**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 2/13/2025, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment; and did not maintain comfortable temperature levels between 71 degrees Fahrenheit to 81 degrees Fahrenheit for two (Harbor View and City View units) of four units. Specifically, air temperatures were below 71 degrees Fahrenheit in resident rooms and shared resident areas on the Harbor View unit. In addition, shower chairs and the shower floor were observed with dried brown debris on them on the City View and Harbor View units. The findings are: The policy titled Home Like Environment, created 9/19/2022, documented residents were provided with a safe, clean, comfortable, and homelike environment and encouraged to use their own personal belongings to the extent possible. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. Characterized by cleanliness and order, comfortable yet adequate lighting, inviting colors and décor, personalized furniture and room arrangements, pleasant neutral scents, plants and flowers when appropriate, comfortable temperatures and noise levels. 1.The policy titled Temperature - Room, last revised 8/2019, documented comfortable and safe temperature levels were when the ambient temperature would be in relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia, respiratory ailments, and colds. The temperature in the facility rooms would be maintained at a temperature range of between 71 degrees to 81 degrees Fahrenheit. Temperatures would be measured as needed when there is a complaint about air temperature. Concerns would be reported to the supervisor and then to maintenance for review and further actions as necessary. Observations of the Harbor View unit and temperatures obtained using the surveyor's stem type thermometer revealed the following: -On 2/06/25 at 8:49 AM, Licensed Practical Nurse #7 was at their medication cart, wearing a winter hat. -On 2/6/25 at 9:44 AM, the air temperature in the hallway outside of Resident room [ROOM NUMBER] was 68.5 degrees Fahrenheit and felt cold; at 9:45 AM, the air temperature inside Resident room [ROOM NUMBER] was 67.8 degrees Fahrenheit, the window was closed, and the shade was down. The resident stated they felt cold and had three blankets on. -On 2/6/25 at 10:10 AM, Resident room [ROOM NUMBER] the air temperature was 67.2 degrees Fahrenheit and felt cold. The resident was in the room and was not interviewable. -On 2/7/25 at 8:23 AM, the hallway air temperature near Resident room [ROOM NUMBER] was 67.7 degrees Fahrenheit. Licensed Practical Nurse #7 stated they were not cold today, but yesterday they wore their winter hat because they were cold. -On 2/7/25 at 9:17 AM, The air temperature was 68.3 degrees Fahrenheit in the hallway near Resident room [ROOM NUMBER]. Resident #108 was self-propelling their wheelchair in the hallway near room [ROOM NUMBER], they were wearing a jacket and stated it was freezing in the building someone turn on the heat. -On 2/7/25 at 9:19 AM, the common area adjacent to the nurse's station air temperature was 69 degrees Fahrenheit. There were two residents in the area, one was wearing a hooded sweatshirt with the hood pulled up over their head. -On 2/7/25 at 9:22 AM, the common area diagonal from the nurse's station air temperature was 67.4 degrees Fahrenheit. There were three residents seated in the area. -On 2/7/25 at 10:40 AM, Licensed Practical Nurse #11 stated it was cold in the facility every day. The air temperature in the center of the common area was 66.7 degrees Fahrenheit and Resident #108 was wrapped in a blanket covering their nose and mouth. They stated their nose was freezing. There were four other residents seated in the area. -On 2/7/25 at 12:10 PM, the air temperature in Resident room [ROOM NUMBER] was 67.5 degrees Fahrenheit using the facility's infrared thermometer pointed at an interior wall. During an interview at the time of the observation, the Assistant Maintenance Director stated the thermostat in this room controlled the baseboard heat, and it was set to 70 degrees Fahrenheit. The Maintenance Director stated a floor mat was covering the baseboard, and they moved the floor mat and stated it might have affected the air temperatures. - On 2/7/25 at 12:15 PM the air temperature in the common area across from the nurse's station was 69.6 degrees Fahrenheit with both the Surveyor's stem-type thermometer and the facility's infrared thermometer. The Assistant Maintenance Director stated the heat in that area came from the rooftop air handling unit and PTAC units (packaged terminal air conditioner, a self-contained heating and cooling unit that's mounted through a wall). Five residents were in the common area and both PTAC units were off. The Maintenance Director turned on one of the PTAC units in the Lounge. At 12:30 PM, the air temperature in the common area had reached 70.1 degrees Fahrenheit with the Surveyor's stem-type thermometer. -On 2/11/25 at 11:28 AM, the air temperature in the hallway outside Resident room [ROOM NUMBER] was 69.1 degrees Fahrenheit; at 11:30 AM the air temperature inside Resident room [ROOM NUMBER] was 67.7. degrees Fahrenheit. At 11:33 AM, Licensed Practical Nurse #7 stated the rooms at the end of the hallway were always cold and they have told maintenance about it, supposedly they ordered a part, and it was fixed. They stated they were cold, and they moved around, so they could only imagine what it was like for the residents. The thermostat on the wall in Resident room [ROOM NUMBER] was observed set at 65 degrees Fahrenheit and was encased in a clear plastic locked box. -On 2/11/25 at 11:39 AM, Certified Nurse Aid #6 stated Resident room [ROOM NUMBER] was cold, and the air seeped in through the large window. They gave the resident extra blankets when they were cold. During an observation and interview on 2/11/25 at 11:47 AM, the air temperature of Resident room [ROOM NUMBER] was taken with the Maintenance Director using their infrared thermometer aimed at an interior wall with a result of 68.5 degrees Fahrenheit. At 11:49 AM, Resident room [ROOM NUMBER] was 68.1 degrees Fahrenheit. The Maintenance Director stated they liked to see resident rooms between 71 and 72 degrees Fahrenheit, and not lower than 71 degrees. They observed the thermostat in room [ROOM NUMBER] and said it was at 65 degrees right now. They stated the Assistant Maintenance Director took daily temperatures of rooms and that they could turn up the thermostat in room [ROOM NUMBER]. During an observation and interview on 2/11/25 at 11:53 AM, the Assistant Maintenance Director stated they checked air temperatures daily, they stated there were not any entries for cold room temperatures on the maintenance logbook on the Harbor View unit and the air handlers on that side of the building have been in working order. They stated they took an air temperature in room [ROOM NUMBER] around 7:00 AM that day and it was 74.1 degrees Fahrenheit using their infrared thermometer. At 11:59 AM, the Assistant Maintenance Director went into room [ROOM NUMBER], unlocked the thermostat and stated they were turning it up. The resident was lying in bed at this time. They took an air temperature of the room with their infrared thermometer and got 68.2 degrees Fahrenheit when they aimed it at an interior wall. They stated the temperatures should be between 71 to 72 degrees Fahrenheit but liked it at 74 degrees Fahrenheit. They stated the end rooms were always slightly colder. During an interview on 2/11/25 at 1:32 PM, Resident #77 stated it could be warmer in the facility, the windows were drafty and old. The resident was wearing a winter hat. During an interview on 2/11/25 at 8:39 AM, Registered Nurse Unit Manager #7 stated when the unit felt cold, they would call the maintenance staff to let them know so they could adjust the heat. They were the ones who controlled it. They stated they would get residents extra blankets if they were cold until it got warmer. During an interview on 2/11/25 at 12:19 PM, Licensed Practical Nurse #9 stated they noticed the cold air temperatures and that the resident in room [ROOM NUMBER] probably had five blankets on them. The building was very cold at night. During an observation on 2/12/25 at 9:20 AM, Resident room [ROOM NUMBER] was 66.7 degrees Fahrenheit, the resident stated they were cold and was wearing three blankets. Certified Nurse Aide #9 stated it was freezing in the room. During an interview on 2/13/25 at 12:04 PM with the Director of Clinical Operations present, the Director of Nursing stated someone had mentioned a resident was complaining of colder temperatures. The temperature range should be 71 degrees to 81 degrees Fahrenheit. They stated for a temperature of 67 degrees Fahrenheit and below staff would need to pass out extra blankets. 2.The policy titled Cleaning/Disinfecting Resident Care Items and Equipment, last revised 11/2018, documented reusable resident care items and equipment should be cleaned and disinfected according to current CDC (Center for Disease Control) recommendations for disinfection of healthcare facilities and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. Shared resident care items are items and equipment that can be used in the care of multiple residents. These reusable items should be cleaned/disinfected between each resident and use. Items/equipment visibly contaminated with blood and/or other potentially infectious materials should be promptly cleansed and decontaminated following Occupational Safety and Health Administration guidelines. The policy titled Environmental Services Cleaning of Shower Room, last revised 5/2018, documented the facility provided a safe and sanitary environment to prevent the development and transmission of disease and infection. Sweep and mop tile floor according to floor cleaning procedure. During an observation on 2/6/2025 at 9:33 AM the shower room on City view was soiled with dried brown fecal matter (approximately 6 x 2 inches) in the right corner of the shower stall floor. There were 2 smaller chunks of brown fecal matter under the shower chair. This was the only usable shower stall; the other stall was full of equipment. During an observation on 2/7/2025 at 9:09 AM the shower room floor remained soiled with dried brown debris and under the shower chair. The shower chair was soiled with dried brown fecal matter smeared on the seat. This was the only usable shower stall; the other stall was full of equipment. During an observation and interview on 2/7/2025 at 10:33 AM, Certified Nurse Aide #10 stated the dried brown debris on the shower room floor and shower chair on Harbor View was feces and it needed to be cleaned. Certified Nurse Aide #10 stated whoever gave the shower last was responsible for cleaning the shower chair and housekeeping was responsible for mopping the floors. They should ensure the shower stalls and chairs are cleansed for infection control reasons, they don't want to spread germs because the chairs are used for multiple residents. During an interview on 2/13/2025 at 10:53 AM, Certified Nurse Aide #10 stated the dried brown debris on the shower chair and floor did not present a homelike environment. They wouldn't want their house to look like that, that's gross. During an observation and interview on 2/7/2025 at 10:37 AM, Licensed Practical Nurse Unit Manager #5 stated the dried brown debris on the shower chair on City View was feces. They stated they believed the dried brown debris area on the shower stall floor was dirty or stained but could not say for sure what it was. The Certified Nurse Aide who gave a shower last was responsible for cleaning the shower chair, then housekeeping followed up with cleaning the shower stall. Licensed Practical Nurse Unit Manager #5 stated the Certified Nurse Aides should use the disinfecting wipes provided to them to clean the shower equipment before and after each use. It was important for infection control reasons. During an interview on 2/13/2025 at 10:50 AM, Licensed Practical Nurse Unit Manager #5 stated dried feces on shower chairs and floors was not conducive to a homelike environment. During an observation and interview on 2/7/2025 at 10:41 AM, Housekeeping Aide #1 stated the dried brown debris on the shower chair and dried brown debris smear on the shower floor on Harbor View was probably feces. Certified Nurse Aides were responsible for cleaning up any linens and bodily fluids and housekeeping was responsible for cleaning shower stalls and floors. During an observation on 2/13/2025 at 8:00 AM the shower chair seat in Harbor View shower room was completely covered in smeared dried brown debris (feces) (approximately 6 x 12 inches). During an observation and interview on 2/13/2025 at 8:01 AM, Certified Nurse Aide #9 stated the dried brown debris smear across the shower chair in Harbor View shower room was probably feces and that presented a risk for cross contamination. They stated the Certified Nurse Aide who gave a shower last responsible for cleaning the shower chair after. During an observation and interview on 2/13/2025 at 8:07 AM, Registered Nurse Unit Manager #7 stated the dried brown debris on the shower chair in Harbor View shower room could be feces. It was an infection control issue and could cause cross contamination. Certified Nurse Aides are responsible for cleaning up before and after they gave a shower, and housekeeping cleaned the shower stalls. During an interview on 2/13/2025 at 9:15 AM, the Director of Nursing stated shower rooms and shower chairs should be cleaned before and after every shower. Housekeepers are responsible for cleaning shower stalls and whoever gave the shower was responsible for cleaning the chair. During a follow up interview at 2/13/2025 at 11:08 AM, the Director of Nursing stated the dried brown debris on the shower chairs and/or floor did not present a homelike environment. They would not want their house to look like that. During an interview on 2/13/2025 at 11:44 AM, the Director of Clinical Operations/ Interim Infection Preventionist stated they expected staff to clean all equipment before and after each use, including shower chairs. The dried brown debris on shower chairs and/or floor put residents at risk for the spread of pathogens and did not present as homelike. During an interview on 2/13/2025 at 12:27 PM, the Administrator stated they expected staff to clean equipment prior to and after each use. They would not want another resident using equipment that was soiled with feces, it is an infection control issue and could cause cross contamination. Housekeeping cleansed and sanitized shower stalls but did not touch urine or feces. The Administrator stated they would not want dried brown debris in their home or to sit on it, it was not homelike. 10 NYCRR 415.5(h)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during Complaint investigations (Complaint #s NY00362643 and NY00369017) during the Standard survey completed on 2/13/25, 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 two (Residents #39 and #96) of 9 residents reviewed. Specifically, Resident #39 was not gotten out of bed on multiple days and had an unkempt beard. Resident #96 had a moderate amount of long chin hair and jagged dirty fingernails. The findings are: The policy titled Activities of Daily Living Care and Support dated 3/13/24 documented care and support will be provided for residents who were unable to carry out activities of daily living independently in accordance with the resident's assessed needs, personal preferences, and individualized plan of care that includes assistance with hygiene (grooming) and mobility (transfers). Nail care should be provided as needed and facial hair will be groomed per resident's preference. 1. Resident #39 had diagnoses including osteomyelitis (infection in bone), gastrostomy (an opening into the stomach wall that allows feeding tube insertion), and atrial fibrillation (irregular heart rate). The Minimum Data Set (a resident assessment tool) dated 11/19/24 documented the resident had moderate cognitive impairment, and for transfers and personal hygiene the resident was dependent on staff to complete all the activity. The undated comprehensive care plan identified as current by the Director of Nursing, documented the resident had difficulty communicating due to garbled speech, interventions included to anticipate the resident's needs. The resident required assistance with activities of daily living and interventions included for bed to chair transfers two staff were to use a mechanical lift and for personal hygiene the resident was dependent on one staff. The [NAME] Report (a guide used by staff to provide care) dated 2/10/25 documented Resident #39 required two people using a mechanical lift to be transferred from their bed to a chair and required one person to complete all personal hygiene tasks (the resident could not use their own strength for any part of the activity). Adaptive equipment included a wheelchair. During an observation and interview on 2/6/25 at 9:03 AM, Resident #39 was lying in bed, watching television. They had a long, unkempt beard on their face. The resident stated they would like their beard shaved because it can get itchy at times, and nobody ever asked them if they wanted it shaved. Resident #39 stated when they had asked staff about being shaved, staff would say they looked cute with their beard. Resident #39 stated they never got out of bed because of their feeding tube and that staff never shaved them. The resident stated they would like to be out of bed sometimes. There was no wheelchair or Geri chair (a medical reclining chair) in the resident's room or outside their room in the hallway. Further observations of Resident #39 revealed the following: -On 2/7/25 at 10:43 AM, the resident was lying in bed, sleeping. -On 2/10/25 at 8:11 AM, the resident was lying in bed, watching television. Their beard was unkempt and had not been trimmed or shaved. -On 2/10/25 at 2:50 PM, the resident was lying in bed and was not observed to be out of bed on this date. During an observation of morning care and wound care on 2/11/25 from 9:58 AM to 11:20 AM; Certified Nurse Aide #6 and Certified Nurse Aide #7 provided incontinence care. At 10:26 AM, Certified Nurse Aide #6 stated they were finished providing care for the resident. At 10:28 AM, Licensed Practical Nurse #7 started the resident's wound treatments and completed them at 11:20 AM. None of the staff offered to get the resident up out of their bed or to shave them. During an interview on 2/11/25 at 12:06 PM, Certified Nurse Aide #8 (assigned to Resident #39) stated that they didn't usually work on this unit, and they fed the resident this morning. They stated that Certified Nurse Aide #6 was supposed to wash up and provide a bed bath for Resident #39 that morning. During an interview on 2/11/25 at 12:09 PM, Certified Nurse Aide #6 stated they were asked to provide incontinent care to Resident #39 this morning. They were not told to provide morning care, the assigned aide (Certified Nurse Aide #8) was supposed to do that part of care. They stated the resident didn't usually get out of bed and they weren't sure why. During further interview on 2/11/25 at 1:57 PM, Certified Nurse Aide #6 stated there was a certified nurse aide who worked weekends, and they usually shaved the residents, they stated right now Resident #39's beard was decent, but residents have to ask to be shaved and be vocal about what they want. During an observation interview on 2/12/25 at 9:42 AM, Registered Nurse Unit Manager #7 was standing outside of Resident #39's room, the resident was awake, lying in bed. The Registered Nurse Unit Manager #7 stated Certified Nurse Aides were supposed to offer shaving to the residents, usually done on shower days. They stated the resident was in bed mostly because of their pressure sore and they never asked if the resident wanted to get out of bed. They stated the resident was on a different unit prior being on this unit and that therapy were the ones that provided chairs to residents. At 9:47 AM, Resident #39 stated they would like to get out of bed. During an interview on 2/12/25 at 9:48 AM, Certified Nurse Aide #9 stated the resident never got up out of bed and they weren't exactly sure why but probably because they had a sore. They stated they never asked the resident if they wanted to get up and they didn't have a chair that's why they didn't ask the resident. Certified Nurse Aide #9 stated the resident was on a different unit, then went out to the hospital and when they came back, they were on this unit. The resident would probably say yes if staff asked if they wanted to get up. During an interview on 2/13/25 at 12:25 PM, Licensed Practical Nurse #7 stated the resident didn't have a chair, at one point therapy said they were looking for one, but they had tossed out some equipment. They stated the resident's friend used to shave them but hadn't been in to visit for a while. During an interview on 2/13/25 at 8:39 AM, the Registered Nurse Unit Manager #7 stated that the resident should be offered a shave, and that the resident didn't like the razors. They stated the activity director came over and shaved the resident with an electric razor and that it worked better for the resident. During an interview on 2/13/25 at 12:04 PM with the Director of Clinical Services present, the Director of Nursing stated unit managers were supposed to make sure staff were providing activities of daily living to residents. The Director of Nursing stated the staff should have offered Resident #39 to be out of bed and they liked everyone to be out of bed everyday unless it was contraindicated, but this resident could be up for several hours daily. The Director of Nursing stated a lot of the time this resident is scruffy because they don't like the razors here. 2. Resident #96 had diagnoses that included fracture of orbital (eye socket) floor, major depressive disorder, and osteoarthritis (chronic degenerative bone disease; breakdown of cartilage and other tissues within the joint). The Minimum Data Set, dated [DATE], documented Resident #96 was cognitively intact, understands, and was understood. The Minimum Data Set documented that Resident #96 required a partial/moderate assist of one staff member for personal hygiene. The [NAME] with a printout date of 2/13/25 documented Resident #96 received their showers Saturdays during the 7:00 AM - 3:00 PM shift and Wednesday during the 3:00 PM- 11:00 PM shift. Additionally, the [NAME] documented to prevent the resident from scratching and keep hands and body parts from excessive moisture, keep fingernails short. The comprehensive care plan dated 2/30/24 documented Resident #96 required assist with self-care and mobility related to impaired balance. Resident #96 required supervision or verbal cues or touching assist of one staff member with self-care and personal hygiene and required a substantial assist of one staff member for showering/bathing Review of nursing progress notes dated 10/1/24 to 2/13/25 revealed no documented evidence that Resident #96 refused shaving or nail care. During an observation and interview on 2/7/25 at 8:03 AM, Resident #96 was sitting on the side of their bed eating breakfast. They stated they could not see well because they were legally blind. Resident #96's fingernails were long, slightly jagged, and dirty with brown debris. The resident also had 0.5 to 1-inch white whiskers on their face and chin. During an observation and interview on 2/7/25 at 8:56 AM, Resident #96 pulled at the whiskers on their chin and stated they were bothered by them. They stated staff rush and tell them they do not have time to shave them when providing care. During an observation and interview on 2/11/25 at 8:01 AM, Resident #96 was sitting on the side of their bed eating scrambled eggs with their fingers of their right hand. The brown debris remained under their fingernails and the whiskers remained on their face and chin. During an observation and interview on 2/11/25 at 9:13 AM, Certified Nurse Aide #5 performed morning care for Resident #96 by washing, rinsing, and drying the resident's face, neck, underneath their breasts and armpits, peri area and buttocks. Resident #96 was dressed and was gotten out of bed. Certified Nurse Aide #5 exited the room to obtain foot pedals. At 9:37 AM Resident #96 stated their nails were long and had brown debris under them and they needed to be cleaned and cut. They were bothered by them, and it was hard to manipulate food with them being that long. Certified Nurse Aide #5 reentered with foot pedals, placed them on Resident #96's wheelchair then offered to brush Resident #96's teeth. They did not wash nor offer to clean Resident #96's hands and nails or assist with removal of their chin hair. During an interview on 2/11/25 at 9:52 AM, Certified Nurse Aide #5 stated they did not shave or offer to shave Resident #96, and they should have. They said it was important to keep the residents looking good and for dignity reasons. They should have offered even if they refuse or have refused because shaving is included in morning care. All Certified Nurse Aides were responsible for shaving their residents whenever, not just on shower days. Certified Nurse Aide #5 stated they did not offer to wash Resident #96's hands during morning care or perform nail care and they should have. They noticed there was some brown debris under the nails but forgot to do them. Certified Nurse Aide #5 stated Resident #96 eats with their hands often so it is important to clean the hands and under the nails for infection control reasons. They stated nails should be kept short and filed to avoid residents scratching themselves, germs can get inside of scratches. During an interview on 2/11/25 at 9:58 AM, Licensed Practical Nurse #6 stated shaving and nail care should always be offered to residents. It was important for infection control and dignity reasons. Certified Nurse Aides were responsible for shaving and providing nail care to residents and nurses were responsible for ensuring aides were offering and providing them. During an interview on 2/11/25 at 10:31 AM, Licensed Practical Nurse Unit Manager #5 stated Certified Nurse Aide #5 should have offered to wash Resident #96's hands, provide nail care, and shave them during morning care. It was important for infection control and dignity reasons. They stated nurses and team leaders were responsible for ensuring certified nurse aides were completing their assignments. During an interview on 2/12/25 at 2:08 PM, the Director of Nursing stated morning care for the dependent resident consisted of a basic bed bath; wash face, arm pits, incontinent care, oral care, hair, dressed, nail care if warranted and shaving if wanted. Residents should be offered to be shaved, for dignity reasons. The Director of Nursing stated they would have expected Certified Nurse Aide #5 to have offered to shave Resident #96 during morning care and wash hands and provide nail care if they noticed they needed to be done. Resident #96 should have had their nails soaked and cleaned properly. It was an infection control issue, especially if they eat with their hands. They stated the Unit Manager was responsible for ensuring nail care and shaving was being provided to the residents on the unit. During an interview on 2/13/25 at 9:23 AM, the Nurse Educator stated Certified Nurse Aide #5 should have offered to shave and provide nail care to Resident #96 when performing morning care. They stated it was important for dignity reasons to at least offer to shave residents. Not offering or providing nail care was an infection control issue, especially if Resident #96 eats with their hand. Certified Nurse Aides should review the residents care plan prior to providing care to know what level of assistance the resident requires. 