facility maintain each resident's highest practicable level of functioning and quality of life, by helping them utilize medications appropriately or minimize adverse consequences related to medication therapy to the extent possible. The Pharmacy Consultant should report irregularities to the attending physician, medical director, and the DON with the resident's medication regimen. The unit manager/designee will make sure all recommendations are acted upon, reported to the physician, document in the resident's chart it was done, and remind the physician to sign the resident's consultant report that is filed in the resident chart. 1. Resident #10 was admitted to the facility with diagnoses including peripheral vascular disease (PVD-poor circulation of the lower extremities), lymphedema (blockage of the lymphatic vessels leads to fluid retention), and urinary tract infection (UTI). The Minimum Data Set (MDS-a resident assessment tool) dated 9/26/22 documented the resident had intact cognition, was understood, and understands. The MDS further documented the resident received a diuretic medication six of the past seven days. Review of the Pharmacist Consultant report titled Note to Attending Physician/Prescriber dated 4/13/22 documented recommendations for a basal metabolic profile (BMP- a test that measures several important aspects of your blood) for the next lab day and every 6 months thereafter due to diuretic use and was not filled in or signed by the physician as of 10/18/22. No follow up documented by the Pharmacist Consultant noted. Review of Lab results from April 2022 through October 2022 revealed there was no BMP was drawn. 2. Resident #27 was admitted to the facility with diagnoses including depression, anxiety, and diabetes mellitus (DM). The MDS dated [DATE] documented the resident had intact cognition, was understood, and understands. Review of the Pharmacist Consultant report titled Note to Attending Physician/Prescriber dated 5/23/22 documented Resident #27 receives Plavix (a medication to prevent blood clots) and has at least one risk factor for gastrointestinal ulceration (open sores that develop on the lining of the stomach) without gastroprotective therapy with a proton pump inhibitor (medications that cause a profound and prolonged reduction of stomach acid production). The Pharmacy Consultant recommended Pantoprazole (a medication that reduces acid reflux) 20mg and was not filled in or signed by the physician as of 10/18/22. There was no follow up documented by the Pharmacist Consultant. Review of the Order Summary Report dated 5/23/22 through 10/18/22 documented there was no order for Pantoprazole. During a telephone interview on 10/18/22 at 9:04 AM, the Pharmacy Consultant stated all Medication Regimen Reviews (MRR) were reviewed monthly. When irregularities were identified a Note to Attending Physician/Prescriber with recommendations were completed and emailed to the Unit Managers and the DON. The Pharmacy Consultant stated recommendations were addressed, reviewed, and signed by the physician within 30 days. Recommendations were reissued when no appropriate response was received after 60 days. The Pharmacy Consultant stated the recommendations for Resident #10 on 4/13/22 and Resident #27 on 5/23/22 were overlooked and never followed up. During an interview on 10/18/22 at 9:43AM, Licensed Practical Nurse (LPN) #9 Unit Manager (UM) stated pharmacy recommendations were received through email. UMs or the DON were responsible to print the recommendations. The recommendations were reviewed the next day, discussed with the provider, and implemented. LPN #9 stated they were not printed consistently and assumed the DON had printed them and therefore were not addressed. It's the responsibility of the UM to ensure recommendations were addressed. The signed and completed recommendations were given to the DON to be kept in a monthly review binder. During an interview on 10/18/22 at 10:30 AM, the Medical Director stated the requisitions dated 4/13/22 and 5/23/22 were missed and not addressed. The Unit Manager should have brought them to my attention. No harmful effects occurred to Resident #10 or #27 due to the missed requisitions. During an interview on 10/18/22 at 12:45 PM, the DON stated MRRs were completed monthly by the Pharmacy Consultant and printed by the UM who addressed the recommendations with the provider. The provider agreed or disagreed with the recommendation. Providers signed the recommendations once reviewed. New orders would be implemented. The signed MRRs were returned to the DON and placed into a binder. At 1:08 PM the DON while in the presence of the Regional Director of Clinical Services stated, the Pharmacist Consultant should have identified the unsigned recommendations for Resident #10 and Resident #27. 415.18 (C)(2)