10 NYCRR 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during a Compliant investigation (#NY00359451) during the Standard survey completed on 2/12/25, the facility did not ensure that residents who are fed by enteral means (by way of the intestine to deliver part or all of a person's caloric requirements) received the appropriate treatment and services to prevent possible complications for two (2) (Resident #147 and Resident #39) of two (2) residents reviewed for feeding tubes. Specifically, the facility did not provide the tube feed formula as ordered by the physician. In addition, the nursing staff inaccurately documented the formula was administered as ordered. The findings are: The facility policy and procedure titled Enteral Feedings last reviewed 2/23 documented it was the policy of the facility to provide enteral nutrition therapy to residents unable to obtain nutrition orally, when such therapy was ordered by the physician and not clinically contraindicated. The procedure included instructions to verify the physician's order, review the resident's care plan and to provide for any special needs of the resident, to ensure the equipment and devices were working properly. It also instructed to document date and time of procedure, type and amount of enteral feeding, name and title of the individual performing the procedure, if resident refused the procedure and reason(s) why and interventions taken, and the signature and title of the person recording the data. The facility policy and procedure titled Physician Orders last revised 2/20 documented enteral nutrition therapy orders would include the following components: formula, amount, route, flow rate, pump/gravity/bolus use; flushes: amount, frequency and type. The facility policy and procedure titled Medication Administration Review last revised 8/19 documented licensed nurses (Registered Nurses, Licensed Practical Nurses) must ensure that prior to the end of their shift all medications/treatments administered/refused/held, etc., were properly documented on the Medication Administration Record. 1. Resident #39 had diagnoses including osteomyelitis (infection in bone), gastrostomy (an opening into the stomach wall that allows feeding tube insertion), and atrial fibrillation (irregular heart rate). The Minimum Data Set (a resident assessment tool) dated 11/19/24 documented the resident had moderate cognitive impairment, had a feeding tube and received greater than 51% (percent) of their total calories through the feeding tube. The undated comprehensive care plan identified as current by the Director of Nursing, documented Resident #39 had a risk for altered nutrition related to dysphagia (difficulty swallowing), alternate feeding as primary nutritional source. Interventions included to provide feeding and flushes as ordered, monitor for tolerance. The Clinical Physician Orders dated 2/12/25 documented an order for FS Peptamen 1.5 via enteral tube at a rate of 80 milliliters per hour to begin at 2:00 PM for a total volume of 1600 milliliters to be delivered over 24 hours. May use FS Pivot 1.5 if Peptamen 1.5 was not available started on 12/23/24. An order for full nectar thickened liquid diet for oral gratification was ordered on 11/13/24. Observations of Resident #39 revealed the following: -on 2/6/25 at 9:13 AM, the resident was lying in bed, watching TV with a tube feeding Pivot 1.5, running at 80 milliliters per hour. The resident stated they were not on the tube feeding 24 hours per day, more like 20 hours per day. -on 2/7/25 at 8:23 AM, the resident was in bed; their tube feeding was not running. At 9:15 AM, the enteral feed was not running and Licensed Practical Nurse #7 stated that the enteral feed was hung at 2:00 PM every day and it wasn't usually running when they arrived for their shift. They stated that yesterday they hung it at 2:00 PM and it was done infusing earlier and they would hang a new bottle at 2:00 PM. -on 2/10/25 at 8:11 AM, the resident was in bed, their enteral feed was not running. The resident said it was running at night and staff took it down that morning. At 8:28 AM, Licensed Practical Nurse #7 stated the resident's feed was already done when they arrived for their shift that morning, they worked yesterday and hung it up at 2:00 PM. At 2:37 PM, the tube feed was not running. At 2:44 PM, the Licensed Practical Nurse #7 state they were going to hang the enteral feeding because they got busy earlier. The Licensed Practical Nurse #7 removed a bottle of Pivot 1.5 (33.8 fluid ounces/1500calories per 1000 milliliters) from a box in the resident's room and labeled it with the date, time and their initials. There were 6 bottles left in the box (that could hold 8 bottles) located on top of the resident's dresser in their room. At 2:50 PM, the nurse loaded the enteral feeding pump and primed the tubing, programmed the pump to 80 milliliters per hour to infuse 1600 milliliters with 240 milliliter flush every 4 hours. -on 2/11/25 at 7:21 AM, the resident was in bed, not hooked up to their tube feeding. The tube feeding pole was in their bathroom with a full bottle of Pivot 1.5 hanging dated 2/11/25. There were 5 bottles of Pivot 1.5 left in the box on top of the resident's dresser. During continuous observation from 9:58 AM until 11:20 AM, the resident's enteral feed was not running. During a telephone interview on 2/11/25 at 7:39 AM, Licensed Practical Nurse #8 stated they usually worked the 3:00 PM to 11:00 PM shift, but the night before they worked a double shift until 7:00 AM that morning (2/11/25). The resident's enteral feed was usually running when they arrived for their shift and it was set up for automatic flushes, they usually don't have to disconnect it on the 3:00 PM-11:00 PM shift. They stated the prior night they took the enteral feed down around 3:00 AM or 4:00 AM as the bottle had infused. They stated the rate was 80 milliliters per hour and the time it came down, depended on the time it was started. They did not know how much feed the bottle held and had unhooked it after the bottle infused. They didn't hang another bottle; they did get another bottle ready for the day shift to hang. They stated the resident had tolerated the feed and flushes and had no emesis. The Licensed Practical Nurse #8 stated if only one bottle (about 1000 milliliters) was infused then the resident wasn't getting enough and wasn't getting the amount ordered. During a telephone interview on 2/11/25 at 12:19 PM, Licensed Practical Nurse #9 stated the resident's tube feeding was usually running when they arrived for their shifts (full time 11:00 PM-7:00 AM), the resident got scheduled medications during their shift, so they flushed the feeding tube at those times. They stated the enteral feed usually ended around 6:00 AM or 6:30 AM, and they never had to hang another bottle. They thought the problem was how the order was written and that it was supposed to run over 20 hours, and 4 hours was for care, but the resident didn't get 4 hours of care in a 24-hour period, so they reached their maximum amount before their shift ended, so they took it all down. The Licensed Practical Nurse #9 state they didn't have to change the bottle, when the bottle was done, the resident was done. They stated they didn't know how much solution was in the bottle and they thought the resident was supposed to get 1200 milliliters (but they weren't sure at this time and didn't have the record to review). They stated a bottle had 1200 or 1400 milliliters in it. When the surveyor informed them that the bottle had 1000 milliliters, the Licensed Practical Nurse #9 stated that bottles were always overfilled and the amount in the bottle was always over the top line. They stated they wouldn't take it down if it had a lot more to go. They stated they could tell how much was infused if they looked at the pump, but sometimes the pump might not be cleared, and it might say that 3000 milliliters was infused. During an interview on 2/12/25 at 8:12 AM, the Registered Dietician #1 stated Resident #39 was on Peptamen 1.5 and could be substituted with Pivot 1.5, due to a shortage of tube feedings it depended on what was available from their 3rd party provider. The resident's feeding should be running at 80 milliliters per hour for a total volume of 1600 milliliters. It is infused over 24 hours, but it was meeting the resident's needs in 20 or 22 hours, because they would need to stop it to provide care. The bottles are 1000 milliliters, so the resident would need 1 whole bottle and 2/3rds of another bottle. They stated if nursing was not hanging another bottle, then the resident was not getting the feeding according to the provider's order. The resident should be observed to be hooked up to the feeding 24 hours per day. The resident's estimated needs based on their assessment the end of December were 2280-2660 calories at 30-35 calories per kilogram of body weight and protein needs were 114-152 based on 1.5-2 grams per kilogram of body weight for wound healing purposes. The formula is 1.5 calories per milliliter, so if the resident was getting 1000 milliliters, they were getting 1500 calories per day, and it was not meeting their needs. The resident hasn't had any recent weight loss, their weight went up 0.8 pounds since January. The Registered Dietician #1 stated nurses should know how much volume was in the enteral feed bottle and the order was clear for 1600 milliliters, it's like a medication and they needed to follow the amount ordered. During an interview on 2/13/24 at 12:21 PM, Licensed Practical Nurse #7 stated the order for the tube feeding was confusing, they would have to do the math, and they figured it would infuse for 20 out of 24 hours, they had questioned it before, but it was not cleared up. There was a button on the pump that has a history, but if nobody cleared it, it would be over the amount that was supposed to be infused. Prior to this current enteral feed, they were on a different formula at a different rate. During an interview on 2/13/25 at 12:04 PM with the Director of Clinical Operations present, the Director of Nursing stated they expected nurses to follow the order for tube feedings and it would take multiple bottles to meet Resident #39's needs. The Director of Nursing stated the Registered Dietician #1 usually put all the orders in for tube feedings. The Director of Clinical Operations stated someone checked the pump the other day to see how much was infused and it was over 1600 milliliters. They stated they didn't like the way the order was written and thought the order was confusing for the nurses. They stated the nurses weren't aware of how much formula was in the bottles and if the nurses were unsure of the order, they could have clarified it with Registered Dietician #1 or the Director of Nursing. 2. Resident #147 had diagnoses including Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), dysphagia, and gastrostomy (an opening into the stomach wall that allows feeding tube insertion, and a way to deliver part or all of a person's caloric requirements). The Minimum Data Set, dated [DATE] documented Resident #147 had moderate cognitive impairment, had a feeding tube and received greater than 51% of their total daily calories through the feeding tube. The undated comprehensive care plan identified as current by the Director of Nursing, documented Resident #147 had the potential for altered nutrition related to their diagnoses of Parkinson's Disease, dysphagia, and dementia, required a modified diet for oral gratification with alternate feeding (enteral feeding via tube) as primary nutrition. The Clinical Physician Orders dated 2/10/25 documented and order for Nutren 2.0 via enteral tube at a rate of 45 milliliters per hour to begin at 7:00 PM for a total volume of 1000 milliliters to be delivered over 24 hours. May use TwoCal HN if Nutren 2.0 unavailable started on 12/30/24. An order for honey thick/moderately thick consistency liquids and regular diet puree texture for foods was ordered 12/19/24. An order to change the enteral feeding setup (tubing, Piston Syringe, Graduated cylinder) every 24 hours was ordered on 11/24/24, and on order for a gastrostomy-tube check for placement before administration was ordered on 11/24/24. Review of the Medication Administration Record for February 2025 for Resident #147 documented for the evening shift to stop the enteral feeding at total volume of 1000 milliliters/document volume infused, flush per order and re-start feeding at 45 milliliters per hour. The documentation only included space for initials and a checkmark, there was no documentation of volume infused. The order was dated 12/30/24. Observations of Resident #147 revealed the following: -on 2/10/25 at 9:06 AM, Resident #147 was observed sitting in their wheelchair with the feeding tube attached and running. The formula bag was dated 2/9/25 and timed 8:00 PM. The enteral feeding pump was set to 45 milliliters per hour and there were 400 milliliters left in the bag of formula. The formula was Nutren 2.0 and held 1000 milliliters when full. -on 2/11/25 at 10:20 AM, Resident #147 was in observed in bed. Their enteral feed was not hooked up, the formula bag was observed on the pole and was dated 2/9/25 at 8:00 PM and was empty. Resident #147 stated the enteral feed had not been connected to their gastrostomy tube since the day before. Licensed Practical Nurse Unit Manager #1, stated a fresh formula bag should have been hung and started during the evening shift on 2/10/25 and this bag was empty and appeared to be from the day prior. Licensed Practical Nurse Unit Manager #1 checked the Medication Administration Record and stated that Licensed Practical Nurse #2 completed the Medication Administration Record for both the evening shift and the overnight shift into 2/11/25. On the Morning on 2/11/25, Licensed Practical Nurse #3 documented the enteral feed check on the Medication Administration Record. Licensed Practical Nurse #1 stated it was a concern that a fresh formula bag was not started on 2/10/25 at the ordered time of 7:00 PM because the resident needed the nutrition it provided and should receive the formula as ordered. During an interview on 2/11/25 at 11:08 AM, Director of Nursing #1 stated it was clear the enteral feed had not been hung and started as ordered on 2/10/25 and the formula and flush bags should be hung every day on the evening shift and both bags should be initialed and dated by the nurse who hung them. During a telephone interview on 2/11/15 at 11:43 AM, Licensed Practical Nurse #2 stated they did not remember hanging a bag of formula for Resident #147 during the evening shift on 2/10/25. They stated they did not remember how much formula was in the bag that was on the pole, and they did not check the formula bag for a date and time that it was hung. They stated they also worked the night shift and administered a thyroid medication to Resident #147 via bolus at about 6:00 AM and again stated they did not check how full the formula bag was, at that time. During an interview on 2/13/25 at 9:07 AM, Licensed Practical Nurse #3 stated they worked the 7:00 AM to 3:00 PM shift on 2/11/25 and went home sick at 10:00 AM. They checked the electronic Medication Administration Record and stated they had checked Resident #147's enteral formula bag at 7:21 AM on 2/11/25. They stated they remembered there was very little formula in the bag, so they turned the machine off and unhooked it. They stated they did not tell anyone that the formula bag for Resident #147 was almost empty, and that they had turned it off. When asked to calculate for how long the formula should be running at a rate of 45 milliliters up to a volume of 1000 milliliters, they stated it should be running for 22 hours and that would allow for medication administration and required flushes to be performed. During an interview on 2/11/25 at 11:15 AM, Registered Dietician #1 stated they were the person who calculated how much formula each resident required and someone missing their enteral feed was a concern as they would not be receiving the nutrition their body required. NYCRR 415.12(g)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey, completed on 2/13/25, the facility did not ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with the physician's orders, and the comprehensive person-centered care plan for one (Resident #16) of one resident reviewed for peripherally inserted central catheter (PICC- a long, thin tube that is inserted through a vein in an arm and passed through to the larger veins near the heart) use. Specifically, Resident #16 was readmitted to the facility with a peripherally inserted central catheter in their left upper arm (PICC). There was a lack of physician orders and assessments, for monitoring arm circumference, external length, dressing changes and flushes for the peripherally inserted central catheter. Additionally, the comprehensive care plan was not developed to include the peripherally inserted central catheter. The finding is: The policy titled PICC (peripherally inserted central catheter) line dressing Change, last revised 1/2022, documented the PICC catheter insertion site is a potential entry site for bacteria that could produce a catheter-related infection, and sites should be assessed at least daily. The assessment of the site is to include the absence or presence of erythema, drainage, or swelling, induration, skin temperature at site, or complaint of tenderness at the site or along the vein tract. The dressing should be changed at least every 7 days, or sooner if the dressing is wet, soiled or loose. The policy titled Physician Orders, last revised 2/2020, documented the licensed nurse receiving orders is required to transcribe the order to the EMAR (electronic medical records) containing all required information. 1. Resident #16 had diagnoses including type II diabetes, end stage renal disease (severe kidney disease) requiring hemodialysis (medical procedure that filters waste, and excess fluid from the blood when the kidneys are no longer able to do so), and a history of Methicillin resistant staphylococcus aureus (common antibiotic-resistant bacteria) and carrier of Carbapenem-resistant Acinetobacter baumannii (bacteria resistant to many antibiotics). The Minimum Data Set (a resident assessment tool), dated 11/20/24, documented Resident #16 was cognitively intact, always understood and understands. The assessment documented they had intravenous access and intravenous medications. Resident #16's admission/readmission assessment dated [DATE], documented they had a peripherally inserted central catheter present upon readmission from the hospital. Resident #16's physician order listing report dated 2/11/25, revealed there were no orders for a peripherally inserted central catheter that included the use, monitoring, flushes, care and dressing changes. In addition, there were no orders for intravenous medications. Resident #16's care plan report, last revised 1/10/25, revealed there were no interventions for a peripherally inserted central catheter. During an observation and interview on 2/11/25 at 11:35 AM, Resident #16 was in their room in their wheelchair. There was a single lumen (tube) peripherally inserted central catheter in their left bicep. The dressing was dated 1/7/25 with illegible initials. The dressing was lifted at the base and soiled with brown debris. Resident #16 stated the catheter was placed at the hospital, and no one at the facility had addressed it since they had been back. During an observation and interview on 2/11/25 at 11:39 AM, Registered Nurse #2 observed the peripherally inserted central catheter in Resident #16's left arm. They stated they did not know the resident had it because the resident always wore long sleeves. Registered Nurse #2 stated the soiled dressing and lack of attention to the peripherally inserted central catheter put the resident at risk for infection. During an observation and interview on 2/11/25 at 12:01 PM, Licensed Practical Nurse #1 Unit Manager observed the peripherally inserted central catheter in Resident #16's left arm. They stated they did not know the resident had it, there were no orders for it, and it was not on their care plan. Licensed Practical Nurse #1 Unit Manager stated the dressing was soiled and lifting, and it was an infection risk. Licensed Practical Nurse #1 Unit Manager #1 stated the registered nurse that completed the admission assessment should have added the orders and updated the care plan for the peripherally inserted central catheter. They said it was very important to have orders so the staff would know how to care for it. During an interview on 2/12/25 at 9:37 AM, Physician's Assistant #1 stated they did not know Resident #16 had a peripherally inserted central catheter until they were notified on 2/11/25. They stated they expected the admitting nurse to add orders for any devices a resident was admitted with because the provider was not usually present when the resident was admitted . They stated it was very important for a resident with a peripherally inserted central catheter to have orders for monitoring placement, dressing changes, assessment and flushes. Physician's Assistant #1 stated that accessing a peripherally inserted central catheter after such a long time would put the resident at risk for a possible infection, a possible blot clot becoming dislodged and the possibility that the catheter had moved into the heart, which could lead to an arrythmia (an irregular heartbeat). During an interview on 2/12/25 at 11:47 AM, the Director of Nursing stated they expected the nurse that did the admission assessment for Resident #16 to enter the orders, and update the care plan, for the peripherally inserted central catheter. They stated the orders were important because it was how staff knew to take care of it. They stated peripherally inserted central catheters needed to be flushed every day, assessed regularly for infection and placement and the dressing should be changed at least weekly. The Director of Nursing stated, by not addressing the peripherally inserted central catheter, it put Resident #16 at risk for infection. 10 NYCRR 415.12 (k)(2)

Based on observation, interview and record review conducted during the Standard survey completed on 2/13/25, the facility did not ensure that residents who require dialysis, received services consistent with professional standards of practice for one (Resident #16) of one resident reviewed. Specifically, Resident #16 did not have ongoing monitoring upon leaving the facility and returning from hemodialysis (treatment that filters waste and excess fluid from the blood when the kidneys were unable to). There were no assessments of their access site and there was no communication between the dialysis center and the facility. Additionally, the wrong type of hemodialysis access device was listed on the resident's provider orders. The finding is: The policy titled Dialysis Management, last reviewed 5/2019, documented residents receiving hemodialysis treatments will be assessed and monitored to ensure quality of life and well-being. On admission the resident will be assessed for the type of access device and the site will be observed for function and signs of infection. The facility will establish open communication with the resident's dialysis center, utilizing a Dialysis Communication Book. The nurse will establish pre-dialysis vital signs (blood pressure, pulse, temperature, and respirations), advanced directives and any pertinent resident information. On return from the dialysis center the nurse will review the communication, specifically reviewing pre and post vital signs, treatment tolerance and any medications given, and any new orders for resident care. The nurse will evaluate the resident for mental status, pain, access site condition and response to treatment. Following the review the nurse will notify the provider as needed, and document in nurse's notes. The policy titled Dialysis Access Care, last reviewed 5/2019, documented the different types of access devices for hemodialysis. The policy documented, post dialysis to monitor the dressing, that was changed at the center, for excess bleeding. The nurse should document the location of the catheter, condition of the dressing (interventions if needed), if dialysis was done during shift, any part of report from dialysis nurse post-dialysis being given, and observations post-dialysis. Resident #16 had diagnoses including type II diabetes, end stage renal disease (severe kidney disease) requiring hemodialysis, and a history of methicillin resistant staphylococcus aureus (common antibiotic-resistant bacteria). The Minimum Data Set (a resident assessment tool), dated 11/20/24, documented the resident was cognitively intact, always understood and understands and did not receive hemodialysis at the time of the assessment. Resident #16's Order Listing Report printed 2/12/25, documented an order dated 1/10/25 for an AV (arterial-venous) fistula/AV Graft (dialysis access device, created by combining an artery and a vein), monitor for bruit (sound of pulse in an artery) and thrill (feeling of pulse in an artery) every shift and notify the medical provider for absence, monitor for bleeding, if noted apply pressure and notify the medical provider, and no blood pressure in the left arm. An order dated 1/13/25 documented the resident was to attend dialysis two times a week on Monday and Thursday. An order dated 2/3/25 documented to obtain a weight every day shift. The comprehensive care plan, initiated 1/10/25, documented Resident #16 had impaired renal function (without a catheter) related to end stage renal disease. The care plan did not include the care and monitoring of their dialysis device or the resident's dialysis schedule. Review of the Progress Notes dated 1/10/25 -2/11/25, revealed a nurse note dated 2/6/25 at 12:55 PM that Resident #16 was weighed in their wheelchair and would be leaving for dialysis soon. There were no other notes regarding information related to dialysis or assessment of the resident prior to or after they returned from dialysis and no documented communication with the dialysis center. Review of the nursing evaluations from 1/10/25- 2/11/25, revealed no pre/post dialysis evaluations in the electronic medical record for Resident #16. There were no other assessments regarding information related to dialysis or assessment of the resident prior to or after they returned from dialysis and no documented communication with the dialysis center. Review of the Treatment Administration Records from 1/10/25-2/11/25, revealed nurses documented that they monitored an AV (arterial-venous) fistula/graft for bruit, thrill and bleeding every shift. The resident did not have an AV (arterial-venous) fistula/graft. The Dialysis Communication Book labeled with Resident #16's name was located at the nurse's station on 2/11/25 at 10:15 AM. The book contained blank communication sheets, meant for communication between the facility and the dialysis center and a medication list. During an interview on 2/11/25 at 10:39 AM, Registered Nurse #2 stated that residents that go to dialysis were supposed to take a binder to the center with them and thought the unit manager dealt with that and any communication between the facility and the dialysis center. They stated that staff were supposed to take vital signs and give the resident the medications they may have missed when they returned to the facility. Registered Nurse #2 stated that Resident #16 did not usually come right back to the unit when they came back from dialysis because they stayed downstairs to smoke. They stated the dialysis center staff monitored the fistula in the residents left arm at dialysis. During an interview on 2/11/25 at 11:12 AM, Unit Manager Licensed Practical Nurse #1 stated that when a resident went to dialysis, the medication nurse should send an updated medication list, what medications they received, and a recent weight to the dialysis center with the resident. Then when the resident returned, they should review the communication from the dialysis center and monitor the resident's dialysis device for bleeding. There was a binder for that information that the resident should take with them to dialysis. There is an assessment the nurse was supposed to complete, in the electronic medical record, with the pre and post dialysis information. Unit Manager Licensed Practical Nurse #1 reviewed Resident #16's electronic medical record and stated they were unable to locate any assessments with pre and post dialysis data. They stated that it was important to monitor the resident and communicate with the dialysis center to be sure they were giving the resident the proper care. During an observation and interview on 2/11/25 at 11:35 AM, Resident #16 was in their wheelchair in their room. They revealed their left arm there was a PICC (peripherally inserted central catheter - a catheter that is inserted through a vein and advanced until the tip enters the central venous system) line present, and no evidence of an arterial-venous fistula. Resident #16 had a dressing covering a perma-cath (a long, flexible tube inserted into a vein for long term access to the bloodstream for dialysis) in their left upper chest. Registered Nurse #2 stated they must have misread the order for the AV (arterial-venous) fistula, and they were monitoring the perma-cath when they documented on the Treatment Administration Record. During an interview on 2/11/25 at 12:21 PM, Resident #16 stated they had never brought a communication binder with them to dialysis. They stated that the nurse at dialysis had asked them if they could bring a medication list, but they did not know how to get that information. During an interview on 2/12/25 at 9:37 AM, Physician's Assistant #1 stated communication between the facility and a resident's dialysis center was important because the dialysis center needed to know what medications the resident was on, and if there were any changes. They also need to know what medications the resident got prior to dialysis and what their vital signs were. It was particularly important if the resident had a low blood pressure prior to treatment, and then monitoring how much fluid the dialysis treatment removed and if they had any complications during treatment. They did not know if the facility was sending the communication sheets or completing their pre and post assessments. They did not realize there was an order to monitor an AV (arterial-venous) fistula but stated it should not be there because the resident did not have one. They had a perma-cath in their chest for dialysis. During a telephone interview on 2/12/25 at 11:29 AM, the dialysis center Registered Nurse #8 stated Resident #16 came to the dialysis center twice a week. They stated the facility did not send any information with the resident. Registered Nurse #8 stated it was important to have communication between the facility and the dialysis center because they should at least know the resident's advanced directives, medications they received that day, especially blood pressure medications, what their weights were, and the facility should know if they had any issues during dialysis. During an interview on 2/12/25 at 11:47 AM, the Director of Nursing stated they expected the nurses to give the resident their morning medications and complete the communication sheet prior to going to dialysis. The resident should take the communication binder with them to dialysis and the center should complete their portion for the nurse to review when they came back. They stated there was a pre and post dialysis template in the electronic medical record for the nurse to complete every time the resident went to dialysis. The Director of Nursing was unable to locate any documentation regarding dialysis for Resident #16. They also stated the nurses should not have been documenting on the AV (arterial-venous) fistula on the Treatment Administration Record, they should have told someone that the resident did not have a fistula. The Director of Nursing stated there was no education on dialysis access devices or the procedure for a resident going to dialysis. During an interview on 2/13/25 at 10:50 AM, the Administrator stated there should be communication between the facility and the dialysis center each time the resident went for their treatment. They stated they expected that one of the nurses would have spoken up that the resident did not have an AV (arterial-venous) fistula instead of documenting on something that wasn't there. 10 NYCRR 415.12

Based on observation, interview, and record review conducted during a Standard survey completed on 2/13/25, the facility did not ensure that all drugs and biologicals were securely stored in accordance with State and Federal Laws for one of one facility reviewed for medication storage. Specifically, there were two full boxes that contained discontinued prescription medications for 22 residents located in an unsecured first floor conference room. This involved Resident #'s 10, 21, 23, 31, 32, 34, 35, 51, 60, 69, 70, 79, 81, 85, 130, 133, 135, 502, 503, 504, 505, and 506. Additionally, there was one full box of discontinued prescription medications for 32 residents located on the second floor in a Nurse Manager's office that was open and unlocked. This involved Resident #'s 9, 10, 23, 29, 31, 41, 42, 55, 57, 79, 92, 97, 108, 111, 115, 128, 131, 139, 402, 403, 404, 405, 406, 407, 507, 508, 509, 510, 512, 513, 514, and 515. The findings are: The policy and procedure titled Medication Storage dated 1/2019, documented that medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with the Department of health guidelines. With exception of Emergency Drug Kits, all medications will be stores in a locked cabinet, cart, or medication room that is accessible only to authorized personnel. During an observation on 2/11/25 at 8:18 AM, the unlocked first-floor conference room had two boxes of medications that were on the floor under a table and were easily visible. Box #1 was unlabeled and unsealed with the top flap of the box opened. Box #2 was labeled discontinued medications and was opened and not sealed. Both boxes contained multiple blister packs of prescription medications and bottles of stock medications that included but not limited to insulin pens, inhalers, antipsychotic (used to treat psychosis) injectable and pill form medications, antibiotics, antidepressants, anxiolytics (used to treat anxiety), anticonvulsants (used to treat seizures), diuretics, corticosteroids (used to treat inflammation), antihypertensives (used to treat high blood pressure) and vitamin supplements. There were no return receipts located in either box of medications. The Resident's involved included Resident #'s 10, 21, 23, 31, 32, 34, 35, 51, 60, 69, 70, 79, 81, 85, 130, 133, 135, 502, 503, 504, 505, and 506. During an interview on 2/11/25 at 9:28 AM, the Director of Nursing stated the boxes of medications located in the conference room were discontinued resident medications waiting to be sent back to the pharmacy. They stated that discontinued medications were to be kept in the medication rooms on the unit or would be placed in their office until they were picked up by pharmacy. The Director of Nursing stated they were unaware how long the boxes of medications had been in the conference room, and that the nursing supervisor may have placed them there because they did not have access to their office. The Director of Nursing stated that the conference room was not considered a medication storage room, and medications should not have been stored there because staff and residents could access the room. During a telephone interview on 2/11/25 at 9:59 AM, Pharmacist #1 stated the pharmacy made two deliveries a day to the facility and would pick up discontinued medications at that time. They stated they would expect the facility to keep discontinued medications locked up and secured to ensure they were not being taken by someone who should not have them and would not want the discontinued medications to be mixed up with the residents' active medications. During an observation and interview on 2/11/25 at 11:31 AM, on the second floor Riverview unit, the nurse managers office was door was open and a full box of medications was on the floor in the office, unsealed and visibly seen. Licensed Practical Nurse Manager #1 stated the box contained discontinued resident medications and that discontinued medications were kept in their office until they arranged a pickup time with the pharmacy. During an observation and interview on 2/11/25 at 3:37 PM, Licensed Practical Nurse Manager #1 revealed the box of prescription medications in their office contained 162 blister packs of resident prescription medications that included but not limited to psychotropic medication, antidepressants, antihypertensive, diuretics, and various prescribed resident inhalers (device to give medication that is inhaled through the nose or mouth). Licensed Practical Nurse Manager #1 stated that they would try to close their office door when they would leave the unit but that it was not always locked. They stated it was possible for residents to enter their office when the door was unlocked. Licensed Practical Nurse Manger #1 stated that they should have taken the discontinued medications down to the Director of Nursing. This involved Resident #'s 9, 10, 23, 29, 31, 41, 42, 55, 57, 79, 92, 97, 108, 111, 115, 128, 131, 139, 402, 403, 404, 405, 406, 407, 507, 508, 509, 510, 512, 513, 514, and 515. During an interview on 2/11/25 at 3:35 PM, Registered Nurse Manager #7 stated discontinued resident medications were boxed up and taken down to the conference room and placed under the table until the pharmacy picked up the medications. Registered Nurse Manager #7 stated the conference room was unlocked during the day and that staff had access to the conference room. They stated they were unsure what time the conference room was locked at night. During an interview on 2/12/25 at 3:13 PM, Licensed Practical Nurse #7, stated supervise on the evening shift (3:00 PM -11:00 PM) and would bring discontinued resident medications to the conference room or would place them in a crate behind the reception desk when they knew the pharmacy was expected. During an interview on 2/13/25 at 10:43 AM, the Administrator stated discontinued resident medications should not be kept in the conference room or out in the open. They stated they were not aware discontinued medications were being placed in the conference room and should not be. The conference room was not considered a secured location, and that residents, staff and visitors would have access to them. The Administrator stated they would expect discontinued resident medications to be kept locked and secured on the units until they were picked up by pharmacy. They stated they would consider the unit manager's office secured only if it was locked and not left opened. 10 NYCRR 415.18 (e) (1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a Standard survey completed 2/13/25, 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 four (4) (Residents #39, #96, #119 and #139) of seven (7) residents observed for hands-on care. Specifically, Resident #39 was on Enhanced Barrier Precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities) and staff did not wear a gown during medication and parenteral feed administration through a percutaneous endoscopic gastrostomy tube (a method of delivering liquid nutrition fluids and medicine directly into the stomach), staff did not change gloves or wash their hands after providing fecal incontinence care, and prior to touching clean items; and soiled linens were placed directly on the floor without a barrier in place (#96); staff did not wear a gown while emptying a foley catheter (tube inserted into bladder to drain urine) urine drainage bag (#119); and for Resident #139 staff did not wear a gown while flushing a cholecystostomy tube (a thin tube inserted into the gallbladder to drain infected or blocked fluid). Additionally, Residents #119 and #139 did not have signage that indicated Enhanced Barrier Precautions were required. The findings are: The policy titled Enhanced Barrier Precautions dated 5/30/24, documented enhanced barrier precautions will be initiated and implemented for residents as applicable in accordance with Centers for Medicare & Medicaid Services and/or state regulations and/or in accordance with Centers for Disease Control and Prevention guidance to reduce the risks of transmission of Multiple Drug-Resistant Organisms. Enhanced Barrier Precautions 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. The facility's Enhanced Barrier Precautions education power point documented, enhanced barrier precautions are indicated for residents with any of the following: infection or colonization with a Multiple Drug-Resistant Organisms when contact precautions do not otherwise apply or a resident has a wound and/or an indwelling medical device even if the resident is not known to be infected or colonized with a Multiple Drug-Resistant Organisms. Review of the enhanced barrier precaution signage (a sign used by the facility that was supposed to be 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: device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care (any skin opening requiring a dressing). The policy titled Hand Hygiene dated 5/30/24 documented, the facility adheres to recommendations by the Centers for Disease Control and Prevention (CDC) for the practice of hand hygiene in accordance with standard, enhanced barrier, and transmission-based precautions. Hand hygiene is performed as a minimum at these times; include before and after contact with a resident, after contact with blood, body fluids, visibly contaminated surfaces, after contact with objects or surfaces in the resident's room, after removing personal protective equipment (gloves, gown, facemask, eye protection). 1a. Resident #39 had diagnoses including osteomyelitis (infection in bone), gastrostomy (an opening into the stomach wall that allows feeding tube insertion), and atrial fibrillation (irregular heart rate). The Minimum Data Set (a resident assessment tool) dated 11/19/24 documented Resident #39 had moderate cognitive impairment, had a feeding tube and received greater than 51% (percent) of their total calories through the feeding tube, for personal hygiene and bathing the resident was dependent on staff to complete all the activity. The comprehensive care plan identified as current by the Director of Nursing, documented the resident had a risk for altered nutrition related to dysphagia, alternate feeding as primary nutritional source. Interventions included to provide feeding and flushes as ordered, monitor for tolerance. The resident had bladder and bowel incontinence, interventions included to check them every 2-4 hours to assist with toileting as needed and to provide incontinence care The [NAME] Report (a guide used by staff to provide care) dated 2/10/25 documented Resident #39 was on Enhanced Barrier Precautions. Staff were to wear a gown and gloves when completing high contact activities at the bedside including device care. During an observation on 2/6/25 at 9:13 AM, Resident #39 was in bed in their room. There was a sign on the wall next to their doorway that indicated the resident was on Enhanced Barrier Precautions. There was personal protective equipment in the hallway across from the resident's doorway. During an observation on 2/10/25 at 8:28 AM, Licensed Practical Nurse #7 prepared medications to administer to Resident #39. At 8:38 AM, they entered the resident's room, donned (put on) gloves but did not wear a gown. The Licensed Practical Nurse #7 filled a container with water, used a syringe to draw up water, and accessed the resident's gastrostomy tube. They flushed the tube with water and administered all their medications with water flushes in between each medication. During an interview on 2/10/25 at 8:57 AM, Licensed Practical Nurse #7 stated the resident was on Enhanced Barrier Precautions because they were positive for clostridium difficile (bacteria in the bowel that may cause diarrhea) several months ago but was now asymptomatic. They stated when they did their wound treatments, they followed the Enhanced Barrier Precautions. During an observation on 2/10/25 at 2:50 PM, Licensed Practical Nurse #7 accessed Resident #39's gastrostomy tube wearing gloves and no gown. They flushed the tube with water and connected the tube feeding. During an interview on 2/13/25 at 11:44 AM, the Director of Clinical Operations/Interim Infection Preventionist stated when staff entered a room of a resident on Enhanced Barrier Precautions, they had to don (put on) gown and gloves, and if they felt there was a risk of splash then they could wear a face shield or mask). If staff did not wear personal protective equipment when providing care to a resident on Enhanced Barrier Precautions, they risked the spread of pathogens. The nurse not wearing the gown while administering meds and flushes via the gastrostomy tube put the resident and other residents at risk for the spread of organisms. They stated the nurse providing care was ultimately responsible for ensuring they wear the appropriate personal protective equipment, and they should take accountability. b. During an observation of Resident #39's morning care on 2/11/25 at 9:58 AM, Certified Nurse Aide #6 and Certified Nurse Aide #7 donned a gown and gloves. Certified Nurse Aide #6 unfastened the resident's incontinence brief and cleaned the resident's genitalia and groin. They turned the resident onto their right side and Certified Nurse Aide #6 cleaned the resident's buttocks and anal cleft. There was a moderate amount of feces cleaned off the resident. Without changing their gloves and washing their hands, the Certified Nurse Aide #6 applied a clean incontinence brief, changed the resident's gown and covered the resident with blankets, and used the bed remote to elevate the resident's head of bed. During an interview on 2/11/25 at 12:09 PM, Certified Nurse Aide #6 stated they usually changed their gloves after providing bowel incontinence care, but they forgot because they were being watched. They stated they did this, so they didn't get germs or their dirty gloves on any clean items. During an interview on 2/12/25 at 9:42 AM, the Registered Nurse Unit Manager #7 stated staff should change their gloves and wash their hands when soiled or after providing care for infection control purposes. 2. Resident #96 had diagnoses including fracture of orbital (eye socket) floor, major depressive disorder, and osteoarthritis (chronic degenerative bone disease; breakdown of cartilage and other tissues within the joint). The Minimum Data Set, dated [DATE], documented Resident #96 was cognitively intact, understands, and was understood. Resident #96 was frequently incontinent of bowel and bladder and was dependent on staff for toileting hygiene. The [NAME] with a printout date of 2/13/25 documented Resident #96 was dependent and required a physical assist of one staff member for toileting hygiene. and required partial to substantial assist of one helper for dressing The comprehensive care plan dated 2/30/24, documented Resident #96 was at risk for pressure injury development related to impaired mobility and incontinence. Interventions included to minimize extended exposure of skin to moisture by providing frequent incontinence care and prompt removal of wet/damp clothing or sheets as needed, to turn and position every 2-4 hours as indicated. During an observation of incontinent care on 2/11/25 at 9:20 AM, Certified Nurse Aide #5 performed hand hygiene, applied gloves then performed morning care for Resident #96 by washing, rinsing, and drying the resident's face, neck, underneath their breasts and armpits. Certified Nurse Aide #5 then unfastened the tabs on Resident #96's incontinence brief, tucked it in between their legs and stated they were incontinent of urine. They cleansed their genitalia and perineal area (area between the anus and genitalia) with perineal cleansing spray (no rinse, was applied on to towel), folding the towel over in between each pass. Resident #96 was rolled onto their left side and a moderate amount of brown feces were observed in the crease of their buttock. Certified Nurse Aide #96 cleansed the left buttock, then right buttock, then cleansed the crease from front to back, folding the towel over in between each pass until the feces was removed. The soiled incontinence brief was tucked under the resident, they were rolled onto their right side, and the brief was removed. A new incontinence brief was applied, and resident was rolled onto their back. The brief tabs were fastened, and the soiled towel and incontinence brief were rolled into a ball and placed directly on the bed. There was no barrier in place. Certified Nurse Aide #5 did not remove their gloves or perform hand hygiene, then walked over to Resident #96's closet, grabbed the handle, opened the door and removed pants and a shirt. They put the pants on Resident #96 and secured the tie string of the pants. Grabbed the bed remote, lowered the bed down, and assisted Resident #96 into a sitting position on the side of their bed by grabbing one of Resident #96's hands with their soiled gloved hand. Certified Nurse Aide #5 then donned (put on) Resident #96's shirt, then shoes, grabbed their wheelchair and placed it next to the bed. Then placed the soiled incontinence brief and soiled linen rolled up in a ball directly onto the floor at the end of Resident #96's bed; there was no barrier in place. Certified Nurse Aide #5 assisted Resident #96 into their wheelchair, brushed their hair, and offered to have Resident #96 brush teeth but they stated they wanted to wait. Certified Nurse Aide #5 then removed their gloves and performed hand hygiene. Certified Nurse Aide #5 exited room to look for Resident #96's foot pedals, returned and stated therapy was getting new foot pedals. Placed clean gloves on and picked up soiled brief and linen from Resident #96's floor, exited the room, entered the soiled work room and discarded soiled linen and brief into proper receptacles. Returned to room with foot pedals and placed them on Resident #96's wheelchair and wheeled Resident #96 to the dining room. During an interview on 2/11/25 at 9:52 AM, Certified Nurse Aide #5 stated they did not remove their gloves or perform hand hygiene after performing incontinent care, and they should have. There were urine and feces present and they touched things in the room afterwards. It was important to remove gloves and perform hand hygiene after performing incontinent care because germs could be passed along. Certified Nurse Aide #5 stated they should not have placed the soiled incontinence brief and soiled linen on the bed or floor without a barrier because that was cross contamination. They stated these all were infection control issues. During an interview on 2/11/25 at 9:58 AM, Licensed Practical Nurse #6 stated glove changes and hand hygiene should be performed right after incontinent care, especially if feces were involved. They stated a barrier should always be placed for soiled linen and briefs. It was important to stop the spread of germs. These were basic infection control practices and were important for staff to follow. During an interview on 2/11/25 at 10:31 PM, Licensed Practical Nurse Unit Manager #5 stated glove changes and hand hygiene should always be performed right after incontinent care involving feces and a barrier should be placed for soiled items. During an interview on 2/12/25 at 2:08 PM, the Director of Nursing stated they expected staff to perform glove changes and hand hygiene prior to, frequently during, and following incontinent care, and directly after whenever feces was present. They expected some sort of barrier to be in place for soiled items. These issues were infection control nightmares. During an interview on 2/13/25 at 11:44 AM, the Director of Clinical Operations/ Interim Infection Preventionist stated they expected staff to have a barrier in place for soiled items, they should never be placed directly on the bed or floor to ensure there was no spread of blood borne pathogens or bacteria. They expected staff to perform glove changes immediately after incontinent care before touching anything else in the room, especially if feces were involved. Staff should wash their hands then provide further care to the resident. It was important to perform hand hygiene to stop the spread of pathogens. 3. Resident #119 had diagnoses including chronic kidney disease, diabetes mellitus type 2, and urinary tract infection. The Minimum Data Set, dated [DATE] documented Resident #119 had moderate cognitive impairment, and an indwelling urinary catheter. The comprehensive care plan dated 11/1/24 documented Resident #119 had an indwelling catheter related neurogenic bladder (a bladder dysfunction caused by nervous system conditions). Interventions include catheter/perineal care and Resident #119 was at risk for infection related to frequent urinary tract infections and chronic indwelling foley catheter. During an observation on 2/7/2025 at 9:11 AM, Nursing Supervisor Registered Nurse #5 was observed emptying Resident #119's foley catheter drainage bag wearing gloves and but not gown. There was no Enhanced Barrier Precaution signage on the resident's door. During an interview on 2/10/25 at 3:11 PM, Nursing Supervisor Registered Nurse #5 stated they emptied Resident #119's foley catheter bag on 2/7/25 and they were not wearing a gown because they didn't need to wear a gown unless they were flushing the catheter tubing. 4. Resident #139 had diagnoses including chronic cholecystitis (inflammation of gallbladder), depression and hypertension. The Minimum Data Set, dated [DATE] documented Resident #139 was cognitively intact. Resident #139's [NAME] dated 12/18/24 documented enhanced barrier precautions, wear gown and gloves when providing high contact activities including, device care. The comprehensive care plan dated 2/7/25 documented Resident #139 was at risk for Multiple Drug-Resistant Organisms colonization/infections related to invasive devices cholecystostomy tube (C-tube), interventions included Enhanced Barrier Precautions dated 2/7/25. During an observation on 2/6/25 at 12:21 PM, Resident #139 had a cholecystostomy tube and there was no Enhanced Barrier Precaution signage on Resident #139's door and no personal protective equipment available outside the resident's room. During an observation on 2/10/25 at 11:38 AM, Enhanced Barrier Precaution signage was on Resident #139's door and Nursing Supervisor Registered Nurse #5 was observed to flush Resident #139's cholecystostomy tube without wearing a gown. During an interview on 2/10/25 at 11:41 AM, Nursing Supervisor Registered Nurse #5 stated they had not noticed the Enhanced Barrier Precaution signage on Resident #139's door or the personal protection bin outside Resident #139's door. They stated they did not know they were on Enhanced Barrier Precautions. Upon reading the enhanced barrier precaution sign Nursing Supervisor Registered Nurse #5 stated they should have been wearing a gown while flushing the cholecystostomy tube for infection control purposes. During an interview on 2/11/25 at 4:25 PM, Registered Nurse Educator #6 stated they educate all staff on policy and procedure of Enhanced Barrier Precautions. All residents with an open wound, an indwelling medical device or a diagnosis of multidrug-resistant organisms' staff should be wearing a gown and gloves and if suspected splash the staff should be wearing a face mask and face shield or goggles. They stated Enhanced Barrier Precautions was to protect the residents and staff while performing high-contact resident care activities. They stated they would have expected Nursing Supervisor Registered Nurse #5 to have worn a gown in addition to wearing the gloves while emptying the foley catheter drainage bag for Resident #119 and while flushing the cholecystostomy tube for Resident #139. During an interview on 2/13/25 at 10:38 AM, Unit Manager Licensed Practical Nurse #1 stated the Enhanced Barrier Precaution signage was posted outside Resident #119's door per the facility's policy after the observation of Nursing Supervisor Register Nurse #5 emptying the foley drainage bag on 2/7/25. They stated they were responsible to ensure the Enhanced Barrier Precaution signage and personal protective equipment set up was in place for residents on their unit. During an interview on 2/13/25 at 11:06 AM, the Director of Clinical Operations/Interim Infection Preventionist stated they would have expected Nursing Supervisor Registered Nurse #5 to have worn a gown in addition to wearing the gloves while emptying the foley catheter drainage bag for Resident #119 and while flushing the cholecystostomy tube for Resident #139. The Director of Clinical Operations stated they would have expected the Infection Control Preventionist and Director of Nursing to have ensured the Unit Managers were following the facility policy and procedures and had the Enhanced Barrier Precaution signage and personal protective equipment bins already in place for Resident #119. 10 NYCRR 415.19(a)(2) (b)(4)