Based on observation, interview, and record review conducted during the Standard survey started 10/12/22 and completed 10/18/22, the facility did not maintain an infection prevention and control program to ensure the health and safety of residents to help present the transmission of COVID-19. Specifically, the COVID-19 Swabber/Receptionist did not utilize appropriate personal protective equipment (PPE) (a N-95 mask and eye protection) while collecting COVID-19 specimens for two (Physical Therapist (PT) and Certified Nurse Aide (CNA) #3) of two employees observed. The finding is: The Centers for Medicare and Medicaid Services (CMS) QSO 20-38-NH revised 9/23/22 documented during specimen collection, facilities must maintain proper infection control and use recommended PPE, which includes a NIOSH-approved N95 or equivalent or higher-level respirator, eye protection, gloves, and a gown, when collecting COVID-19 specimens. The Centers for Disease Control and Prevention (CDC), Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 Testing updated July 15, 2022, documented healthcare providers collecting specimens should maintain proper infection control and use recommended PPE, which includes an N95 or higher-level respirator, eye protection, gloves, and a gown. The facility policy and procedure (P&P) titled COVID-19 Testing Staff revised 9/19/22 documented that staff preforming testing should wear appropriate PPE: N95 mask, gown, goggles or face shield and gloves. During an interview on 10/13/22 at 3:28 PM, the Nurse Educator/Infection Preventionist (IP) stated the facility was testing all employees, regardless of their vaccination status, twice weekly due to the COVID-19 rate of transmission being high. The Nurse Educator/IP stated there were no COVID-19 positive residents in the facility and there were three COIVD-19 positive employees out of work. They stated employees were tested for COVID-19 via rapid point of care and if the test was positive then that employee would be tested again using the polymerase chain reaction (POC) method of testing. During an observation on 10/14/22 at 1:46 PM, the COVID-19 Swabber/Receptionist preformed a COVID-19 rapid point of care nasal swab on the PT. The COVID-19 Swabber/Receptionist was wearing an isolation gown, gloves, surgical mask, and their personal eyeglasses. During a further observation at 2:12 PM the COVID-19 Swabber/Receptionist preformed a COVID-19 rapid point of care nasal swab on CNA #3 wearing an isolation gown, gloves, surgical mask, and their personal eyeglasses. During both observations the COVID-19 Swabber/Receptionist did not wear a N95 mask nor a face/shield or goggles. During a telephone interview on 10/14/22 at 3:52 PM, the COVID-19 Swabber/Receptionist stated that when they perform a COVID-19 rapid point of care test the PPE they would wear was a gown, gloves, surgical mask, and their personal eyeglasses. They stated that the Former Nurse Educator educated them on how to perform a nasal COVID-19 swab and told them they only needed to wear a N95 mask and a face shield if the facility was in a COVID-19 outbreak. The COVID-19 Swabber/Receptionist stated they would only wear a face shield and a N95 mask if they noticed that the COVID-19 cases in the facility were rising or if they needed to perform a PCR test on an employee. During an interview on 10/14/22 at 4:24 PM, the Nurse Educator/IP stated that a N95 mask, gown, gloves, and goggles were to be worn when collecting COVID-19 specimens. They stated if the employee did not wear the appropriate PPE, they could become a mode of transmission themselves and possibly infect others. During an interview on 10/14/22 at 4:31 PM, the Director of Nursing (DON) stated the full PPE should be worn when preforming a COVID-19 swab and that included a gown, gloves, N95 mask and goggles/face shield. The DON stated that a N95 mask and googles/face shield should have been worn because the employee being swabbed could be COIVD-19 positive. The DON stated not wearing full PPE could possibly cause cross-contamination and spread COVID-19 to others. 415.19