Based on observation, interviews, and record review conducted during Complaint investigations (Complaint #s NY00359253 and NY00368473) during the Standard survey completed on 2/13/25, the facility did not ensure that food and drink was palatable, attractive and at a safe and appetizing temperature for three (Cityview, Skyview, and Harborview units) of four test trays. Specifically, food was served during meals at suboptimal temperatures and was not palatable. Residents #3, #55, #63, #65, #96, #104, and #203 were involved. The findings are: The facility policy and procedure titled Food Temperature Policy last reviewed 3/23, documented food sent to remote kitchens for distribution (such as meals, snacks, nourishments, oral supplement) will be transported and delivered to maintain temperatures at or below 41 degrees Fahrenheit for cold foods and at or above 140 degrees Fahrenheit for hot foods. All employees are responsible to notify their supervisor of any food item that does not meet the regulated safe acceptable service ranges (at or below 41 degrees Fahrenheit or above 135 degrees Fahrenheit). The Menu Planning and Food Service Committee-Meeting Attendance minutes dated 1/15/25 documented 16 residents were in attendance and that residents complained of cold food at times. A noted concern was that food carts sit at nurse station prior to pass. The Centers Health Care Food Safety attachment to the facility policy and procedure titled Food from Outside revised 7/12/23 documented the responsibility for food safety begins with decisions on purchasing and ends when food is safely served, or when potentially unsafe food is discarded. For holding hot foods that they were to be served immediately or held at or above 135 degrees Fahrenheit. During an interview on 2/6/25 at 10:31 AM, Resident #104 stated the food was lousy and was not served hot enough. During an interview on 2/6/25 at 3:53 PM, Resident #3 stated hot foods were often cold once they arrive on the unit and food was frequently overcooked or undercooked and inedible. During an interview on 2/6/25 at 3:04 PM, Resident #203 stated the food usually wasn't that good, was served lukewarm, and staff said they couldn't reheat it. During an interview on 2/7/25 at 8:58 AM, Resident #96 stated the food was bleh and only decent once in a while. They stated they were served fish on 2/6/25 and it was deep fried and too hard for them to chew. During a lunch meal tray line observation on 2/10/25, the temperatures of food items taken on the steam table in the main kitchen at 11:36 AM were taken by the cook prior to the start of tray line and were as follows: Chicken tenders measured 186 degrees Fahrenheit Ground chicken tenders measured 172 degrees Fahrenheit Pureed baked chicken measured 188 degrees Fahrenheit Sweet potato fries measured 196 degrees Fahrenheit Corn measured 189 degrees Fahrenheit Mashed potatoes measured 198 degrees Fahrenheit Pureed broccoli measured 198 degrees Fahrenheit Gravy measured 180 degrees Fahrenheit Coffee measured 180 degrees Fahrenheit Tray line commenced immediately after temperatures were taken. Plates were taken from a plate warmer, and insulators were used under and on top of plates, as they were placed on trays. Cold drinks and desserts had been removed from temporary storage in the walk-in freezer and were held on trays without ice. Coffee was pre-poured into commercial food service coffee mugs and held on trays. All drinks and desserts were covered with individual plastic disposable covers. The test tray for the Cityview unit left the kitchen in an insulated cart at 11:57 AM. The test tray for the Skyview unit left the kitchen in a closed metal cart at 12:17 PM. The test tray for the Harborview unit left the kitchen at 12:27 PM on top of an insulated cart in a plastic clam shell container, as the kitchen had run out of insulators and was waiting for some more to the brought from the dish room. All resident meals served from the steam tables from 12:26 PM to 12:30 PM were sent out in plastic disposable clam shell containers. As of 12:32 PM, resident meals once again were served on plates with top and bottom insulators. During an interview on 2/10/25 at 12:35 PM, Registered Dietician/Food Service Director #1 stated the facility had just received new insulators and plates that day and a cart with unopened boxes of insulators and plates was observed in the dietary supervisor's office. a.During an observation of a lunch meal tray on 2/10/25 on the Cityview unit, all trays were passed at 12:04 PM and the food temperatures on the pureed texture test tray were taken at 12:10 PM, when the Diet Technician #1 arrived on the unit and used the facility's dial thermometer. The temperatures and taste were as follows: Pureed baked chicken: no gravy, tasted cold, dry and unpalatable. The temperature was 91 degrees Fahrenheit. Mashed potatoes: no gravy, tasted cold, dry and unpalatable. The temperature was 96 degrees Fahrenheit. Pureed broccoli: tasted cold and unpalatable. The temperature was 95 degrees Fahrenheit. During an interview on 2/10/25 at 12:15 PM, Diet Technician #1 stated they thought the food tasted good and was hot enough. They stated when they did test trays, they did not test for a specific temperature but for a good taste. They did not know what the safe temperature range for food should be. During an interview on 2/10/25 at 12:18 PM, resident #65 stated their lunch was not good. They did not get any chicken, and their broccoli and rice were cold. They also stated their coffee was cold, which happened every day, for every meal, and they have complained to staff. b. During an observation of a lunch meal tray on 2/10/25 on the Skyview Unit, the second meal cart arrived on the unit at 12:07 PM, all trays were passed at 12:19 PM, and the food temperatures on the test tray were taken at 12:20 PM using Diet Technician #1's dial thermometer as follows: Chicken tenders measured at 85 degrees Fahrenheit; were cool to the taste. Sweet Potato Fries measured at 83 degrees Fahrenheit; and were cool, soft and limp without any crispiness and unpalatable. Corn measured at 81 degrees Fahrenheit; and was cool, bland, dry and chewy and unpalatable. During an interview at the time of the test tray, Diet Technician #1 stated they did not judge a test tray based on the temperature while serving because they go by the palatability. They stated if the tray was palatable then the temperature of the food did not matter. They felt the chicken tasted delicious, the sweet potato fries were fine and that corn was corn. During an interview on 2/10/25 at 12:37 PM, Resident #55 stated their lunch tray was a little on the dry side and was cold. When they received their tray, they thought their Sweet Potato Fries were burnt French Fries at first, the corn was bland, and they preferred their food warmer. c. During an observation of a lunch meal tray on 2/10/25 on the Harborview unit the first meal tray cart arrived at 12:12 PM and staff started passing the trays. The second cart with the test tray arrived at 12:31 PM and staff started passing the trays while continuing to pass trays from the first cart. All trays were passed at 12:41 PM, and the food temperatures on the test tray were taken at 12:42 PM with Diet Technician #1 using the facility's dial thermometer. The temperatures and taste were as follows: Corn measured 75 degrees Fahrenheit, tasted cold, chewy and was not palatable. Sweet potato fries measured 72 degrees Fahrenheit, were cold, not crispy and not palatable. Chicken tenders measured 105 degrees Fahrenheit, tasted lukewarm and not palatable. Diet Technician #1 stated they didn't have a specific temperature range that food should be served at, it was based on palatability. Diet Technician #1 tasted the corn, sweet potato fries, and chicken tenders and stated they thought the corn and chicken tenders were palatable but would like the sweet potato fries to be warmer. During an interview on 2/10/25 at 12:53 PM, Resident #63 had their lunch tray in their room and stated it was cold. They stated it was like that every day. During an interview on 2/10/25 at 1:01 PM, Registered Dietician/Food Service Director #1 stated foods needed to be served palatable to taste, they expected hot foods to reach the residents at 135-140 degrees Fahrenheit, and cold foods should be 45 degrees Fahrenheit or below. During an interview on 2/13/25 at 9:37 AM, the Director of Nursing stated 80 degrees Fahrenheit and below was too cold for hot foods to be served at and bacteria could grow at such temperatures. During an interview on 2/13/25 at 9:40 AM, the Administrator stated warm foods should be served at temperatures per preference and if food was supposed to be held at 140 degrees Fahrenheit to start, temperatures in the 70s, 80s and 90s at time of service were not good. There could be issues with food safety and residents could get sick. During an interview on 2/13/25 at 9:57 AM, the Director of Clinical Operations stated they were acting as the facility's Infection Preventionist, and safe warm food temperatures were 140 degrees Fahrenheit or above, food temperatures below that were a comfort issue for residents. If food was cooked to the required temperature in the kitchen and hit the benchmark and trays were passed timely, there should not be an issue with illness. 10NYCRR 415.14(d)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint investigation (Complaint #NY00324268) during a Standard survey completed on 10/4/23 the facility did not ensure that it promoted and facilitated resident self-determination through the support of resident choice for two (Residents #93 and #398) of four residents reviewed for choices. Specifically, preferred number of showers were not provided in accordance with resident wishes per week. The findings are: The facility policy and procedure title ADL-Personal Hygiene with a revision date of 10/2019 documented the purpose is to direct the nursing staff to meet the residents needs per the plan of care and [NAME] on a daily basis. Resident bath or showers will be scheduled per resident preference but at least weekly per the unit shower schedule and a bed bath will be provided on non- shower days. If the resident refused assistance with care needs, the reason(s) why and the intervention taken will be documented by the Licensed Nurse. 1. Resident #398 had diagnoses including cerebral vascular accident (CVA- stroke) with left sided hemiparesis (weakness of one side of the body) and cerebral palsy (CP-a disorder that prevents a person's movement, balance and posture). Review of the Minimum Data Set (MDS- a resident assessment tool) dated 9/13/23 revealed the resident was understood, understands and was cognitively intact. The MDS further documented the resident was an extensive assist for personal hygiene and it was very important how they chose between a tub bath, shower, or bed bath. Review of the [NAME] (guide used by staff to provide care) dated 10/3/23 revealed under the section Bathing totally dependent x 2 staff. Shower/Bath (specify day/shift) was left blank. Review of the undated Unit Shower Schedule revealed Resident #398 was scheduled for two showers per week on Tuesdays and Fridays and that every resident on the unit was scheduled for two showers. Additional review of the shower schedule revealed that no residents were scheduled for more than two shower per week. Review of the Bathing Task documented in the electronic medical record (EMR) (certified nurse aide (CNA) documentation) from 9/11/23 through 10/3/23 documented the resident only receive one shower on 9/23/23. Review of the Progress Notes dated 9/6/23 through 10/3/23 revealed no documented evidence Resident #398 refused their showers. During an interview on 10/3/23 at 10:40 AM with Resident #398 stated their stay has not been good, staff do what they want to do and when they want to do it, they have not had a shower since they have been at the facility for a month and would like a shower every day or at a minimum of three times a week. Staff do not ask them if they want a shower, and they have never refused to have a shower. 2. Resident #93 had diagnoses including dementia, depression and anxiety. Review of the MDS dated [DATE] documented the resident was understood, understands and was cognitively intact. The MDS further documented the resident was an extensive assist for personal hygiene. The MDS dated [DATE] documented it was very important how they chose between a tub bath, shower, or bed bath. During an interview on 9/29/23 at 10:35 AM Resident #93 stated they do not get their showers every day like they prefer. Review of the Visual/ Bedside [NAME] Report dated 10/4/23 documented under Bathing the resident was to receive a Shower on Monday, Wednesday, Friday on the 7am-3pm shift and Tuesday, Thursday and Saturday on the 3pm-11pm shift. Resident prefers daily showers. Review of the undated Assignment sheet documented Resident #93 prefers daily showers. Review of the Documentation Survey Report Sep-23 dated 10/4/23 revealed under Shower from 9/1/23 through 9/30/23 Resident #93 received nine showers out of twenty-six. Review of the Progress Notes dated 9/1/23 through 10/3/23 revealed no documented evidence Resident #93 refused their showers. During an interview on 10/3/23 at 10:54 AM CNA #3 stated the Unit Manager (UM) writes the showers on the assignment sheet, most residents get a shower 1-2 times per week but if they ask for more, they can have more showers. CNA #3 was unsure of Resident #93 or #398 shower schedule and stated it should be documented in the shower book at the nurse's station. If the resident refused, they would tell the nurse. During an interview on 10/3/23 at 11:42 AM Registered Nurse (RN) #1 UM stated the nursing supervisor on admission will ask the resident their shower preferences. Showers also go by room number two times per week; showers for the day get highlighted on the assignment sheet. RN UM #1 was unsure of the resident #398 preferences for a shower or why the resident had not had a shower since admission. During an interview on 10/03/23 at 12:16 PM the Assistant Director of Nursing (ADON) and with Regional Director of Clinical Services present stated the supervisor on admission discusses shower preference with residents. The resident's preference should be documented on the care plan and [NAME]. The ADON stated residents should get their showers per their preference and they're not. During an interview on 10/4/23 at 12:08 PM the Regional Director of Clinical Services stated Resident #93 was care planned for a shower every day and was not getting it every day and should be. 415.5(b)(1)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during a Standard survey completed on 10/4/23, the facility did not ensure that they immediately informed the resident's representative when there was a significant change in the resident's health, mental, or psychosocial status for two (Resident #s 27 and #54) of two residents reviewed. Specifically, there was no evidence Resident #54's Health Care Proxy/Responsible Party (HCP/RP) was informed that the resident was transferred to the hospital on 7/20/23 and staff did not contact Resident #27's alternate representative when they could not reach their primary representative to notify of an acute hip fracture. The findings are: The policy titled Notification of a Change in a Resident's Condition or Status dated 12/2016 documented unless otherwise instructed by the resident, a nurse will notify the resident's representative when the resident was involved in an accident or incident that resulted in an injury including injuries of unknown source and when it was necessary to transfer the resident to a hospital. 1. Resident #54 had diagnoses including traumatic brain injury, epilepsy, and cerebral infarction (a stroke). The Minimum Data Set (MDS, a resident assessment tool) dated 7/31/23 documented Resident #54 had moderately impaired cognition and required extensive assistance for eating. Review of nursing Progress Note dated 7/20/23 at 7:05 PM, written by Registered Nurse (RN) #3, documented the physician ordered the resident to be sent to the hospital due to abnormal labs due to gallstones. There was no documented evidence that the HCP/RP was notified. Review of the Facility 24 Hour Report dated 7/20/23 and 7/21/23 revealed no documented evidence that Resident #54's HCP/RP was notified of the transfer to the hospital. During a telephone interview on 9/27/23 at 11:20 AM, Resident #54's HCP/RP stated the resident had been in the hospital recently and the facility did not notify them of the transfer. They stated they found out from the hospital. During an interview on 10/4/23 at 7:52 AM, Licensed Practical Nurse (LPN) Unit Manager #2 stated the supervisor who sent the resident to the hospital was responsible for updating the resident's responsible party (RP/HCP) of the transfer, no matter what time of the day. The LPN UM #2 stated if they couldn't get to it, they should pass it on to the next shifts so someone could follow up. The LPN UM #2 stated they did not notify Resident #54's RP of the transfer to the hospital on 7/20/23. During an interview on 10/4/23 at 8:55 AM, the Director of Nursing (DON) stated the person who sent Resident #54 to the hospital should have notified the family and documented it in a progress note. 2. Resident #27 had diagnoses including nondisplaced fracture of the left femur, age-related osteoporosis (a condition where bones become weak and brittle) and dementia. The MDS dated [DATE], documented the resident was understood, usually understands, and had severely impaired cognitive skills. The comprehensive care plan (CCP) dated 7/26/23 documented that Resident #27 had an alteration in physical function related to a left hip fracture. The Care Plan Note dated 7/19/23 at 1:31 PM, the Director of Social Work documented that Resident #27 was a full code with no MOLST in place and the family member makes all decisions for them. The Radiology Report dated 7/25/23 documented an acute or recent impacted left femoral neck fracture with no change from the 7/24/23 report. The Physician Progress Note dated 7/25/23 at 1:42 PM, the Nurse Practitioner (NP) #1 documented that Resident #27 had an acute left femur fracture. NP #1 documented the resident would likely benefit from conservative management rather than surgical and the unit manager was to discuss with the HCP. A progress noted dated 7/27/23 at 1:08 PM, MD #1 documented that Resident #27 had an x-ray confirmed acute fracture of the left femoral head and a message was left for the emergency contact with no return call. MD #1 documented that due to Resident #27's cognitive impairment, frailty and other co-morbidities, conservative treatment was preferred to surgical and will await call back from the HCP. Review of the Progress notes revealed the following: -On 7/25/23 at 1:38 PM, LPN #6 documented they telephoned Resident #27's family member and left a message for them to return call to the facility to inform them about the fracture. -On 8/2/23 at 3:18 PM, LPN #6 documented they left a telephone message for Resident #27's family member to return call. -On 8/4/23 at 8:55 AM, LPN #10 documented they left a telephone message for Resident #27's emergency contact #2 to return call. There was no documentation from 7/25/23-8/3/23 that Resident #27's alternate representative was contacted when staff were unable to contact their primary representative. During an interview on 9/28/23 at 1:35 PM, the NP #1 stated that they consulted with MD #1, and they wanted to treat Resident #27 left femur fracture treated conservatively and the unit manager was to speak with the resident's family member. During further interview on 10/3/23 at 10:41 AM, NP #1 stated they would have expected the second representative to be contacted if the facility they were unable to get in contacted with Resident #27 first representative. During a telephone interview on 10/3/23 at 12:33 PM, LPN #6 stated they believe they attempted to get in contact with Resident #27's representative about their broken hip. LPN #6 stated they do not recall if they attempted to contact Resident #27's second representative. LPN #6 stated that they would have documented all attempts they made to contact Resident #27's representatives. During a telephone interview on 10/3/23 at 2:15 PM, MD #1 stated that they preferred to treat Resident #27 fracture femur by conversative measures due to their geriatric judgement. The MD #1 stated they wanted the facility to get in contact with the resident representative to make the decision and they would have expected the facility to update them (the MD #1) sooner that they were unable not get in contact with Resident #27's representative. During an interview on 10/4/23 at 9:22 AM, the DON stated they were unaware that the unit manger did not get in contact with the family member prior to 8/4/23 and they would have expected LPN #6 to call Resident #27's representatives every day. The DON stated that Resident #27's second family member was contacted when the resident was sent to the emergency room for evaluation of the hip fracture on 8/4/23 and they should have been contacted sooner. The DON stated that would have expected all attempts to contact the family members to be documented. During an interview on 10/4/23 at 10:22 AM, the Administrator stated their expected the resident's representatives would be contacted daily until one of the representatives were reached. The Administrator stated their expectation for that all attempts of representative notification be documented. 10NYCRR 415.3(f)(2)(ii)(d)

Based on observation, interview, and record review conducted during the Standard survey completed on 10/4/23, the facility did not provide a safe, clean, comfortable, and homelike environment for one unit (Riverview) of four resident units. Specifically, there were strong odors of cigarette smoke, ashes on the floor, and cigarette butts in the toilet and on the floor of the Riverview shower room. The policy and procedure (P&P) Smoking Program, revised 6/2019, documented the facility shall establish and maintain safe resident smoking practices. While the facility does promote a smoke free environment, those residents who wish to smoke will be provided with appropriate accommodations to safely do so. The undated P&P Homelike Environment documented residents are provided with a safe, clean, comfortable, and homelike environment. The findings are: During an observation on 9/26/23 at 11:30 AM, a strong cigarette smoke odor was detected in the Riverview unit shower room and there was a cigarette butt inside the bathtub. During an interview on 9/27/23 at 8:36 AM, Resident #107 stated the shower room smelled of stale cigarette smoke, cigarette butts, ashes were on the floor, and the shower room floor was slimy. During an observation on 9/27/23 at 8:54 AM, a strong cigarette smoke odor was detected in the Riverview unit shower room, and cigarette ashes were observed on the floor near the toilet. During an observation on 9/28/23 at 8:40 AM, a strong cigarette smoke odor was detected in the Riverview unit shower room, and cigarette ashes were observed on the floor near the sink. Additionally, a cigarette butt was observed on the floor next to the bathtub. During an interview on 9/29/23 at 11:58 AM, Riverview Housekeeper #1 stated they often smell cigarette smoke in the Riverview shower room but have never seen anyone smoking in the shower room. Additionally, there are often cigarette butts and cigarette ashes in the shower room that they clean. During an observation on 10/2/23 at 7:31 AM, a strong cigarette smoke odor was detected in the Riverview unit shower room, cigarette ashes were observed on the floor, and two cigarette butts were observed in the toilet. During an observation/interview on 10/2/23 at 11:39 AM, with the Maintenance Director, a strong cigarette smoke odor was detected in the Riverview shower room, cigarette ashes were observed on the floor, and three cigarette butts were observed in the toilet. The Maintenance Director stated the Riverview shower room smelled of cigarette smoke, and they were notified that residents were smoking in the Riverview unit shower room. During an interview on 10/3/23 at 7:33 AM, the Administrator stated they were aware someone was smoking in the Riverview unit shower room, and that put other residents' safety at risk. During an interview on 10/4/23 at 7:33 AM, the Director of Nursing (DON) stated they were aware a resident smoked in the Riverview unit shower room and smoking in the facility posed a safety risk to the residents on the unit and in the facility. 10NYCRR 415.5(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a complaint investigation (Complaint #NY00317844) during the Standard survey completed on 10/4/23, the facility did not ensure the development and implementation of an effective discharge process that focused on resident's discharge goals, and effectively transitioned them to post-discharge care, including regular re-evaluation to identify changes that require modification of the discharge plan for two (Resident #3 and #400) of four residents reviewed for discharge planning. Specifically, there was no evidence that referrals were made, facilities contacted, family contact, and there was no follow up with the resident for the status of their discharge plan (Resident #3), also there were no referrals for post discharge care made prior to their discharge from the facility (Resident #400). The findings are: The policy titled Discharge-Planning dated 12/19, documented the Social Worker (SW) will be responsible for the duties of discharge coordinator which includes to initiate all necessary referrals for post discharge needs which may include home care services and document the steps taken for discharge planning in the resident's medical record. 1. Resident #400 had diagnoses including hypertension (HTN - high blood pressure), hyperlipidemia (elevated fat levels in the blood), and anemia. The MDS dated [DATE] documented Resident #400 was cognitively intact, and a referral to the local contact agency had been made. The comprehensive care plan created on 10/24/22, documented Resident #400 was at the facility for subacute rehabilitation (SAR) with the goal to be safely discharged to the community with eligible community services/resources. The Social Services Discharge Instruction, signed and dated 6/1/23 by the Director of Social Work (DSW), documented a referral was made to a home care agency. The Progress Notes General Documentation, dated 6/1/23 12:14 PM, documented Resident #400 was discharged from the facility at 12:15 PM on 6/1/23. The Social Service Documentation created by the DSW on 6/7/23 at 4:17 PM with an effective date of 5/30/23, documented a referral was made to a home care agency for supportive services for discharge. During a telephone interview on 9/28/23 at 8:19 AM, the home care agency central intake representative stated a referral for Resident #400 was received by the home care agency on 6/8/23. Additionally, they stated there were no previous referrals for Resident #400. During an interview on 9/28/23 at 9:57 AM, the DSW stated they were unable to locate any documentation a referral was made to the home care agency prior to 6/8/23. During an interview on 9/28/23 at 10:12 AM, the Director of Nursing (DON) stated they were unable to locate any documentation a referral was made to the home care agency prior to 6/8/23. During an interview on 10/4/23 at 8:57 AM, the Administrator stated a referral should have been made to the home care agency prior to Resident #400's discharge. 2. Resident #3 had diagnoses including chronic respiratory failure, hypertension, and congestive heart failure. The MDS dated [DATE] documented Resident #3 was cognitively intact and there was no active discharge plan to return to the community. The comprehensive care plan initiated on 7/27/22 documented Resident #3 was in the facility for long term care with an overall goal of securing placement in the Carolinas to be closer to their family. The interventions were dated 5/11/18 and included assisting the resident with applications for community resources, making appropriate referrals as needed, and SW (social work) will meet with resident and/or designated representative to identify needs for discharge. There were no specific interventions addressing placement in the Carolinas. Review of the Social Service Assessment and Documentation dated 10/7/22, 12/27/22, 3/28/23, 6/12/23, 9/8/23, completed by the DSW, documented the resident had writer working on a possible lateral transfer to a facility down south near their family. To date, no facility has offered the resident a bed at this time. There is a barrier to getting resident to North Carolina (NC) due to them not having insurance and needing insurance there. SW had been working with the resident on how to do this process. The SW assessments did not document any updates, referrals made, or progress in securing insurance or that any applications were submitted to other nursing facilities. Review of the social services Progress Notes dated 10/6/22 at 1:31 PM, 10/28/22 at 10:36 AM, 12/26/22 at 10:44 AM, 3/23/23 at 1:32 PM, 6/6/23 at 3:04 PM, 6/21/23 at 2:23 PM, and 8/25/23 at 9:02 AM, completed by the DSW, documented the SW continued to work with the resident and get them closer to their family and try to secure placement. There was no evidence of what specific interventions were done to secure discharge to another facility or obtaining insurance. During an interview on 9/26/23 at 2:11 PM, Resident #3 stated they wanted to be transferred to another facility in North Carolina (NC) because their family lived down there. The resident stated they had provided the SW phone numbers for a couple facilities near their family, but nothing has been done about it. The resident stated they had changed their health insurance to one that was accepted in North Carolina, but nobody at the facility had any answers for them. During an interview on 10/2/23 at 2:43 PM, the DSW stated Resident #3 wanted to go to NC, however they have not talked to the resident's family to clarify their plan for when the resident got down there. The DSW stated the resident was able to make their own medical decisions, and that the resident had not told them of any places. The SW stated they referred the resident to an agency maybe a year ago, and this agency provided a list of places the resident could possibly go to in NC. The DSW stated this was not documented in the medical record and this should have been, however they don't have time to document. The DSW stated they have not submitted any applications to any facilities in NC and had not contacted the resident's family because the resident had not given them permission to contact family. During a telephone interview on 10/3/23 at 2:31 PM, the Regional SW stated discharge planning was the SW's responsibility and the DSW hadn't reached out to them for guidance. The Regional SW stated an out of state transfer needed a lot of coordination and work. The SW should document anything they've done for the process, any referrals made, and the follow ups completed. During an interview on 10/4/23 at 9:00 AM, the DON stated the SW should document what referrals had been made, what specifically had been done for the discharge, and any conversations they have had with the resident. 10 NYCRR 415.11(d)(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 10/4/23, the facility did not ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal hygiene for two (Resident #54 and 104) of eight residents reviewed. Specifically, a resident with a significant weight loss, that required extensive assistance with eating, was not provided extensive assistance (Resident #54); and a resident that was totally dependent on staff for care was not provided showers, nor was their hair washed (Resident #104). The findings are: 1. Resident #54 had diagnoses including traumatic brain injury, epilepsy, and cerebral infarction (a stroke). The Minimum Data Set (MDS, a resident assessment tool) dated 7/31/23 documented Resident #54 had moderately impaired cognition and required extensive assistance for eating. The undated policy and procedure (P&P) titled Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol documented the resident with functional impairment most likely needs some form of assistance with eating. Assistance may include ensuring that needed implements (eyeglasses, dentures, etc.) are used, providing assistive utensils and devices as identified in the plan of care, and providing feeding assistance as needed. The nursing staff will monitor and document the weight and dietary intake of residents. The comprehensive care plan, identified as current by the Director of Nursing (DON), documented Resident #54 required assistance with ADLs related to limited mobility and had altered nutrition related to significant weight loss and modified diet consistency. Interventions included the resident required extensive assistance with eating and encourage meal intake and completion. The [NAME] (a guide used by staff to provide care) dated 9/29/23 documented the resident required extensive assistance with meals. During an observation of the lunch meal on 9/28/23 at 11:54 AM, Resident #54 was seated at a table in the lounge area near the nurse's station. The resident had their lunch tray in front of them and there were no staff seated next to the resident. Licensed Practical Nurse (LPN) #1 was assisting another resident with their lunch at another table. At 11:58 AM, the resident picked up their fork and took two bites of their food and put the fork down. At 11:59 AM, a resident asked a visitor if they would help this Resident #54 eat, and LPN #1 stated they would be right over to help the resident. At 12:08 PM, the resident was not attempting to eat, and no staff were assisting or encouraging Resident #54 to eat. At 12:09 PM, LPN #1 left the unit. At 12:15 PM, Certified Nurse Aide (CNA) #4 cleared three trays from other residents in the lounge area and sat down. At 12:17 PM, Resident #54 attempted to feed themselves and dropped the food into their lap, then dropped their fork. The CNA #4 was watching the television at this time. At 12:24 PM, the resident picked up their napkin, wiped their mouth, picked up their milk carton, attempted to take a sip, then dropped it onto themselves. CNA #4 responded and brought the resident to their room. During an interview on 9/28/23 at 12:28 PM, CNA #4 stated Resident #54 did need help to eat, but they also ate on their own. The CNA #4 stated the [NAME] had the level of assist the resident needed to eat and that sometimes the resident was combative with care. During an interview on 9/28/23 at 12:35 PM, LPN #1 stated they were about to assist Resident #54 with their lunch, however they were called away. LPN #1 stated the resident could feed themselves and would have to look at the [NAME] to see what level assist they needed. LPN #1 stated if a resident was having difficulty eating, staff should try to help them, and LPN #1 didn't remember if they asked any other staff to assist this resident when they were called away. During an interview on 9/28/23 12:39 PM, LPN Unit Manager (UM) #2 stated the resident was on an Occupational Therapy (OT) program currently as they had a decline in their ADLs, several hospitalizations, and they've had weight loss. LPN UM #2 stated if a resident was having difficulty feeding themselves, staff should have tried to help and should not be watching the television. During an interview on 10/4/23 at 8:55 AM, the DON stated if a resident wasn't feeding themselves or were having difficulty staff should have attempted to help the resident. The resident has had declines, has been hospitalized several times and had lost weight. Nurses should be ensuring residents were being assisted. 2. Resident #104 had diagnoses including multiple sclerosis (MS - disease that affects central nervous system), epilepsy (neurological disorder that causes seizures or unusual sensations and behaviors), and anxiety. The MDS dated [DATE] documented Resident #104 was cognitively intact, exhibited no rejections of care, and was totally dependent on staff for hygiene and bathing. The MDS dated [DATE] documented it was very important for the resident to choose between a tub bath, shower, bed bath or sponge bath. The P&P titled ADL - Personal Hygiene revision dated 10/2019 documented resident bath or shower will be scheduled per resident preference but at least weekly per the Unit shower schedule and a bed bath will be provided on non-shower days. Hair grooming will be provided with AM and PM care/shower day/or by appointment at hairdressers. All observation data and care given will be documented and notify the supervisor if the resident refuses any care or if care needs are not met for any reason. The [NAME] dated 9/29/23 documented Resident #104 was dependent on 2 staff members for bathing and personal hygiene. Shower/Bath was scheduled on Monday 7-3 shift and Wednesday 3-11 shift. The comprehensive care plan (CCP) dated 5/23/23 included the resident was totally dependent on 2 staff members for personal hygiene and bathing. Shower/Bath was scheduled Monday 7-3 and Wednesday 3-11. There was no problem area that included rejection of care in the CCP. Progress Notes dated 8/1/23 - 9/29/23 documented no refusals of care. During an interview and observation on 9/27/23 at 9:22 AM, Resident #104 stated they have not been offered nor received a shower since May 2023, and their hair needs to be washed desperately. Resident #104's hair was oily with large, scaly, crusty chunks of dandruff throughout the scalp, hair, and on their shoulders. During an interview on 9/28/23 at 9:31 AM, Resident #104 stated they were neither offered nor received a shower on 9/27/23 on the 3:00 PM - 11:00 PM shift. During an interview on 9/28/23 at 3:06 PM, CNA #9 stated they are often the only CNA scheduled on the Riverview unit for the 3:00 PM - 11:00 PM shift, and they are unable to complete the scheduled showers. During an interview on 9/29/23 at 9:19 AM, Resident #104 stated a CNA washed their hair the previous evening. Additionally, the resident stated it took the CNA approximately 30 minutes to wash their hair because there was a lot of dead skin built up from not being washed in so long. During an interview on 9/29/23 at 11:48 AM, CNA #9 stated they washed Resident #104's hair on 9/28/23. Additionally, the CNA stated it appeared Resident #104's hair had not been washed for months, and they would have to wash the resident's hair again on the 3:00 PM - 11:00 PM (9/29/23) secondary to they were unable to remove all the chunks of dandruff from their hair and scalp. During an interview on 9/29/23 at 9:31 AM, the DON stated showers are to be given per the care plan and if a resident refuses, the refusals would be documented, and care planned in the electronic medical record (EMR). During an interview on 10/3/23 at 10:58 AM, Nurse Practitioner (NP) #1 stated they had noticed dandruff in Resident #104's hair and scalp and expected the resident to receive showers and have their hair washed on a regular basis. During an interview on 10/4/23 at 9:00 AM, the Administrator stated residents should receive showers per the plan of care, and refusals should be documented, and care planned. 10 NYCRR 415.12(A)(iii)

Based on observation, interview and record review conducted during the Standard survey completed on 10/4/23, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #126) of eight reviewed for quality of care related to skin conditions (non-pressure) and pressure ulcers. Specifically, the facility did not provide pressure ulcer care and venous ulcer care per the physician's orders, dressings were not changed daily and/or dressings were not in place. The finding is: The policy and procedure titled Skin and Pressure Injury Prevention revision dated 3/13/23 documented the facility will assess residents for risk in the development of pressure injuries and implement preventative measures in accordance with current standards of practice. 1. Resident #126 had diagnoses including malignant neoplasm cervix (cancer lower part of uterus), chronic peripheral venous insufficiency (condition affecting blood flow from legs), and hypothyroidism. The Minimum Data Set (MDS- as resident assessment tool) dated 9/5/23 documented Resident #126 was cognitively intact, had one stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer, and open lesion(s) other than ulcers, rashes, cuts. a. The comprehensive care plan (CCP) dated 4/14/23 documented the resident had a stage 4 pressure injury to the sacrum (area above the tail bone on right and left buttocks). Interventions included monitor dressing daily to ensure it was clean/dry/intact. The Skin and Wound Note, dated and signed 9/26/23 9:36 AM by Nurse Practitioner (NP) #2 Wound Consultant, documented a full thickness stage 4 pressure ulcer of the sacrum. The treatment recommendations were to cleanse with 0.125% (percent) Dakin's solution (wound cleanser), apply silver alginate (highly absorbent antibacterial pad) to base of the wound, secure with superabsorbent dressing, change daily. The Physician Orders included the following: Silver external pad. Apply to sacrum topically every day shift for wound care. Cleanse with 0.125% Dakin's solution, apply silver alginate to base of the wound, secure with super absorbent dressing and had a start date of 9/12/23. The Treatment Administration Record (TAR) dated 9/1/23 - 9/30/23 included the following: Silver external pad. Apply to sacrum topically every day shift for wound care. Cleanse with 0.125% Dakin's solution, apply silver alginate to base of the wound, secure with super absorbent dressing. Scheduled daily 7:00 AM-. The TAR documented 5 days (9/21/23, 9/23/23, 9/24/23, 9/25/23, and 9/30/23) the treatment was not signed as completed. b. The CCP documented the resident had a vascular ulcer on the right calf, date initiated 6/13/23. Interventions included apply treatment per MD order. The Skin and Wound Note, dated and signed 9/26/23 9:36 AM by NP #2 Wound Consultant, documented a full thickness venous ulcer of the right lower leg calf. The treatment recommendations were to cleanse with normal saline (NS), apply Iodoform (antiseptic) packing strip to base of the wound, secure with bordered gauze, change daily. The Physician Orders included the following: Right lower leg calf treatment every dayshift for wound care. Cleanse with NS, apply iodoform packing strip to base of the wound, secure with bordered gauze with a start date of 9/21/23. The TAR dated 9/1/23 - 9/30/23 included the following: Right lower leg calf treatment every dayshift for wound care. Cleanse with NS, apply iodoform packing strip to base of the wound, secure with bordered gauze. Scheduled daily 7:00 AM-. Review of the TAR revealed 5 days (9/21/23, 9/23/23, 9/24/23, 9/25/23, and 9/30/23) the treatment was not signed as completed. During an interview on 9/26/23 at 11:05 AM, Resident #126 stated their dressings (sacrum and calf) have not been done since 9/21/23, the dressings were to be changed daily, and the treatments were not consistently completed daily. During an observation on 9/26/23 at 11:16 AM, there was no dressing on the sacral pressure ulcer, and the right lower leg calf wound. During an observation on 10/2/23 at 12:11 PM, there was no dressing on Resident #126's sacral pressure ulcer, and the dressing on the right lower leg calf was dated 9/29/23. During an interview on 10/2/23 at 2:09 PM, Licensed Practical Nurse (LPN) #1 stated it was not reported that Resident #126's sacral dressing was not intact. During an interview on 10/3/23 at 7:58 AM, the Director of Nursing (DON) stated the blanks on the TAR indicated the treatment was not completed. The DON stated they expected staff to follow the physician orders for treatments, complete the treatments as ordered, and document the treatments were completed. Additionally, the DON stated Resident #126 was alert and oriented and was able to communicate whether or not treatments were completed and whether or not dressings were intact. During an interview on 10/3/23 at 10:20 AM, NP #2 stated they expected a dressing to cover both the sacral pressure ulcer and the right lower leg calf wound at all times secondary to increased risk of infection. Additionally, treatments should be completed as per the physician orders. During an interview on 10/4/23 at 9:04 AM, the Administrator stated they expected nursing staff to complete and document treatments per the physician orders. 10 NYCRR 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 10/4/23, the facility did not ensure that each resident receives adequate supervision to prevent accidents for one (Resident #80) of one resident reviewed. Specifically, a resident with a diagnosis of dysphagia (difficulty swallowing) and a physician ordered pureed diet (consistency of smooth, thick paste) with soft sandwiches, received a deli meat sandwich. The finding is: The policy titled Modified Food Consistency dated 4/2020 documented the food and nutrition services department will be responsible for preparing and serving the diet texture as ordered, care will be taken to serve the foods as ordered on the consistency altered diet. Food consistency changes should not be made without a written order, upgrading or downgrading consistency may need to be evaluated by the Speech Language Pathologist (SLP). 1. Resident #80 had diagnoses including gastroesophageal reflux disease (GERD), hypothyroidism, and heart failure. The Minimum Data Set (MDS, a resident assessment tool) dated 6/21/23 documented Resident #80 had moderately impaired cognition. The comprehensive care plan identified as current by the Director of Nursing (DON) documented Resident #80 had a potential for altered nutrition related to a stroke with dysphagia diagnosis and a history of aspiration pneumonia with a mechanically altered diet. Interventions included a pureed consistency diet with soft sandwiches allowed per the SLP. The [NAME] (guide used by staff to provide care) dated 10/2/23 documented the resident was on a pureed diet and could have soft sandwiches. Review of the Clinical Physician Orders dated 9/13/23 revealed an order for a regular diet, puree texture, and may have soft sandwiches. During an observation on 9/26/23 at 12:20 PM, Resident #80 was sitting in their wheelchair in the lounge area near the nurse's station. The resident had their lunch tray in front of them, a pureed consistency meal and Certified Nurse Aide (CNA) #7 provided the resident with two turkey and cheese sandwiches. The resident was feeding themselves the sandwich. During an interview on 9/26/23 at 12:21 PM, CNA #7 stated they had to check the electronic medical record (EMR) for Resident #80's diet but thought they were on a regular diet. CNA #7 checked the meal ticket on Resident #80's tray, stated the resident was on a pureed diet and that sandwiches weren't part of a pureed diet, but they had seen the resident eating sandwiches before, so they must have ok'd it. The resident was observed eating the turkey and cheese sandwich at this time. During an interview on 9/26/23 at 12:25 PM, Licensed Practical Nurse (LPN) Unit Manager (UM) #2 stated Resident #80 was allowed to have sandwiches. During further interview on 9/26/23 at 12:29 PM, LPN UM #2 stated Resident #80 could not have a turkey and cheese sandwich but was allowed to have peanut butter and jelly. During further interview on 9/26/23 at 12:31 PM, CNA #7 stated they knew the resident could have sandwiches but didn't know only a certain kind. During an interview on 9/29/23 at 2:42 PM, SLP #1 stated Resident #80 was on a pureed diet but could have soft sandwiches like peanut butter and jelly, tuna salad or egg salad. The SLP stated deli meats like turkey, ham or salami were not considered soft sandwiches and the resident should not have had a turkey and cheese sandwich because they were at risk for aspiration. During an interview on 10/4/23 at 8:54 AM, the DON stated it was important that residents received the correct items in their diet, so they don't choke and that nurses were supposed to make sure staff were giving residents the correct diet consistency. 10 NYCRR 415.12(h)(1)