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey started on 10/12/22 completed 10/18/22, the facility did not ensure that each resident's drug regimen is free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose or duration, without adequate monitoring, without adequate indication, in the presence of adverse consequences and in any combination as stated. Specifically, one (Resident #10) of six residents reviewed for unnecessary medications was treated with an antibiotic for an excessive duration, without adequate indication for its continued use. The finding is: Review of facility policy and procedure (P&P) titled Urinary Tract Infection (UTI) revised 12/19 documented the facility provides the highest quality of care using most up to date clinical standards. Facility wide surveillance of infections is collected as part of the infection control program. The physician will help nursing staff interpret the significance of signs, symptoms, and lab test results. Before diagnosing a UTI and ordering antibiotics, the physician should consider the overall picture including specific evidence that confirms or refute the diagnosis of a UTI. Review of the P&P titled Antibiotic Stewardship, revised 12/19, documented the Antibiotic Stewardship refers to a set of commitments and activities designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents. 1. Resident #10 was admitted to the facility with diagnoses including peripheral vascular disease (PVD, decreased circulation of lower extremities) lymphedema (blockage of the lymphatic vessels leads to fluid retention), and UTI. The Minimum Data Set(MDS-a resident assessment tool) dated 9/26/22 documented Resident #10 had intact cognition, was understood, and understands. The MDS further documented the resident did not have a urinary tract infection in the last thirty days. Review of the Hospital Discharge summary dated [DATE] documented Resident #10's urine was grossly infected and had been started on Bactrim DS (antibiotic). Review of the Order Summary Report documented the following: - Bactrim DS tablet-800-160mg, one tablet every 12 hours for bacterial infection for 14 days. The start date was 7/8/21 with the end date of 7/22/21. - Macrobid Capsule 100 mg (milligrams), one capsule by mouth one time a day for UTI/prophy with an order date of 8/4/21. The start date was 8/5/21 with no end date. Review of the admission Physician Progress Note dated 7/9/21 documented Resident #10 was on Bactrim twice daily (BID) x 14 days for UTI. The physician did not document why the Macrobid was started on 8/5/21. The Medication Administration Record (MAR) dated July 2021 through October 2022 revealed Bactrim DS was completed on 7/22/21. Starting on 8/5/21 Resident # 10 received the Macrobid Capsule (antibiotic) 100 mg (milligrams) once daily for UTI prophylaxis with no stop date. Nursing Progress Notes from 7/8/21 through 8/4/21 revealed there was no documented evidence of urinary tract infection symptoms, urine culture, urology consults or nursing documentation to justify the use of the Macrobid. Review of the current Comprehensive Care Plan (CCP) with a revision date of 9/30/21 documented Resident #10 had chronic UTIs'. The plan included to administer medications as ordered and to monitor labs. Monitoring for signs and symptoms of a urinary tract infection and long-term antibiotic use was not reflected in the plan. Further review of the Physician Progress Notes revealed the following: -11/3/21,1/27/22, and 4/30/22 chronic UTI, continue with Macrobid. -7/26/22 chronic UTI, UTI prophylaxis, continue with Macrobid. During an interview on 10/18/22 at 10:01 AM, Licensed Practical Nurse (LPN) #9 Unit Manager (UM) stated Resident #10 received the Macrobid daily for UTI prophylaxis. Interdisciplinary (IDT) Meetings did not include review of long- term use of antibiotics. Typically, the Pharmacist reviewed long-term use antibiotics and providers wouldn't order antibiotics unless a positive urine culture was received. LPN# 9 stated no urine cultures had been completed for Resident #10. A urology consult was discussed with Resident #10 last August, was overlooked and never arranged. LPN #9 stated they contacted the urologist and The resident had not seen the urologist within three years. During a telephone interview on 10/18/22 at 10:31 AM, the Consultant Pharmacist stated they never questioned the start of the Macrobid and did not make any recommendations to the provider about the long-term use of the medication. The antibiotic use was not discussed at interdisciplinary team (IDT) meetings. All medications were reviewed monthly during the drug regimen review. The provider documented chronic UTI's, and to continue Macrobid on 11/3/21, 1/27/22, 4/30/22. On 7/26/22 the provider