Based on observation, interview and record review conducted during the Standard survey completed on 10/4/23, the facility did not provide pharmaceutical services to meet the needs of each resident and the facility did not ensure that drug records were in order and that an account of all controlled drugs is maintained and periodically reconciled for four (River View, Harbor View, City View and Sky View) of four units. Specifically, on the Riverview Unit Licensed Practical Nurse (LPN) #4 was observed to have pre-poured resident medications and two narcotic reconciliation books with the keys to a medication cart and narcotic cupboard were left unattended in the medication room. Additionally, on the Sky View Unit LPN #7 was observed to have completed a narcotic reconciliation by themselves without the presence of the nurse going off duty. Furthermore, the controlled drug records for all the units shift to shift counts were not consistently signed off as completed. The findings are: The facility Policy and Procedure (P&P) titled Medication Administration dated 12/19 documented that medications may not be prepared in advance and must be administered within one hour of their prescribed time, unless otherwise specified. The facility P&P titled Controlled Substance Management dated 8/22 documented separate records shall be maintained on all controlled substances in the form of a declining inventory record. Such records shall be accurately maintained. The P&P documented that such records shall be reconciled by the incoming and outgoing nurse. Two nurses must count the remaining medication at each shift and any handoff of narcotic keys. 1) During an observation/interview on 10/3/23 at 8:43 AM, the River View A Medication Cart top drawer contained 8 souffle cups of pre-poured medications marked by room numbers. LPN #4 stated the medication pass on the Riverview unit was very heavy and they pre-pour medications to administer the medications as efficiently as they can to complete the medication administrations on time. LPN #4 stated they are not supposed to pre-pour medications, as it can cause a medication administration error. Additionally, LPN #4 stated they were unable to identify the medications nor the residents the pre-poured medications were to be administered to without observing the Medication Administration Records (MAR's) associated with the room numbers indicated on the souffle cups. During an interview on 10/3/23 at 8:53 AM, the Assistant Director of Nursing (ADON) stated medications are not to be pre-poured secondary to increased risk of medication administration errors. During an interview on 10/3/23 at 9:21 AM, the Director of Nursing (DON) stated it was not acceptable to pre-pour medications, medications should be administered to one resident at a time to decrease the risk of medication administration errors. During an interview on 10/3/23 at 10:58 AM, Nurse Practitioner (NP) #1 stated nurses should not pre-pour medications secondary to increased risk of medication errors. Medications should be administered to one resident at a time, after the medications are dispensed from the pharmacy packaging. During an observation of the River View Medication Room on 10/4/23 at 7:49 AM, two narcotic reconciliation books were observed with the keys to a medication cart and narcotic cupboard placed inside the front cover of each book. 2) During an observation/ interview in the medication room on the Sky View Unit on 9/28/23 at 9:26 AM, LPN #7 was observed performing a narcotic count reconciliation with no other nurse present for Team One medication cart. LPN #7 stated the narcotic keys were left in the narcotic book on top of the medication cart from the previous 11:00 PM- 7:00 AM shift. LPN #7 stated that the second 7:00 AM- 3:00 PM nurse on the unit refused to count and pass medications for the whole unit that morning. LPN #7 stated they were the corporate restoration nurse and just arrived at the facility and was directed to pass medications on the unit. LPN #7 stated they have observed in the past that nurses leave at the end of their shift not preforming narcotic reconciliation if the oncoming nurse was late. During an interview on 9/28/23 at 9:30 AM, LPN #4 stated they reconciled narcotics for the Sky View Unit Team Two with LPN #8 that morning. LPN #4 stated they refuse to take narcotic keys for both medication carts on any unit and did not reconcile narcotics for Team One. LPN #4 stated there was supposed to be a second nurse on the 7:00 AM- 3:00 PM shift and LPN #8 did not ask them to do narcotic reconciliation for Team One prior to them leaving. During an interview on 9/29/23 at 6:40 AM LPN #8 stated they did not perform a narcotic count reconciliation on 9/28/23 prior to them leaving their 11:00 PM-7:00 AM shift for Sky View Team One. LPN #8 stated that the second nurse was not on time, and they left the narcotic keys in the book and left the building because it was the end of their shift. LPN #8 stated they did not tell a supervisor that they did not reconcile their narcotics but should have. During an interview on 10/4/23 at 8:24 AM, LPN #1 stated when they pass the narcotic keys they do the count and then both nurses sign off at the back of the book. LPN #1 stated sometimes nurses just leave their keys and don't count with the oncoming shift. When the next nurse has arrived for their shift they have to count by themselves because nobody on the previous shift stayed until their relief arrived. LPN #1 stated this happens especially on the weekends. LPN #1 stated if their relief doesn't arrive, they give them 1.5 hours, then they call the supervisor to do the count and take the keys. LPN #1 stated the supervisors can't force staff to stay and even if a supervisor was on the unit, they would still leave. 3) Review of the Shift Count (Narcotic Count Records) from 9/8/23-9/29/23 the following lacked documented evidence that narcotic reconciliation was completed by the oncoming and outgoing nurses: -River View team one cart had 41 shifts -River View team two cart had 48 shifts -Harbor View team one cart had 28 shifts -Harbor View team two cart 36 shifts -City View team one cart 31 shifts -City View team two cart 26 shifts -Sky View team one cart had 38 shifts -Sky View team two cart had 32 shifts During an interview on 10/4/23 at 7:33 AM, the DON stated there were no nurses on the River View Unit, and the 11:00 PM - 7:00 AM nurse had left the facility prior to reconciling the narcotic count. The DON stated nursing staff are expected to remain in the facility until their relief arrives on the unit, and narcotics are to be reconciled between the off going and oncoming nurses. At 9:04 AM the DON stated that they were not aware on 9/28/23 that the narcotic keys were left in the book and the narcotics were not reconciled for Sky View Team One for the 7:00 AM- 3:00 PM shift. The DON stated that all narcotics need to be reconciled between two nurses at shift change because the count could be off and prevent diversion. During an interview on 10/4/23 at 9:58 AM, the Pharmacist Consultant stated that narcotic reconciliation occurs with the oncoming nurse and the nurse that is leaving. They stated that it is not proper practice to leave the narcotic keys in the narcotic book on top of the medication cart or for a nurse to leave without reconciling the narcotics because anyone can have access to the narcotic and there is a potential for diversion. 10 NYCRR 415.18(a)(b)(3)

Based on observation, interview, and record review conducted during Complaint investigations (#NY00296344, #NY00320402 and #NY00297199) during the Standard survey completed on 10/4/23, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for four (River View, Sky View, Harbor View, and City View) of four resident care units. Specifically, the facility did not have adequate nursing staff based on the facility's established minimum numbers of staff for each shift. Additionally, there was a lack of sufficient nursing staff to get residents out of bed, pass medications timely and according to physician orders, and not meeting resident care needs (showers). Resident #'s 1, 3, 8, 9, 11, 13, 19, 21, 23, 29, 37, 45, 49, 51, 52, 62, 73, 79, 80, 85, 98, 104, 107, 116, 118, 126, 142 and 401 were involved. The findings are: Refer to F677- Activities of Daily Living, scope and severity (S/S) =D Refer to F755- Pharmacy Services/Procedures/Pharmacist/Records 1. Review of the Facility Assessment Portfolio dated 9/26/23 documented the facility's bed capacity was 160 residents and census on assessment date was 145 residents. The facility assessment documented that all units were budgeted for 4 Certified Nursing Assistants (CNA) (except for 5 CNAs on the River View Unit) for day shift on each unit; 3 CNAs on the evening shift for each unit; and 2 CNAs for night shift on each unit. The facility assessment documented that each unit was budgeted for 2 medication nurses each shift, a unit manager, with an addition of Registered Nurse (RN) charge nurse for the evening and night shift on the River View unit. The facility was also budgeted for a RN Supervisor each shift. Review of a document provided by the Acting Administrator titled (Facility Name) Minimum Staffing Pattern dated 8/24/23 documented the day shift minimal staffing would be a total of 5 Licensed Practical Nurses (LPN) or RNs and 8 CNAs. The evening shift would have a minimum total of 4 LPNs or RNs and 8 CNAs. The night shift would have a minimum total of 3 LPNs or RNs and 4 CNAs. The minimum staffing pattern did not document/include the RN supervisor each shift. Review of the Daily Staffing Sheets on 7/16/23 and from 8/27/23 to 10/3/23 documented the facility did not meet their minimum number of staff: 7/16/23 3:00 PM - 11:00 PM shift - down one nurse and three CNAs 7/16/23 11:00 PM - 7:00 AM shift - down two nurses 8/27/23 3:00 PM - 11:00 PM shift - down two CNAs 8/28/23 7:00 AM - 3:00 PM shift - down one CNA 9/4/23 11:00 PM - 7:00 AM shift - down one nurse 9/11/23 7:00 AM - 3:00 PM down - one nurse 9/16/23 7:00 AM - 3:00 PM down - one nurse 10/1/23 7:00 AM - 3:00 PM shift - down one CNA During an interview on 9/29/23 at 2:04 PM, the Staffing Coordinator stated they used the (Facility Name) Minimum Staffing Pattern to staff the facility. The Staffing Coordinator stated they also needed a nursing supervisor per shift that was not included in the minimum staffing numbers. They stated they have been working the position for the past two weeks and they have not fallen below the minimum number of staff since they started. The Staffing coordinator stated that it was their goal to staff above the critical and if they did go below minimum it is because of staff call-offs. During an interview on 10/2/23 at 8:37 AM, the Assistant Director of Nursing (ADON) stated they received a couple calls yesterday from the day shift supervisor to help with getting more staff to come in. The ADON stated the evening shift supervisor, who worked 3:00 PM to 3:00 AM, also called to get more staff. The ADON stated they did not get a call from the night shift which was unusual. The ADON stated the DON was on call from 3:00 AM - 7:00 AM after the evening shift supervisor left at 3:00 AM. During a further interview on 10/3/23 at 4:40 PM, the ADON stated that on 7/16/23 the facility fell below the minimum staffing numbers. The ADON stated they did not know if any management came into the facility to assist. The ADON stated that if any management did come into assist, then it should have been documented. During an interview on 10/3/23 at 9:00 AM, the Director of Nursing (DON) stated the (Facility Name) Minimum Staffing Pattern was a guide of minimal number of staff needed in the facility. The DON stated in addition to the minimum staffing pattern a nursing supervisor was needed for each shift. The DON reviewed the daily staffing sheets dated 8/27/23, 8/28/23, 9/4/23, 9/11/23, 9/16/23, and 10/1/23 the DON stated the facility did not meet their minimum numbers. The DON stated when a shift fell below the minimum staffing number, the nursing supervisor was to call management into work. The DON stated they did not come into assist on the 11-7 shift. The DON stated there were open positions for an in-service coordinator and two-unit managers. The DON stated the importance of meeting the minimum staffing numbers was to provide adequate care to the residents. The DON stated that they did not feel the residents were receiving the services they should be such as treatments, incontinent care every 2-4 hours, getting out of bed, ADL care, and showers due to low staffing numbers. 2. Review of provided Resident Council minutes revealed on 3/15/23 and 9/13/23 customer service concerns were reported. Additionally, documented on the 9/13/23 the minutes were concerns regarding staffing shortages on the weekends and that the DON was in attendance by invitation of residents to help understand issues concerning staffing and care being provided by nursing staff. During an interview on 9/29/23 at 1:34 PM, Activities Director #1 stated the customer service concern in the resident council minutes (3/15 and 9/13) referred to staff not being courteous, having an attitude, not treating residents with respect. Activities Director #1 stated that they had seen this themselves and that customer service for residents had declined over the years. During a Resident Council meeting held on 9/27/23 at 1:41 PM with 15 residents participating revealed residents had concerns that involved long time wait times for the staff to answer call lights, and they often received their medications late particularly on the weekends. Residents also stated the facility had a lot of call-offs. It was also reported by the residents that they were told there was nothing the facility could do about short staffing, as there was a union involved. 3. Interviews with Residents, Ombudsman, Family Members and Staff: During an interview on 9/26/23 at 10:57 AM, Resident #126 stated medications were administered late, and the facility was often short staffed with only one nurse on the River View unit. During an interview on 9/26/23 at 10:57 AM, Resident #13 stated there was not enough staff and some days they were left in their urine for a long time During an interview on 9/26/23 at 11:47 AM, Resident #62 stated there were not enough CNAs and nurses. Sometimes they had to wait a while for incontinent care or had to remain in bed because there was not enough staff to get them out of bed. During a telephone interview on 9/26/23 at 1:37 PM, Resident #9's health care proxy stated that at times when they visit, they see residents that had fallen onto the floor, and they feel there was not enough nursing staff. During an interview on 9/26/23 at 2:08 PM, Resident #3 stated the staffing at the facility was horrible, especially on weekends. Sometimes there was only one CNA and one nurse for each floor. Sometimes there wasn't even a nurse, so a supervisor had to pass the medications which in turn then end up being late. Resident #3 stated they have talked to Administration several times about the poor staffing, and they just say they were trying their best. During an interview on 9/27/23 at 8:34 AM, Resident #107 stated medications were administered late, and the facility was often short staffed with only one nurse on the River View unit. During an interview on 9/27/23 at 8:47 AM, Resident #19 stated the facility needed to get more staff, sometimes they had to wait a long time for the staff to change their brief or to get assistance with eating. Resident #19 stated they feel rushed during meals. During an interview on 9/27/23 at 9:00 AM, Resident #142 stated the evening and night shifts were especially short staffed, they stated there were times when the call light was not answered for an entire shift. During an interview on 9/27/23 at 9:19 AM, Resident #104 stated they wait quite a few hours to get their brief changed after having a bowel movement, sometimes 6 - 7 hours due to the lack of staff. Additionally, Resident #104 stated they have not received a shower nor had their hair washed since May of 2023. During an interview on 9/27/23 at 10:20 AM, the Ombudsman stated the facility was short staffed, this results in the residents receiving their medications late or not at all. When there was only one nurse on the floor, they will only pass medications for one side, then residents have to wait for the nursing supervisor to pass the medications on the other side. The staff don't have time to give showers, they have to choose between passing meals or giving showers. The ombudsman also stated that the residents were not getting out of bed. During an interview on 9/28/23 at 12:05 PM, Resident #3 stated there was only one CNA on the 3:00 PM -11:00 PM shift last night (9/27). During an interview on 9/28/23 at 3:32 PM, Resident #401 stated there was only one CNA on the evening shift the prior night (9/27) and nobody changed their roommate all night until after breakfast that morning. During an interview on 9/28/23 at 4:28 PM, CNA #5 (City View Unit) stated they worked 16 hours as the only CNA on the 3:00 PM-11:00 PM and 11:00 PM - 7:00 AM shift yesterday (9/27/23). They worked with one LPN. CNA #5 stated they could not take care of the residents who were two assist, so they could not get care done. CNA #5 stated showers get done for only those residents were one assist. During an interview on 9/28/23 at 4:49 PM, LPN #4 stated they usually work the 7:00 AM - 3:00 PM shift on Harbor View or River View units, and about once a week they work as the only nurse. LPN #4 stated when they were the only nurse, they could not get the residents' medications passed on time, and they usually finish their morning medication pass around noon. They stated they cannot get their charting completed but try to document on the 24-hour report sheet. During an interview on 9/29/23 at 6:22 AM, CNA #1 stated they worked the 11:00 PM - 7:00 AM shift on the City View Unit and were the only CNA on the unit from 4:30 AM to 7:00 AM, because the other CNA had left. When they were the only CNA on the unit, they could only accomplish the bare minimum, which was to get one resident out of bed for dialysis. CNA #1 stated the situation was dreadful. CNA #1 stated they used to have a routine and get residents up in the morning, but with working shorthanded they stated that their responsibility during the night shift was to keep residents dry and ensure their needs were met. On this day (9/29), they required the assistance from the nurse supervisor, as the resident scheduled for dialysis required a 2-assist with a mechanical lift to get out of bed. During an interview on 10/2/23 at 8:35 AM, LPN #1 stated they had just worked the night shift (10/1) on the River View unit, and they were the only one working on the unit. They didn't have any CNAs working with them. RN Supervisor #2 tried calling people in, but nobody would. LPN #1 stated RN Supervisor #2 helped on the unit for a while and the residents who were sleeping, they left alone and that they changed some people. During a telephone interview on 10/2/23 at 8:54 AM, RN Supervisor #2 stated there was one nurse on the River View unit 11:00 PM (10/1/23) to 7:00 AM (10/2/23). RN Supervisor #2 stated they assisted as they were able until their end of shift at 3:00 AM, and when they left building, LPN #1 was alone on River View unit. Additionally, RN Supervisor #2 stated they notified the DON via text message on 10/2/23, between 11:30 PM and 12:00 AM, the facility was at a critical staffing level with four LPNs and three CNAs to staff the building on the 11:00 PM - 7:00 AM shift. During an interview on 10/2/23 at 9:12 AM, the DON stated they were notified via text message by RN Supervisor #2 on 10/1/23 at 11:44 PM of the critical staffing level in the facility. The DON stated that RN Supervisor #2 should not have left the building at 3:00 AM at the end of their shift, should have stayed, and LPN #1 should not have been left alone on the unit for those 4 hours. 4a. During an observation and interview on 9/29/23 at 11:55 AM, Resident #80 was in bed with their lunch tray on the overbed table. Resident #80 stated they were still in bed today because there were only two CNAs working on the unit, and they wanted to get out of bed to go get their money. During an interview on 9/29/23 at 11:57 AM, CNA #6 stated the nurse said Resident #80 could get up after lunch because they only had two aides on the unit today. CNA #6 stated it would have been hard to get the resident out of bed before lunch. 4b. During an interview on 9/29/23 at 7:27 AM, CNA #10 stated they normally work the 7:00 AM - 3:00 PM shift on Sky View. CNA #10 stated about three times a week they work with only with one more CNA on the unit, and they do their best to keep the residents safe, dry, and fed. CNA #10 stated they were only able to provide incontinent care twice a shift when they should be performing care three or four times a shift. CNA #10 stated that they cannot shower the residents and sometimes a two-assist resident remains in bed because of staffing. During an observation and interview on 9/29/23 at 7:39 AM, Resident #29's call light was ringing. Resident #29 stated they wanted to get out of bed and were waiting for CNA #10 to assist them. CNA #10 was observed to turn off Resident #29's call light at 7:45 AM and continued to assist a resident that was having behaviors. During a further observation and interview at 9:34 AM, Resident #29 was sitting in their wheelchair and stated that CNA #10 had just gotten them out of bed and they were angry they had to wait. Resident #29 stated they had to wait until after breakfast to get out of bed because the unit was short staffed. During an interview on 9/29/23 at 1:42 PM, CNA #10 stated they could not get Resident #29 out of bed before breakfast when they first asked because they were assisting another resident and because there was only one other CNA working with on the unit this morning (9/29). During an interview on 10/4/23 at 9:04 AM, the DON that a resident should be able to get out of bed at their request and that at times the residents cannot get out of bed because of low staffing. 5a. During a record review/observation on 9/28/23 at 9:26 AM, the Sky View team one medication cart computer had four residents that were highlighted in red in the EMAR. During an interview at this time, LPN #7 stated the red highlight was an alert that indicated that Residents #49, #116, #37 and #8 had late medications. LPN #7 stated the medications were late because they just arrived to work and were instructed to pass medications. 5b. During a record review/observation on 9/29/23 at 8:35 AM, the Sky View team two medication cart computer had four residents that were highlighted in red on their electronic medication administration record (EMAR). During an interview at this time LPN #5 stated the red highlight indicated that Residents #73, #62, #98 and #116 had late medical provider orders (ex. finger sticks). LPN #5 stated the medications were late because they were currently the only nurse on the unit and that they had not arrived at work until 8:20 AM. During an observation on 9/29/23 at 9:37 AM, LPN #5 was exiting Resident #73's room with an insulin syringe. LPN #5 stated that Resident #73's insulin was ordered for 7:30 AM prior to their breakfast. LPN #5 stated that Resident #73's insulin was given late because they did not arrive to work until 8:20 AM and they obtained fasting blood sugars for team two prior to starting their medication pass. During an interview on 10/4/23 at 9:04 AM, the DON stated they were aware that both nurses where late on 9/29/23 and would have expected the night nurse to perform the fasting blood sugars and to give the insulin. 5c. During a record review/observation on 10/2/23 at 11:23 AM, Sky View team one medication cart had 14 residents that were highlighted in red on their EMAR. During an interview at this time, LPN #1 stated the red highlight indicated that Residents #118, #116, #52, #45, #85, #9, #11, #49, #79, #21, #62, #23, #1 and #51 medications were late. LPN #1 stated the resident's medications were late because they had completed the medication pass on the City View and was not floated to the Sky View unit until 11:00 AM. During an interview on 10/4/23 at 9:04 AM, the DON stated they were not aware that there was no nurse passing medications to Sky View team 1 until 11:00 AM on 10/2/23. 5d. During an observation and interview on 10/3/23 at 8:43 AM, the River View A (team one) medication cart top drawer contained 8 souffle cups of pre-poured medications marked by resident room numbers. LPN #4 stated the medication pass on the River View unit was very heavy and they pre-pour medications to administer the medications as efficiently as they can to complete the medication administrations on time. During an interview on 10/03/23 at 10:47 AM, Nurse Practitioner (NP) #1, stated residents have reported to them that they did not receive their medications until noon or not at all on the weekends. NP #1 stated that it was their expectation that the residents get their medication on time or prioritize the medication pass if the nurses were running late. During an interview on 10/4/23 at 9:04 AM, the DON stated late medication administration was due to low staffing. The DON stated that if there was only one nurse on a unit for the day shift, it would be impossible for medications to be administered on time. During an interview on 10/4/23 at 10:22 AM, the Acting Administrator in the presence of Operation Support, stated they were aware that medications have been given late and their expectation was medications should be given on time. The Acting Administrator stated, probably staffing has had an effect on medications being administrated late. The Acting Administrator stated they were unaware if their staffing number were below minimum, but they added that facility could do much better with our staffing numbers. The Acting Administrator stated that they felt their residents were safe with the minimum staffing number because there was also a building supervisor in addition to the minimum number of staff. Operation's Support stated they agreed with the Acting Administer. 10 NYCRR 415.13(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during an Abbreviated survey (NY00292576 & NY00292233) completed on 1/20/23, the facility did not ensure that each resident received treatment and care based on the comprehensive assessment of the resident that is in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for two (Resident #1 and #2) of three residents reviewed. Specifically, there was a lack of follow up on wound consultant recommendations and the lack of treatment initiation for a resident with vascular wounds. The findings are: The facility policy and procedure (P&P) titled, Consultation / Diagnostic Testing dated March 2018 documented, a licensed nurse reviews recommendation for follow up if needed upon the resident's return from scheduled appointment and informs the unit manager and then the medical doctor. The facility undated P&P titled Physician Orders documented the facility was to secure physician orders for care and services for residents as required by state and federal law. Physician orders will be dated and signed according to state and federal guidelines. Licensed Nurse receiving/accepted order was required to transcribe the order to the medication administration records (MAR) or electronic medication record (EMAR) containing all required information. The facility P&P titled Wound -Treatment Guidelines dated 10/2021 documented the licensed nurse shall use treatment guidelines to initiate treatments on newly discovered skin impairments; document wound/skin impairments in the EHR including wound measurements, description of the wound bed if visible, surrounding tissue, presence of drainage or odor and wound stage if applicable and scope of practice allows. Notification of medical provider of new or worsening wound. Refer to wound care specialist or facility medical provider for further evaluation and treatment recommendations. Treatment Protocols included to consult wound care providers when appropriate. 1. Resident #1was admitted to the facility with diagnoses of unspecified atrial fibrillation (irregular heart rate), peripheral vascular disease (PVD)-poor circulation of the lower extremities) and non-pressure chronic ulcer. The Minimum Data Set (MDS, a resident assessment tool) dated 12/22/22 documented Resident#1 was moderately cognitively impaired was understood and understands. Resident #1 did not reject care and had one venous and arterial ulcer. During an observation on 1/17/23 at 11:14 AM Resident #1 had bandage/ace wraps visible above their socks on the left leg. Review of Resident #1 entire EHR revealed there was no paper work or wound consultation recommendations for the January 28, 2022, February 18, 2022, March 11, 2022, and April 15, 2022 visits. The facility administration stated they were unable provide the consults for these appointments. Surveyors contacted the hospital wound clinic and requested copies of Resident #1's consultation notes for the visits. Registered Nurse (RN) #6 from the wound clinic wound clinic faxed copies of the notes to the Director of Nursing (DON) at the facility as requested. Review of wound clinic consultant recommendations revealed the following: - 1/28/22 Wound cleaning & peri-wound care: cleanse ulcer with soap and water; apply moisturizing lotion to peri wound. Primary wound: left midline lower leg apply Calcium Alginate with silver. Secondary wound: foam. Edema control: 3-layer Compression System to Left lower extremity (LLE), make sure compression is on correctly, wrap from the base of the toes to below the knee. - 2/18/22 Wound cleaning & peri-wound care: cleanse ulcer with soap and water; apply Nystatin Powder (antifungal) to LLE prior to compression application; Moisturizing lotion. Primary wound: left midline lower leg apply Calcium Alginate with silver. Secondary wound: foam. Edema control: 3-layer Compression System to Left lower extremity- make sure compression is on correctly, wrap from the base of the toes to below the knee. Compression wraps to be changed three times per week by nursing home staff - 3/11/22 Wound cleaning & peri-wound care of cleaning with soap and water- wash legs daily. Antifungal powder- apply Nystatin Powder to LLE daily; primary and secondary wound dressing to left, midline lower leg of Calcium Alginate with silver and ABD (abdominal pad); Dry Gauze - Keflex; Coban to secure dressing; change dressing daily. Ensure wound care is completed daily. - 4/15/22 Wound cleaning & peri-wound care of cleaning with soap and water- wash legs daily; apply Nystatin Powder to LLE daily; 3-layer compression system - LLE- to be changed twice weekly. Review of facilities physician orders and Medication/Treatment Administration records (MAR/TAR) dated 1/28/22 to 4/15/22 revealed the following orders: - Apply TED stockings daily for compression therapy-to be taken off at bedtime. Start date 1/4/22 - 03/23/22 - A&D Ointment. Apply to LLE topically as needed, wash extremity daily with warm soap and water-pat dry-apply A&D ointment for daily. Start date 1/3/22 - 3/23/22. - Profore (multi-layer compression bandage) dressing to left lower extremity to be changed at wound clinic every Friday. Check daily to ensure Profore is intact. Every dayshift for wound care. 3/24/22 - 4/15/22. There were no physician orders to reflect the wound consultant's recommendations from 1/18/22 - 4/15/22. A review of the Inter Disciplinary Team (IDT) notes from 12/03/21 through 4/28/22 revealed there was no documented evidence the hospital wound clinic recommendations were reviewed with the facility physician and implemented. During a telephone interview on 1/18/2023 at 8:58 AM, Registered Nurse (RN) #1 from the wound clinic stated orders for wound care were printed out after each visit, put in the patient's folder, and sent back to the facility. We write, 'see orders' on it and send it back in the patients folder. During an interview on 1/18/23 12:06, LPN #1 stated the supervisors or nurse managers handle outside consults. During an interview on 1/18/23 10:22 AM and 11:01 AM, RN #2, stated the recommendations from the hospital wound clinic dated 1/28/2022, 2/28/2022, 3/11/22 and 3/18/22 were not followed and should have been. During an interview on 1/18/23 at 1:32 PM, Medical Director (MD) stated they usually follow the recommendations from the wound consultant and that it was the facility's responsibility to make sure there was follow up on the consultants recommendations, and the orders should have been changed. The Medical Director stated the compression stockings should have been changed as recommended. During an interview on 1/18/23 at 10:28 AM, RN #9 they stated that they were Director of Nursing during 1/18/22 - 4/15/22. RN #9 stated they would have expected the nurses to have followed up on the recommendations from the wound clinic with the facility MD, orders written and the treatments completed as recommended. 