documented prophylaxis. The Pharmacy Consultant stated they never followed up with the provider. The Pharmacy Consultant stated there was no urology consult in the past year and no nursing documentation to justify why the Macrobid was started on 8/5/22. I guess I would expect something to be documented from nursing or the physician at the time of the medication was ordered. Resident #10 had a UTI in the hospital prior to admission and I'm thinking that's why the provider ordered it. During an interview on 10/18/22 at 12:45 PM, the Director of Nurses (DON) stated I would expect a urine culture and a urology consult within the course of the year to determine the need for the medication to continue. There should have been a progress note from the provider at the time the medication was ordered. There should be nursing progress notes to reflect the providers orders. I don't see anything documented. Prophy antibiotic used should be reviewed on a yearly basis by the provider to be deemed necessary. During interview on 10/18/22 at 2:10 PM, MD stated Resident #10 came to the facility on Bactrim DS for 2 weeks. I think the resident told me they were on a prophylaxis antibiotic for UTI's prior to admission to the facility. That's why I started it. The MD did not recommend Resident #10 to see a urologist. A urologist would just do the same thing I would. The MD stated a urine culture was not ordered; I just took the residents' word for it. Prophylactic antibiotics were to be reevaluated yearly and It's been over a year; I'll take responsibility for this one. The Macrobid is unnecessary. 415.12(l)(1)

Based on observation, interview, and record review conducted during the Standard Survey that was started on 10/12/22 and completed on 10/18/22, the facility did not store and distribute food in accordance with professional standards for food service safety. Specifically, three (Second, Third, and Fourth Floors) of three Resident Unit Nourishment refrigerators contained unlabeled, undated, and outdated food. The findings are: The facility policy and procedure titled Food Storage Policy, revised 1/25/22, documented all foods should be covered, labeled, and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Additionally, each leftover food item will be clearly labeled and dated before being refrigerated. Leftover food is used within 24-72 hours or discarded as per the 2017 Federal Food Code. The facility policy and procedure titled Food - From Outside, revised 11/2021, documented food or beverage that is brought in from the outside will be monitored by nursing staff for spoilage, contamination, and safety. Food brought in by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food, a label will identify resident name, room number, item, date received and discard date. All refrigerated foods will be discarded within 48 hours. Additionally, nursing staff will monitor resident's room, unit pantry, and refrigeration units for food and beverage disposal, and will discard perishable foods on or before the discard date. 1a. Observation in the Fourth Floor Nourishment Room on 10/12/22 at 8:40 AM revealed the refrigerator had two signs posted. One sign said, All items placed in this cooler must have resident name, room number, and date on item. Any item without a proper label will be thrown out - Posted 24 August 2020. The other sign said, Resident refrigerator, date on product - today's date, discard product in two days (48 hours), note: please remember to label and date any resident food with today's date - items found to be undated and unlabeled will be discarded. Continued observation at this time revealed the following items in the Fourth Floor Nourishment Room refrigerator: -Unopened half pint of milk with sell-by date 9/29/22 -Unopened half pint of milk with sell-by date 10/9/22 -Facility container single serving of crumble dessert, no name or date -Store packaged single serving of salad, no name -Store packaged single serving of sushi, no name -Store packaged coconut pie, about half remained, no name, store's sell-by date 10/8/22 -Twelve-ounce container of whipped topping, about half full, no name -Commercially prepared single serving of lasagna in freezer, no name -Two sixteen-ounce bottles of lemonade in freezer, no name During an interview at the time of the observation, the Fourth Floor Unit Manager Registered Nurse stated some of these food items belonged to staff members and should not be stored in this refrigerator. At this time, the Fourth Floor Unit Manager Registered Nurse removed the sushi and salad