2. Resident #2 was admitted to the facility with diagnoses including cerebral infarction with flaccid hemiplegia affecting right side (stroke with right sided weakness), PVD, and anxiety disorder. The MDS dated [DATE] documented Resident #2 required extensive assistance of one person for personal hygiene, toilet use, and dressing, did not exhibit behaviors for rejection of care and the resident was not interviewed for mental status. The MDS did not document any open ulcers. The Comprehensive Care Plan dated 3/19/19 documented Residents #2 had impaired skin integrity related to a reopened left shin vascular ulcer. Documented interventions included to apply treatment per the physician's order dated 3/19/19 and an intervention dated 2/23/22 to refer to appropriate medical specialist as needed for evaluation and treatment. In addition, the Comprehensive Care Plan dated 2/21/22 documented Resident #2 had a wound infection of their left leg. Interventions included to provide medication/treatment as ordered, evaluate site of infection and report relevant findings to the physician. The Progress Notes for Resident #2 dated 1/1/22 through 4/1/22 revealed the following: - 2/15/22 at 10:16 PM, RN #7 documented, Resident #2's left leg with multiple open festering sores, there is moderate amount bright red blood and yellow pus to these areas. Physician Assistant (PA #1) was called, informed of resident's condition; new order obtained: wound culture now. - 2/21/22 at 4:24 PM, PA #1 documented, Resident #2 being seen for a follow up concerning the wound on their left leg, per nursing staff resident has had the wound for several weeks now. Resident #2 stated that the wound does not cause pain. However, does complain of foul-smelling drainage from the wound. Assessment plan - Left leg wound infection: start Azithromycin (antibiotic) for 5 days, continue with regular wound care. - 2/22/22 at 4:57 PM, RN #8 documented, Resident #2 was seen on this date by wound consultant Nurse Practitioner (NP #1). Refer to assessments and recommendations: Right lateral foot: Vascular: 3 centimeters (cm) length (L) x 3 cm (W) x 0.1 cm depth (D). scant amount of exudate (drainage) no wound odor, unable to visualize wound bed; wash with warm soap and water daily, apply Xeroform dressing (sterile, non-adherent gauze containing petroleum jelly) to wound base daily, cover with a dry dressing. - 3/1/22 at 11:57 AM RN #2 documented; Left lateral shin - blister: 9 cm L x 6 cm W x 0.1 cm D, scant amount of exudate, no odor, surrounding tissue is normal, wash with warm soap and water daily - apply Xeroform dressing to wound base daily, cover with a dry dressing. - 3/8/22 at 11:57 AM, RN #2 documented wound assessment/ measurements completed. Left lateral shin blister: 5 cm L x 2 cm W x 0.1 cm D, scant amount of exudate, surrounding tissue is normal. Wash with warm soap and water daily, apply Xeroform dressing to wound base daily, cover with a dry dressing. Review of Resident #2's wound consultant notes dated 2/1/22 through 3/15/22 Wound Consultant NP #1 documented the following: - 2/22/22 Resident #2 was seen on follow-up for wound management. Resident has a history of a left lower extremity wound, facility provider evaluated the resident, started on an antibiotic and wound consultant was asked to re-evaluate the resident. Physical exam revealed partial thickness ulceration of the left lateral shin, measurements 3 cm x 3 cm x 0.1 cm, moderate purulent drainage noted. Plan documented to wash with warm soap and water daily, apply Xeroform dressing to wound base daily, cover with a dry dressing. - 3/1/22 Physical exam revealed partial thickness ulceration of the left lateral shin measurements 9 cm x 6 cm x 0.1 cm, wound base clean, pink, epithelial, no evidence of necrosis. Plan included wash with warm soap and water daily, apply Xeroform dressing to wound base daily, cover with a dry dressing. - 3/8/22 Physical exam revealed partial thickness ulceration of the left lateral shin measurements 5 cm x 2 cm x 0.1 cm, wound base clean, pink, epithelial, no evidence of necrosis. Plan included to wash with warm soap and water daily, apply Xeroform dressing to wound base daily, cover with a dry dressing. Review of Resident #2's Order Summary Report dated 1/1/22 through 6/1/22 revealed the following orders: - 2/21/22 wound consultant NP to evaluate and treat as needed. - 2/22/22 apply to left shin topically every-day shift for prevention, wash with warm soap and water daily, apply Xeroform dressing to wound base daily, cover with a dry dressing with an order status discontinued. - 3/8/22 treatment left lateral shin wash with warm soap and water daily, apply Xeroform dressing to wound base daily, cover with a dry dressing following for wound care with an order status discontinued. Review of the Treatment Administration Record (TAR) dated 2/1/22 through 2/28/22 revealed the following order: apply to left shin topically every- day shift for prevention, wash with warm soap and water daily, apply Xeroform dressing to wound base daily, cover with a dry dressing start date 2/23/22 discontinue date 2/22/22. There was no documented evidence a treatment was ordered and/or applied to the resident's left leg wound from 2/15/22 through 2/28/22. Review of the TAR dated 3/1/22 through 3/31/22 revealed the following order: Treatment left lateral shin: wash with warm soap and water daily, apply Xeroform dressing to wound base daily, cover with a dry dressing following every- day shift for wound care with a start date of 3/9/22. There is no documented evidence a treatment was ordered and/or applied to the resident's left leg wound from 3/1/22 - 3/8/22. During an interview on 1/18/23 at 10:23 AM, RN #2 stated they were the Assistant Director of Nursing (ADON) during the time frame of 2/2022 through 4/2022 and recalled Resident #2 having recurring left leg ulcers. RN #2 stated when an open wound was identified the PA or doctor should be notified and a treatment order obtain on 2/15/22. RN #2 reviewed the wound consultant's recommendation and stated the facility's process was the wound consultant's recommendations would have been sent to either them or RN #8, and forwarded to the PA or doctor for review and if the recommendation was approved they would initial the recommendation form and returned back to them or RN #8 to write the treatment order. RN #2 stated they believe RN #8 was responsible to ensure the orders were written during the time frame of 2/15/22 through 3/8/22. RN #2 reviewed Resident #2's medical record and identified 2/22/22 wound consultant's recommendations were not initialed by a provider and doesn't know if the recommendations were reviewed but should have been. Additionally, on 3/1/22 wound consultant's recommendations were initialed by PA (initials identified by RN#2) and the treatment orders should have been written. RN #2 reviewed Resident #2's TARS dated 2/15/22 through 3/8/22 and stated there was no evidence a treatment was ordered and applied to the resident's left leg ulcer between 2/15/22 through 3/8/22. RN #2 stated they did not know if the nurses were applying anything to the left leg ulcer. RN #2 stated they would have expected RN #8 to have ensured there was a treatment order in place to promote healing and prevent infection. The staff nurses should have brought it to their attention that there was not a treatment ordered. During an interview on 1/18/23 at 10:51 AM, wound consultant's NP #1 stated after they assess a resident the recommendations were sent to the facility's ADON, DON, Administrator and providers. It was the facility's responsibility to ensure orders were written to promote healing and prevent infection. During an interview on 1/18/23 at 12:06 PM, LPN #1 stated they were familiar with Resident #2 but unable to recall specifics related to treatments to resident's LLE. LPN #1 stated open skin ulcers should have a treatment ordered to promote healing. During an interview on 1/18/23 at 1:25 PM, the Medical Director (MD) stated they were familiar with Resident #2 and if the nursing staff identified Resident #2 had an open area on 2/15/22 they would have expected a provider (NP, PA, physician) to have been contacted and a treatment order obtained. The MD stated the wound consultant's recommendations should have been reviewed and initialed by a provider, and if initialed, the nursing staff were responsible to write the recommended treatment order. In addition,the MD stated they would have expected Resident #2's leg ulcer to have had a treatment ordered between 2/15/22 through 3/8/22. During an interview on 1/19/23 1:20 PM RN #9 stated, upon review of Resident #2's medical record there was no evidence a treatment was ordered and being completed to the resident's LLE between 2/15/22 through 3/8/22, and they would have expected a treatment to have been ordered and completed to promote healing and prevent infection. During an interview on 1/19/23 at 1:31 PM, PA #1 stated when they were notified there was an open area on the Resident #2's LLE on 2/15/22 they would have expected the nurse to have informed them they needed a treatment order. Additionally, when they initialed the wound consultant's recommendations on 3/1/22 they would have expected the nursing staff to have written the treatment orders as recommended and ensured a treatment was ordered and being applied between 2/15/22 through 3/8/22. During an interview on 1/19/23 at 2:04 PM, the Administrator stated they believed RN #8 was overseeing all wounds and would have expected them to have followed up to ensure treatment orders were in place and the wound consultant's recommendations were followed. RN #8 no longer was employed at the facility and no contact information available. NYCRR 415.12

Based on interviews and record review conducted during a Complaint investigation (Complaint NY#00276496) during the Standard survey completed on 9/22/21 the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one (Resident #1) of three residents reviewed for abuse. Specifically, there was a lack of an investigation completed by the facility to rule out abuse, neglect or mistreatment for a reported allegation that Resident #1 was pushed out of bed (OOB) by a staff member. The finding is: The facility policy and procedure (P&P) dated 2/2016 titled Abuse documented allegations/reports of suspected abuse, neglect shall be promptly and thoroughly investigated by the facility management. The Administrator and the Director of Nursing (DON) are responsible for investigating and reporting. The conclusion must include whether the allegation was substantiated or not and what information supported the decision. 1. Resident #1 was admitted with diagnoses including dementia, depression and seizure disorder. The Minimum Data Set (MDS- a resident assessment tool) dated 2/9/21 documented Resident #1 was usually understood, usually understands and was moderately cognitively impaired. The MDS documented Resident #1 required extensive assist of one person for transfers, dressing and hygiene. Review of the comprehensive Care Plan dated 6/2/21 revealed Resident #1 was at risk for falls and has had an actual fall related to (r/t) deconditioning and muscle weakness with interventions including attempt to prevent injury r/t resident noncompliance, resident self-transfers, attempts to self-ambulate and poor safety awareness. Review of the Fall Risk Assessment dated 4/20/21 revealed Resident #1 was at moderate risk for falls. Review of the Full QA Report dated 5/14/21 at 2:10 AM revealed Resident #1 was found on the floor (FOF) near the bathroom, resident in a hyperglycemic (high blood sugar) state with a blood sugar of 564. The resident was unable to recall the how the incident occurred or how the resident fell. The resident was noted to have a contusion (soft tissue injury) to their forehead and was unable to collect thoughts and answer questions appropriately. The report also documented Resident #1 was sent to the emergency room for evaluation and the health care agent was notified. Review of the progress note dated 5/14/21 at 3:26 AM revealed Resident #1 was FOF with a contusion to the forehead with an abrasion and scant amount of blood. The resident appeared to be confused, and the resident was unable to answer how the fall occurred. Review of the Complaint/Incident Report filed by the facility on 5/20/21 to the New York State Department of Health (NYSDOH) revealed the facility received a phone call from a family member allegedly stating that Resident #1 was transferred to the hospital on 5/14/21 because the resident was pushed OOB by a staff member, family member was unable to describe staff who pushed the resident OOB. The report further revealed the facility will continue to investigate the fall that occurred on 5/14/21. The facility could not provide documented evidence the allegation of the resident being pushed OOB was investigated. During an interview on 9/20/21 at 1:20 PM, the DON stated the investigation for the allegation filed by the facility on 5/20/21 for Resident #1 could not be located, the past DON reported the alleged allegation to the NYSDOH and was unsure if it was done. During an interview on 9/22/21 at 11:53 AM, the Corporate Registered Nurse (RN) stated that they would expect responsible staff to follow up on abuse allegations and to complete an investigation. During an interview on 9/22/21 at 11:55 AM, the Administrator stated they would expect a full investigation to be completed; including statements from staff on any abuse allegation and was unsure if one was completed. 415.4 (b) (3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the Standard survey completed 9/22/21, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and equipment to prevent further decrease in range of motion. Specifically, one (Resident #39) of two residents observed for range of motion (ROM-normal range of motion of a joint) services had issues with not having a palm guard to the left hand as recommended by OT (Occupational Therapy) and per Physician's order. The facility policy and procedure (P&P) titled Appliances - Splints, Braces, Slings revised 4/2019 documented therapy would evaluate residents for a device and order, fabricate, adjust splints/devices. Nursing ensured the proper schedule for donning (applying) and doffing (removal) the appliance was known by certified nursing assistant (CNA) staff, provided appropriate sign off of task options, ensured staff was aware where the device was to be stored and cared for, released devices/appliance per physician orders, and notified the rehabilitation department of any changes, modifications or repairs as needed. The P&P entitled Physician Orders dated 8/2019 documented that physician orders must be given and managed in accordance with applicable laws and regulations; and a physician's order was needed for diets, therapies and other treatments. The finding is: Resident #39 was admitted to the facility with diagnoses of cerebral infarction (also known as a stroke), hemiplegia (loss of strength or almost complete weakness in the half side of the body), and major depressive disorder. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/15/21 revealed the resident was cognitively impaired, usually understood and usually understands. The MDS documented the resident had functional limitations on one side of the upper extremities. Review of the Occupational Therapy Discharge summary dated [DATE] revealed resident would wear left palm guard at all times (AATs) removed for hygiene and clothing management to resident's tolerance to promote skin integrity and prevent skin breakdown. Review of the Clinical Physician Orders printed 9/22/21 revealed an order dated 4/26/21 that the left palm guard was to be worn at all times for contractures and removed for hygiene. Review of the Electronic Medical Record (EMR) on 9/15/21 revealed the comprehensive care plan documented a left palm guard at all times, to be removed for hygiene performed during care. Review of the EMR on 9/15/21 the [NAME] (a guide used by staff to provide care) documented, left palm guard at all times remove for hygiene performed during care. Review of the Treatment Administration Record (TAR) dated 9/1/21 through 9/20/21 revealed the left palm guard was initialed by Licensed Practical Nurse (LPN) #2 with the code of #9 (other / see nurses notes) for the dates of September 6, 7, 8, 9, 11, 12, 14, 15, 16, and 17 2021. There was no documented evidence the resident refused the left palm guard. Review of the Progress Notes dated 9/1/21 through 9/21/21 revealed there was no documented evidence the resident refused the left palm guard. Intermittent observations from 9/15/21 to 9/20/21 between 8:00 AM to 4:00 PM, revealed the resident did not have a palm guard in the left hand and the resident's fingers on their left hand were curled toward their palm. During an interview on 9/20/21 at 1:35 PM, LPN #2 stated the resident was supposed to have a left palm splint but noticed it was missing last week and they had informed the therapy department director and a left palm guard was being ordered for the resident. In another interview on 9/20/21 at 1:52 PM, LPN #2 stated the TAR is coded as a #9 for the left palm splint because they believed the code #9 meant that it was not available. LPN #2 stated they did not document the left palm guard was missing. During an interview on 9/20/21 at 1:39 PM, the Therapy Department Director stated they were not aware the resident has not had a left palm guard splint available, the resident was unable to donn or doff the splint independently and the splint should be applied as recommended to prevent further contractures. During another interview on 9/20/20 at 3:29 PM, the Therapy Department Director stated the facility didn't have a left palm guard splint available therefore a left palm guard splint was ordered and the resident will be provided a palm cushion to simulate a palm guard until the device was available. During an interview on 9/20/21 at 1:42 PM, Occupational Therapist (OT) #1 stated the resident should have the left palm guard on at all times except for hygiene to prevent further contractures and prevent the resident from digging their fingers into their hand. During an interview on 9/20/21 at 2:21 PM, CNA #4 stated they provided care to the resident on 9/17/21 and was unable to recall if the resident had a left palm guard splint. During an interview on 9/21/21 at 11:57 AM, CNA #1 stated they provided care to the resident on 9/20/21 and didn't recall applying a left palm guard splint and was unaware when it came up missing. During an interview on 9/21/21 at 12:05 PM, Registered Nurse Unit Manager (RN UM) #2 stated they were not aware the resident's left palm guard was missing until 9/20/21 and they should have been notified. RN UM #2 stated the therapy department should have been notified immediately to either replace the palm guard or provide another device if one was not available. RN UM #2 stated if a nurse used the #9 code on the TAR there should be a nurse's progress note with an explanation documented. During an interview on 9/21/20 at 12:27 PM, the Director of Nursing (DON) stated they expected the nursing department to follow recommendations to apply the left palm guard splint and if it was missing, the CNAs should have notified the nurses. The nurses should then inform the UM, the therapy department, and when necessary notify the provider to place the splint on hold if one was not available. The DON stated they expected the nurse to document in the progress notes if they were unable to locate the splint. The DON stated they expected the therapy department to have extra splints in stock for replacements and for any newly identified residents that needed a left palm guard splint. During an interview on 9/21/21 at 3:36 PM, the Administrator stated they expected the left palm guard to be applied as recommended and as ordered. If it was not available therapy department should have been notified immediately. The Administrator stated they expected the therapy department to have extra splints in stock. 415.12 (e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 9/22//21, the facility did not ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for three (Resident #56, #100, and #452) of four residents reviewed for respiratory care. Specifically, Residents (#56, #100 and #452) on continuous O2 (oxygen) and/or nebulizer treatments did not have routine tubing changes and/or external concentrator filters were soiled and covered with thick dusty grey debris. Additionally, there was lack of physician orders for the use of continuous O2 (#452). Review of facility policy and procedure (P&P) titled Oxygen Concentrators revised 1/2020 documented oxygen is administered is administered by licensed nurses with a physician's order to provide a resident with sufficient oxygen to their blood and tissues. Orders should specify the oxygen equipment and flow rate, or concentration required as routine or PRN (as needed). Oxygen equipment will be checked daily for correct set up, connection of equipment, correct flow and concentration. Procedures included the following: -Rear filter should be checked daily and cleaned with soap and water as needed. -Oxygen tubing will be changed at least weekly, or as needed based on soiling/breeches in infection control; date and initial tubing when changed. -Do not operate concentrator without a filter in place or with a dirty filter. Review of P&P titled Physician Orders dated 8/2019 documented physician orders must be given and managed in accordance with applicable laws and regulations. Orders, no matter the route of obtaining, must be transcribed to elected EHR (electronic health record) system and follow appropriate order policies for ensuring accuracy. A physician's order is needed for medications, diets, therapies, and other treatments. 1. Resident #56 had diagnoses including chronic obstructive pulmonary disease (COPD- a condition involving constriction of the airways and difficulty in breathing), depression and end stage renal disease. The Minimum Data Set (MDS- a resident assessment tool) dated 7/23/21 documented the resident was understood, understands and was cognitively intact. Further review of the MDS revealed Resident #56 was on O2 therapy while in the facility. Review of the CCP dated 12/9/16 revealed Resident #56 had an alteration in their respiratory system related to (R/T) COPD as evidence by shortness of breath (SOB) and chronic respiratory failure. Interventions included to administer nebulizer treatments and medications per MD order, O2 per MD order and maintain/change tubing per protocol. Review of the Treatment Administration Records (TAR) dated 7/1/21 through 8/31/21 revealed there was no documented evidence to change/clean the O2 concentrator filter or to change the nebulizer and O2 tubing tubing. Review of the Clinical Physicians Orders dated 5/27/20 revealed O2 at 3.5 liters by nasal cannula (NC) continuous, for COPD, change O2 tubing weekly and clean O2 concentrator filter weekly. There was no documented MD order of when to change the nebulizer tubing. Additional review revealed Resident #56 had orders for nebulizer treatments and were being administered. During an observation on 9/16/21 at 9:05 AM revealed the O2 concentrator was not in use and the filter located on the back of the concentrator was soiled with thick grey dusty debris. The O2 tubing connected to the concentrator was a piece of ripped white tape not dated or labeled and the nasal tips were brown in color. The nebulizer tubing connected to the nebulizer located on the bed side table was dated 5/19/21 with a white piece of tape. During an observation on 9/17/21 at 8:59 AM the Resident was in bed sleeping, O2 concentrator was in use, the O2 tubing connected to the concentrator was a piece of ripped white tape not dated or labeled. The filter on the back of the O2 concentrator was covered with thick dusty grey debris. The nebulizer tubing connected to the nebulizer located on the bed side table was dated 5/19/21. During an observation on 9/20/21 at 9:45 AM revealed the O2 concentrator was not in use and the filter located on the back of the concentrator was soiled with thick grey dusty debris. The O2 tubing connected to the concentrator where was a piece of ripped white tape not dated or labeled and the nasal tips were brown in color. The nebulizer tubing connected to the nebulizer located on the bed side table was dated 5/19/21. During an observation on 9/21/21 at 8:50 AM revealed the O2 concentrator was not in use and the filter located on the back of the concentrator was soiled with thick grey dusty debris. The O2 tubing connected to the concentrator was a piece of ripped white tape not dated or labeled and the nasal tips were brown in color. Additionally, there was a second new piece of white tape on the tubing dated 9/20/21. The nebulizer tubing connected to the nebulizer located on the bed side table was dated 5/19/21. Review of the September TAR dated 9/1/21 through 9/30/21 revealed to change the O2 concentrator filter and tubing weekly every Wednesday starting on 9/22/21. There was no documented evidence on when the nebulizer tubing should be changed. During an interview on 9/21/21 at 9:19 AM, LPN #3 stated the nurses were responsible for changing the tubing and cleaning the filters, was unsure how often they should be changed as nights shift was responsible. It's on the TAR to let staff know when it needs to be done. 2. Resident #100 had diagnoses including tracheostomy (an opening in the neck in order to put a tube into a person's windpipe allowing air to enter the lungs), bacterial pneumonia, and quadriplegia (paralysis from the neck down). The MDS dated [DATE] documented the resident was rarely/never understood and rarely/never understands. Further review of the MDS documented the resident received O2 therapy and tracheostomy care while in the facility. Review of the Comprehensive Care Plan (CCP), identified as current, documented the following: Date initiated 9/29/18- Alteration in respiratory system related to (r/t) CVA (stroke); alteration in neurological function, resident has tracheostomy tube with intervention to provide O2 per MD orders. Maintain/change tubing per protocol. Date initiated 11/24/20-Resident at risk for infection related to impaired immunity, risk of aspiration and history of pneumonia with intervention for trach care as ordered. Date initiated 9/12/21-Resident has respiratory infection with intervention to provide medication/treatment as ordered. Intermittent observations 9/16/21 through 9/21/21 revealed the following: -9/16/21 at 11:40 AM Continuous O2 via trach collar. External concentrator filter soiled with thick grey dusty debris. -9/17/21 at 10:37 AM Continuous O2 via trach collar. External concentrator filter soiled with thick grey dusty debris. -9/17/21 at 11:35 AM Continuous O2 via trach collar. External concentrator filter soiled with thick grey dusty debris. -9/20/21 at 09:01 AM Continuous O2 via trach collar. External concentrator filter soiled with thick grey dusty debris. -9/21/21 at 08:40 AM Continuous O2 via trach collar. External concentrator filter soiled with thick grey dusty debris. Review of the Medication and Treatment Administration Record (MAR/TAR) dated 8/1/21 through 8/31/21 and 9/1/21 through 9/30/21 lacked documented evidence of oxygen concentrator filter cleansing/changes. Additional review revealed the resident received Levaquin, for pneumonia, for 14 days each on 8/3/21 and 9/11/21. During an interview on 9/20/21 at 8:43 AM, the Respiratory Therapist (RT) stated nursing was responsible for oxygen tubing changes and concentrator filter cleaning and it should be done once weekly. Additionally, the RT stated Resident #100 was very susceptible to infections and was getting treated for pneumonia. During observation and interview on 9/20/21 at 9:01 AM, Licensed Practical Nurse (LPN) #9 stated they worked for an agency, but it depends on facility policy how often O2 concentrator filters are cleansed or changed. They stated that should be indicated on the MAR/TAR. With a gloved hand LPN #9 scraped the external filter of Resident #100 concentrator filter removing a large portion of thick grey dusty debris and stated the filter was dirty and appeared as though it had not been cleansed or changed in quite some time During interview on 9/21/21 at 10:49 AM, the RT (Respiratory Therapist) stated they observed the external filter on Resident #100 concentrator, and stated the filter was quite dirty, and required changing. 