from the Nourishment Room. 1b. Observation in the Third Floor Nourishment Room on 10/12/22 at 9:20 AM revealed the refrigerator had a sign posted that said, All items placed in this cooler must have resident name, room number, and date on item. Any item without a proper label will be thrown out - Posted 24 August 2020. Continued observation at this time revealed the following items in the Third Floor Nourishment Room refrigerator: -Store packaged multiple serving of cut fruit, no name, store's use-by date 10/9/22 -Store packaged single serving of cut fruit, a resident name and 10/1 hand-written on a piece of tape -One half of a peanut butter and jelly sandwich with a facility-printed label with resident name, dated 10/8 - Two separately wrapped halves of a facility-prepared peanut butter and jelly sandwich with a facility-printed label with resident name, dated 10/9 -Yellow shopping bag with a restaurant style hoagie, no name or date -Fast food cold beverage cup with unwrapped straw in freezer, no name or date 1c. Observation in the Second Floor Nourishment Room on 10/12/22 at 10:05 AM revealed the refrigerator had a sign posted that said, Refrigerator use is for residents only. Please date everything placed in refrigerator. Employee food will be thrown out. Continued observation at this time revealed the following items in the Second Floor Nourishment Room refrigerator: -Fast food paper bag with hamburger in clear plastic wrap, no name or date -Brown bag breakfast that included a hard-boiled egg and facility-prepared fruit cup with a facility-printed label with resident name, dated 10/9/22 -Approximately three quarters of a pound of sausage wrapped in sunflower seeds bag with resident name hand-written on bag, no date -Twelve-ounce container of French onion dip with resident name hand-written on container, about half full, no date -Approximately one pound container of chicken and macaroni cheese with resident name and the words Don't Throw Out written on the container, no date -Approximately one-and-a-half-pound container of chicken, mashed potato, and green vegetable with resident name and the words Don't Throw Out written on the container, no date -Fast food cold beverage cup with unwrapped straw, no name or date -Opened sixteen-ounce soda bottle in freezer, no name or date During an interview on 10/14/22 at 8:55 AM, Certified Nurse Aide (CNA) #1 stated the refrigerators in the Resident Unit Nourishment Rooms were for resident food only. They further stated it was not the responsibility of CNAs to maintain the refrigerators, but if a CNA saw food with an old date, they could throw it out. CNA #1 defined old date as possibly two days. Additionally, CNA #1 stated staff food belonged in the Breakroom on the First Floor. During an interview on 10/14/22 at 9:07 AM, Dietary Supervisor #1 stated maintaining the Resident Unit Nourishment Room refrigerators was the responsibility of the Dietary Supervisors. Dietary Supervisor #1 stated the Resident Unit Nourishment Room refrigerators were for resident food only, and staff's personal food belonged in the Breakroom on the First Floor. They stated food was typically able to be stored in the refrigerator for three days, but the amount of time could depend on the type of food. Specifically, meat and prepared sandwiches would be discarded three days after preparation. Containers of whipped topping or sliced cheese would be discarded three days after opening, but other dairy products, such as French onion dip and milk, would be discarded two days after opening. If no name or date on the product, Dietary Supervisor #1 stated they would have to discard it. Dietary Supervisor #1 stated they use the manufacturer's sell-by date printed on cartons of milk and would discard the milk on the sell-by date. Additionally, any cup with an opened used straw in the Resident Unit Nourishment Rooms would have to be discarded because of germs. Dietary Supervisor #1 also stated the facility does not serve bottles of lemonade, so if they found unopened bottles of lemonade in the Resident Unit Nourishment Room, they would bring it to the Nurse Manager's attention to see if it was brought in by a resident's family and could keep it in the dietary office until identified. Review of the October 2022 Refrigerator Freezer Temperature Log posted on the Second, Third, and Fourth Floor Resident Unit Nourishment Room refrigerators revealed all were checked daily and the entry dated 10/12/22 was initialed by Dietary Supervisor #2. During an interview on 10/14/22 at 1:40 PM, Dietary Supervisor #2 stated the refrigerators in the Resident Unit Nourishment Rooms were checked daily by Dietary Supervisors for temperatures and dates on food, and those refrigerators were for resident food only. They stated they had to throw out staff food from those refrigerators. All food items in these refrigerators must be labeled with a name and date. Dietary Supervisor #2 stated they referred to the dates on each item to decide when a food needed to be discarded, which was two days for milk and meats. They also stated they would discard milk on the manufacturer's sell-by date printed on the carton. Dietary Supervisor #2 stated they would discard hard boiled eggs one day past the prepared date and would discard a beverage with an opened used straw. Additionally, they stated residents sometimes ordered take-out and if they found food in a Resident Unit Nourishment Room refrigerator with no name or date, they would check with a nurse before discarding. Dietary Supervisor #2 also stated many people were in these refrigerators all day adding stuff, so it was hard to keep track of. 1d. A second observation of the Second Floor Nourishment Room on 10/14/22 at 1:50 PM in the presence of the Food Service Director (FSD) revealed the following items were in the refrigerator: -Brown bag breakfast that included a hard boiled egg and facility-prepared fruit cup with facility-printed label with resident name, dated 10/9/22 -Five brown bags with resident name and the words, For Dialysis written on each bag, contained re-usable plastic cup of pickles, no date -Approximately one-half pound of pepperoni in a re-usable plastic container hand-written with resident name and the words, Do Not Dispose, but a facility-printed label located on the inner wrapping contained a different resident name and was dated 10/5/22 -Shopping bag with opened bagged lettuce and opened bag of sliced cheese, labeled with resident name, no date During an interview at the time of the observation, the FSD stated the refrigerators in Resident Unit Nourishment Rooms were for resident food only and they were checked daily by a Dietary Supervisor. The FSD stated they expected names, room numbers, and dates on all foods in these refrigerators. If staff food was found in a Resident Unit Nourishment Room refrigerator, it would be thrown out because staff food belonged in the First Floor Breakroom. They stated all foods should be discarded 72 hours after being prepared or the package being opened, and they would still use the 72-hour rule even if the manufacturer's use-by date on the packaging was current. Additionally, milk would be discarded within 72 hours of being opened, or on the manufacturer's sell-by date, whichever came first. The FSD stated they discarded prepared or opened foods at 72 hours to avoid food spoilage and for resident safety. At this time, the FSD observed the pepperoni and voluntarily discarded it due to the date. The FSD also observed the hard boiled egg and facility-prepared fruit cup in the brown bag dated 10/9/22 and voluntarily discarded it. The FSD stated the contents of the brown bag should have been discarded after it came back from the resident's dialysis appointment uneaten. The FSD observed the five paper bags with the pickles and stated they thought the family brought them in and they would have to speak to nursing about this because the bags must be dated. 415.14 (h) 14-1.43(e)

Based on interview and record review conducted during a Standard survey started on 10/12/22 and completed on 10/18/22, it was determined that the facility did not implement an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. Specifically, one (Resident #10) of one resident reviewed for antibiotic stewardship program revealed the resident was receiving Macrobid (an antibiotic) since 8/4/21 as a urinary tract infection prophylaxis (prevention) without documented evidence for its continued use, appropriate indications for its use, and a lack of monitoring and tracking its use. The finding is: Review of the P&P titled Antibiotic Stewardship, revised 12/19, documented antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program. Antibiotic Stewardship refers to a set of commitments and activities designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The core elements of our program are our leadership commitment, accountability, drug expertise, tracking, actions, reporting and education. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. Staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents. 1. Resident #10 was admitted to the facility with diagnoses including peripheral vascular disease (PVD, decreased circulation of lower extremities) lymphedema (blockage of the lymphatic vessels leads to fluid retention), and UTI. The Minimum Data Set (MDS-a resident assessment tool) dated 9/26/22 documented Resident #10 had intact cognition, was understood and understands. The MDS further documented the resident did not have a urinary tract infection in the last thirty days. Review of the chronological medical record from August 2021 to October 2022 revealed the following: The current Comprehensive Care Plan, CCP with a revision date of 9/30/21 documented Resident #10 had chronic UTIs. The plan documented to administer medications as ordered and to monitor labs. Monitoring for signs and symptoms of a urinary tract infection and long-term antibiotic use was not reflected in the plan. Physician's Orders Summary Report dated 10/18/22 revealed an active physician's order for Macrobid 100 mg (milligrams) daily. The medication was ordered on 8/4/21. Further review of the orders revealed that there was no physician's order for a Urology consult or urinalysis or urine cultures. Medication Administration Record (MAR) dated August 2021 through October 2022 documented Resident # 10 received the Macrobid Capsule (antibiotic) 100 mg (milligrams) once daily for UTI prophylaxis and there was no stop date. Outside consults for Resident #10 did not contain a consultation from a Urologist. Pharmacist Consultant Monthly Medication Review from 8/2021 through 9/2022 did not have recommendations to review antibiotic use for prevention of a urinary tract infection, antibiotic resistance data, or if adjustments to antibiotic therapy would be warranted. The handwritten facility Infection Control & Antibiotic (ABT) Stewardship Program and Tracking Tool form from 8/2021 through 10/2022 revealed Resident #10 was included on the tracking tool for Macrobid 100 mg for UTI prophy in August 2021. The Macrobid was not listed or monitored/tracked monthly thereafter. Physician's Progress Notes revealed the provider documented chronic UTIs on 11/3/21, 1/27/22, 4/30/22, and to continue prophylaxis on 7/26/22. There was no evidence the resident had signs and symptoms of urinary tract infection, laboratory diagnostics/results confirming infection. During a telephone interview on 10/18/22 at 9:04 AM, the Pharmacy Consultant stated antibiotics were reviewed monthly during the Monthly Medication Review (MMR). The provider documented chronic UTIs and continue prophylaxis on 7/26/22 for Resident #10. So I never questioned the chronic antibiotic use. The Pharmacist did not provide antibiotic resistance data to the physician for long-term use. During an interview on 10/18/22 at 11:12 AM, Registered Nurse (RN) Nurse Educator/Infection Preventionist (IP) stated they were not aware of Resident #10 was receiving a daily dose of an antibiotic. They monitored antibiotic use for an active infection which did not include antibiotic prophylaxis. The facility used (computer software program) as a backup system for tracking antibiotic use. The system tracked residents using antibiotics in the last 7, 14 and 30 days. After 30 days, the system automatically removed the resident from the report. The facility had no system to track antibiotic prophylaxis monthly. During an interview on 10/18/22 at 12:45 PM, the Director of Nursing (DON) stated they would expect the Physician and the Pharmacist Consultant to review the resident's medication monthly to see if there were any irregularities and to monitor antibiotic use. The DON stated there was no effective system for monitoring antibiotic prophylaxis. During an interview on 10/18/22 at 1:08 PM, the Regional Director of Clinical Services stated antibiotic prophylaxis should have been included monthly on the tracking forms to determine if it's necessary or if the provider needed a reminder to review the medication. Antibiotics were to reviewed monthly by the provider and the IP. The Regional Director of Clinical Services stated just because it's not an active infection, it's still needs to be monitored. That's the purpose of Antibiotic Stewardship. During interview on 10/18/22 at 2:10 PM, MD stated The resident told me they were on a prophylaxis antibiotic for UTIs prior to admission to the facility. That's why I started it. The MD stated a urine culture was not ordered; I just took the resident's word for it. Prophylactic antibiotics were to be reevaluated yearly and It's been over a year; I'll take responsibility for this one. 415.12(l)(1)