3. Resident #452 had diagnoses including asthma, diabetes, and congestive heart failure (CHF). The MDS dated [DATE] documented the resident was cognitively intact, understands and was understood. Review of the CCP, identified as current, documented the following: Date initiated 12/1/2016- Alteration in cardiovascular function r/t to CHF with intervention to assess O2 needs and provide as ordered by the MD. (2 liters per minute (LPM) via NC. Date initiated 1/11/2019- Alteration in respiratory system r/t asthma with interventions including observe for signs/symptoms of poor airway clearance and gas exchange. Provide O2 per MD orders. Maintain/change tubing per protocol. Review of hospital Discharge summary dated [DATE] documented discharge instructions that included oxygen via nasal cannula at 2 liters (L) per minute. Review of Nursing admission Evaluation Progress Note dated 9/13/21 at 4:30 PM documented respiratory evaluation of oxygen per orders. Intermittent observations 9/15/21 through 9/21/21 revealed the following: -9/15/21 at 9:14 AM O2 via concentrator at 3L via NC. Oxygen tubing was not labeled/dated. -9/15/21 at 12:22 PM O2 via concentrator at 3L via NC. Oxygen tubing was not labeled/dated. -9/16/21 at 10:10 AM O2 via concentrator at 3L via NC. Oxygen tubing was not labeled/dated. -9/17/21 at 12:30 PM O2 via concentrator at 3L via NC. Oxygen tubing was not labeled/dated. -9/17/21 at 2:35 PM O2 via concentrator at 3L via NC. Oxygen tubing was not labeled/dated. -9/20/21 at 8:30 AM O2 via concentrator at 3L via NC. Oxygen tubing was not labeled/dated. -9/21/21 at 10:42 AM O2 via concentrator at 3L via NC. Oxygen tubing was not labeled/dated. Review of EHR Orders 9/15/21 through 9/21/21 at 10:50 AM, revealed the lack of a physician order for continuous O2, oxygen tubing and/or filter cleansing/changes. Review of the MAR/TAR dated 9/1/21 through 9/30/21 lacked documented evidence of a physician order for oxygen, tubing changes, and/or filter cleansing/changes. During an interview on 9/20/21 at 8:42 AM, LPN #8 stated they worked for an agency but if a resident was observed on oxygen that was not reflected in the EHR they would confirm the order in the EHR. If there was no order in the EHR they would notify the Unit Manager or call the MD to confirm the order and verify the flow rate. LPN #8 stated they would follow the orders for changing oxygen tubing and stated they have never changed or cleaned a filter on an oxygen concentrator. During an interview on 9/21/21 at 8:37 AM, LPN #7 stated nurses are responsible for changing oxygen tubing, cleaning concentrators with bleach wipes, and replacing or cleaning filters. It should be done weekly. The Nurse Manager (NM) was responsible to enter the order in the EHR so nurses passing medications and administering treatments can sign it out on the MAR. During an interview on 9/20/21 at 8:43 AM, the Respiratory Therapist (RT) stated nursing was responsible for oxygen tubing changes and it should be done once weekly. During an interview on 9/20/21 at 8:47 AM, Registered Nurse (RN) #3 Unit Manager (UM) stated they had just recently started working at the facility, but oxygen tubing and filter cleaning/changes are usually done once per week. They stated O2 can be applied as a nursing judgement, but the MD should be updated, and order received for continuous or as needed (PRN) use of oxygen. Additionally, on 9/22/21 at 12:38 PM, RN #3 UM stated there should be a physician's order for O2 and they were unaware Resident #452 was missing the order. During an interview on 9/21/21 at 10:07 AM, the Director of Nursing (DON) and Regional RN stated there should be an order in the EHR for PRN and continuous use of oxygen so staff can confirm the prescribed flow rate. The expectation was that tubing should be changed and labeled weekly. Concentrator external filters should be changed weekly by nursing. During observation and interview on 9/21/21 at 10:42 AM, Regional Resource Nurse Manager (RRNM) stated they went through the whole facility and changed/labelled all oxygen tubing last week. The Regional Resource Nurse Manager stated there should be an order if a resident is utilizing O2. On observation of Resident #452 RRNM stated the tubing was not labelled and should be. That is my fault. I should have labelled and signed them out but, didn't. I must have missed this one. Additionally, they stated if it does not appear on the MAR/TAR that tubing is due for change or filter due for cleaning a nurse passing medication would have no way of knowing when it was due for change. I would expect if a nurse observes a resident wearing O2 that they enter the order for weekly change, per policy. 415.12 (k)(6)

Based on observation, interview, and record review during the Standard survey completed on 9/22/21, the facility did not dispose of garbage and refuse properly. Specifically, waste was not properly contained outside of the facility in closed dumpsters, and torn bags of garbage and loose debris were observed on the ground around the dumpsters, which created potential feeding and harborage areas for pests. The finding is: According to the facility policy and procedure called, Food-Related Garbage and Refuse Disposal, revised October 2017, garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests and outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. Additionally, according to the facility policy and procedure called, Grounds, revised May 2008, maintenance shall be responsible for keeping the grounds free of litter Observation on 9/15/21 at 11:50 AM revealed two garbage dumpsters were located in a fenced-in area that measured twenty feet long by ten feet wide, near the employee entrance. Further observation revealed the garbage dumpster on the left had one of two lids open, both of its sliding doors were open, and the level of the garbage inside reached the height of the sliding doors. The garbage dumpster on the right had both sliding doors open and the level of the garbage inside reached the height of the sliding doors. Additionally, there were six full clear garbage bags that were ripped open, and two intact full clear garbage bags located on the ground, outside of the dumpsters, within the fenced-in area. Continued observation at this time revealed food items, disposable personal protective equipment (PPE), empty food containers, and plastic utensils were scattered on the ground inside the fenced-in area. A rodent bait box was also observed in the fenced-in area. During an interview at the time of the observation, the Maintenance Director stated the items on the ground appeared to be dietary items, and was not sure which department was responsible for maintaining the garbage dumpster area. Also, at this same time, Dietary Aide #1 approached the garbage dumpster area, placed garbage bags inside the open sliding door of the garbage dumpster, and left the area without closing any of the dumpster sliding doors or lids. During an interview while leaving the garbage dumpster area, Dietary Aide #1 stated, The items that are on the ground are from the Housekeeping department because the Housekeeping department uses clear bags and the Dietary department uses black bags. The Housekeeping and Maintenance departments maintain this area. I usually close the dumpsters' sliding doors, but did not do it this time because I am planning on coming back soon with another load. During an interview on 9/15/21 at 12:55 PM, the Supervising Administrator stated the Dietary, Maintenance, and Housekeeping departments are all responsible for maintaining the garbage dumpster area. The Supervising Administrator also stated the garbage dumpsters must always be kept shut and gates to the fenced-in area must remain closed. During an interview on 9/15/21 at 4:00 PM, the Environmental Director stated the garbage dumpsters get emptied every weekday from Monday through Friday, but over the weekend, the garbage dumpsters get full and people start throwing garbage bags on the ground. The Environmental Director further stated the dumpsters' sliding doors and lids should be kept closed at all times and the Maintenance department is responsible for maintaining this area. The Environmental Director added that the Housekeeping department does not normally do rounds of this area, but is currently helping out because of the recent change in Maintenance Directors and the last time this area was cleaned was Thursday, 9/9/21. Observation on 9/17/21 at 7:30 AM revealed there were five intact full clear garbage bags located on top of the closed lids of the garbage dumpster on the left. The garbage dumpster on the right had both lids open and one of two sliding doors was half-open with a bag of garbage sticking out. During an interview on 9/17/21 at 2:30 PM, the Food Service Director stated the Maintenance and Housekeeping departments maintain the garbage dumpster area. The Food Service Director further stated, The garbage dumpster lids and sliding doors must be kept closed at all times, and if anything is on the ground, it should be picked up. Normally, the garbage dumpsters are emptied each weekday, and if a Dietary staff member notices that they are full, they are supposed to tell me and I will call Maintenance or Housekeeping and let them know to call the pickup company. The Food Service Director also stated there was a car parked in front of the gates of the fenced-in garbage dumpster area this morning, which delayed pickup. Observation on 9/20/21 at 7:35 AM revealed three full clear garbage bags were on the ground between the garbage dumpsters in the fenced-in area. Each garbage bag was ripped and items, including used Styrofoam food containers, plates, cups, and plastic utensils, were scattered on the ground in the fenced-in area. During an interview on 9/20/21 at 8:00 AM, the Environmental Director stated both garbage dumpsters were already picked up this morning, but over the weekend, the garbage dumpsters were totally full, and people left bags on the ground. The Environmental Director further stated staff must clean up the bags because squirrels rip the bags and scatter the items. Review of the licensed exterminator's Service Slip dated 8/11/21 revealed, Monthly pest control: inspected and maintained all bait stations, high activity noticed while maintaining exterior stations. 415.14(h) 14-1.150

Based on observation interview and record review conducted during the Standard survey completed on 9/22/21, the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, certified nurse aide (CNA) Swab Technician (Tech) #2 did not utilized appropriate PPE (personal protective equipment) while collecting COVID-19 specimens for one of one employee observed (Physical Therapist #1). The finding is: The policy and procedure (P&P) titled Covid 19 Testing of Staff dated 7/5/21 documented all personal will be trained on infection control policies and practices upon hire and periodically thereafter, including where and how to find pertinent equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. The Centers for Medicare and Medicaid Services (CMS) QSO-20-38-NH revised 4/27/21, Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID19 Focused Survey Tool, documented: During specimen collection, facilities must maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown, when collecting specimens. During an observation on 9/15/21 at 1:19 PM in facility beauty shop CNA/Swab Tech #2 preformed a COVID -19 nasal swab specimen collection on Physical Therapist #1 wearing a surgical mash and gloves only. During an interview on 9/15/21 at 1:50 PM, CNA/Swab Tech #2 stated they have been employed with the facility for six months and was hired just to perform COVID-19 swabbing of facility staff. CNA/Swab Tech #2 stated they were educated by the facility on proper technique of performing COVID-19 testing and the use of PPE. The CNA/Swab Tech #2 stated they tested 23 staff for COVID-19 on that day (9/15/21). Additionally, CNA/Swab Tech #2 stated, when they first started swabbing for COVID-19 they would wear full PPE which included a gown, gloves, goggles, and N95 mask, but as more and more staff were vaccinated, when swabbing staff, they only have to wear a surgical masks and gloves. During an interview on 9/17/21 at 2:59 PM, the Infection Control Nurse stated they would expect the COVID-19 swabber to wear a surgical mask and gloves when swabbing staff, maybe goggles. If the facility was in an outbreak for COVID-19 they would expect the swabber to wear full PPE including N95 mask, gown, and goggles. The Infection Control Nurse further stated the facility was not in an outbreak as there were no COVID-19 positive residents in the facility, and only one staff member was out of work and on quarantine for testing positive for COVID-19. During an interview on 9/21/21 at 1:36 PM, the Regional Educator and Assistant Director of Nurses (ADON) revealed they would expect the COVID-19 swabber to wear surgical mask, eye protection and a gown when swabbing, and an N95 mask if the facility was in an COVID-19 outbreak. The interview further revealed an outbreak would consist of a positive resident in the facility for COVID-19. During an interview on 9/22/21 at 11:24 AM, the Corporate Registered Nurse (RN) and the Director of Nursing (DON) stated the facility was in outbreak due to a positive staff member and would expect staff swabbing staff for COVID-19 to wear full PPE to include gown, gloves, eye protection and a N95 mask. 415.19 (a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 9/22/21, the facility did not ensure that the physician signed and dated all orders, with the exception of influenza and pneumococcal vaccines, for 23 (Resident #7, 8, 9, 19, 22, 23, 27, 36, 39, 48, 52, 56, 62, 72, 83, 89, 95, 100, 101, 112, 146, 148, and 452) of 29 residents reviewed for physician orders. Specifically, the facility did not ensure that the physician or non-physician provider evaluated the resident's current medication regimen and renewed orders in the electronic medical record (EMR) at least every 60 days. The findings are but not limited to: Review of facility policy and procedure (P&P) titled Physician Visits revised 5/2019 documented the Attending Physician must visit his/her patients at least once every 30 days for the first 90 days following the resident's admission, and then at least every 60 days thereafter. Non-physician practitioners (Physician Assistant, Nurse Practitioner) may perform required visits (except initial), sign orders and sign certifications, re-certifications as permitted by State and Federal regulations. A P&P titled Physician Orders dated 8/2019 documented physician orders must be given and managed in accordance with applicable laws and regulations. Orders, no matter the roust of obtaining, must be transcribed to elected EHR (electronic health record) system and follow appropriate order policies for ensuring accuracy. Facilities will determine process for physician signature of paper or electronic. Electronic signatures, if used, must be a process in place for all Attending Physicians and cannot be for a selected amount. Physician orders must be renewed in compliance with applicable State and Federal regulations. A physician's order is needed for medications, diets, therapies, and other treatments. 1. Resident #48 was admitted with diagnoses including major depressive disorder, anxiety disorder and diabetes. The Minimum Data Set (MDS- a resident assessment tool) dated 7/21/21 documented the resident was cognitively impaired, sometimes understood and usually understands. Review of the EMR Physician's Orders on 9/17/21 revealed that Standing and Routine orders had not been signed or dated by the Provider since 4/27/21. Review of the Order Review History printed 9/22/21 revealed orders were signed on 9/21/21 and previously signed on the following dates: 4/27/21 and 10/15/20. 2. Resident #62 was admitted to the facility with diagnoses including hypertension (HTN-high blood pressure), major depressive disorder, and dementia. The MDS dated [DATE] documented the resident had moderately cognitive impairment, understands and was understood. Review of the EMR Physician's Orders on 9/17/21 revealed that Standing and Routine orders had not been signed or dated electronically by the Provider since 4/27/21. Review of the Nurse Practitioner (NP) visit note revealed the resident was seen on 9/15/21 by the provider. Review of the EMR Order Review History revealed orders were 118 days overdue for signature. Last signed by the provider on 4/27/21 and the next date due for review/signature was 5/25/21. 3. Resident #452 was admitted with diagnoses including asthma, diabetes, and congestive heart failure (CHF). The MDS dated [DATE] documented the resident was cognitively intact, understands and was understood. Review of the EMR Physician's Orders on 9/17/21 revealed that Standing and Routine orders had not been signed or dated by the provider since 4/27/21. Review of the Nurse Practitioner visit note dated 9/18/21 revealed the resident was seen on this date by the provider. Review of the EMR Order Review History revealed orders were 118 days overdue for signature. Last signed by the provider on 4/27/21 and the next date due for review/signature was 5/25/21. On 9/21/21 the facility further provided emails from the Pharmacy dated 2/25/21 and 6/16/21 revealed the Pharmacy Representative informed the Administrator of 9 pages of orders pending signatures on 2/25/21 and 3 pages of orders pending signatures pending on 6/16/21 and unable to process orders for delivery. During an interview on 9/21/21 at 9:53 AM, Registered Nurse (RN) #2 Unit Manager (UM) stated there are over-due orders that needed to be signed by the physician / provider. New orders are written, signed and as orders are revised every 60 days, they are to be signed by the provider. RN #2 was not aware of who keeps track of over-due orders to be signed. During an interview on 9/21/21 at 11:27 PM and 1:44PM, the Physician stated they were aware of the pending orders due for signature because they get the reports at other facilities. These reports show the orders that are due for signature. The providers here alternate seeing the residents. We all see them, and no one is signing the orders, because no one is tracking them. We would all do it if the facility was tracking who was due for signatures. If we had a list of who needed to be reviewed and signed. We have a systems problem here. It has been an issue here for the last year that has fallen by the wayside since COVID. During an interview on 9/21/21 at 1:51 PM, the Director of Nursing (DON) stated new physician orders are to be signed as soon as possible and monthly orders are to be signed every 60 days after the initial 30 day and 90 day from admission. The DON stated they are not aware of the facility policy or the facility's system for tracking unsigned physician orders. On 9/22/21 at 9:43 AM, the DON stated the facility was in the process of changing Medical Provider Groups due to ongoing issues regarding the lack of timely physician order signatures. The DON stated medications were not current without timely Provider signatures and therefore should not be administered. The Pharmacy Representative identified orders pending for signatures and would email the facility with the number of pages with outstanding signatures from EMR. The Supervising Administrator communicated with the Providers and requested the orders be signed. The DON stated they expected Providers signed orders during each resident visit. During an interview on 9/21/21 at 1:53 PM, the Regional RN stated the providers should be looking at the orders and ensuring they are signed timely. The Medical Director will be assisting the facility to develop a system. During an interview on 9/21/21 at 3:03 PM, the Administrator stated the providers are to make sure the orders are signed timely, an e-mail is generated to the providers to inform them if there are over-due orders that need to be signed. During an interview on 9/22/21 at 8:43 AM, RN #4 UM stated they were unaware of an issue and orders were entered under the provider's name in EMR and the provider would sign the order. During an interview on 9/22/21 at 10:10AM the Supervising Administrator stated they were aware of the ongoing issues with provider signatures and was unsure how to get the Providers to electronically sign their orders. During an interview on 9/22/21 at 10:46AM the Medical Director stated they were aware of the orders not signed timely and was not aware of the orders pending report in EMR. The nurses should be more careful what provider they selected when inputting the orders into EMR. The orders were not physically printed out to sign. The Medical Director stated they attend Quality Assurance meetings virtually and occasionally in person and no plan had been implemented. During an interview on 9/22/21 at 12:32 PM, RN #3 UM stated they were aware orders needed to be signed by the physician/provider every 30, 60, and 90 days and were not aware of who keeps track of physician visits and/or orders. 415.15(b)(2)(iii)

Based on observation, interview, and record review conducted during a Standard survey completed on 9/22/21, the facility did not ensure that residents who receive a psychotropic medication have gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #95) of five residents reviewed for antipsychotic medication use. Specifically, there was a lack of an attempt of a GDR for a resident receiving Seroquel (antipsychotic medication) since September 2019. The finding is: The facility P&P titled Psychotropic Medication Gradual Dose Reduction dated 8/2019 documented that all medications can be tapered and tapering of antipsychotics are referred as gradual dose reduction. Further review of the P&P documented that residents who use antipsychotics shall receive gradual dose reduction unless contraindicated. The facility policy & procedure (P&P) titled Psychotropic Medication revised on 7/2019 documented that physicians and mid-level providers will use psychotropic medication appropriately working with an interdisciplinary team to ensure appropriate use, evaluation and monitoring. The facility P&P titled Antipsychotic Medication Use revised on 7/2019 documented that antipsychotic medications may be considered for residents with dementia as long as causes of behavioral symptoms are investigated. The P&P further states that the antipsychotic medication should be at the lowest dose and for the shortest amount of time. 1. Resident #95 had diagnoses of dementia and chronic obstructive pulmonary disease. The Minimum Data Set (MDS - a resident assessment tool) dated 8/4/21 documented Resident #95 was severely cognitively impaired, sometimes understands and sometimes understood. The MDS documented that there was no gradual dose reduction (GDR) attempted or that a GDR was clinically contraindicated by a physician. Further review of the MDS revealed that Resident #95 did not have any rejection of care or aggressive behaviors. During intermittent observations of Resident #95 conducted during the survey period of 9/15/21 to 9/22/21 from 7:00 AM to 2:00 PM revealed Resident #95 sleeping in their room; self-propelling their wheelchair around the facility with dolls on their lap; and eating lunch. There were no violent outbursts or striking out at staff or residents during these observations. Resident #95's undated care plan documented that the resident had behaviors of being socially inappropriate, verbally aggressive, and physically aggressive at times. Review of the Consultant Pharmacist's Medication Regimen Review (MRR) dated 12/11/19 revealed that the Pharmacist did not make any recommendations for medication changes or GDRs. An interview with the Director of Nursing (DON) at the time of receiving the documents, the DON stated that they could not locate any other MRR reports for Resident #95 before 12/2019. Review of the Consultant Pharmacist's Psychotropic & Sedative/Hypnotic Utilization by Resident dated from March 2020 to August 2021 revealed that Resident #95 was started Seroquel on 9/9/2019 and that no GDR was attempted. An interview with the DON at the time of receiving the documents, the DON stated that they could not find other reports but that the Pharmacist may have them. Review of physician orders for Resident #95 from 9/9/2019 to present (9/17/21) revealed Resident #95 had been receiving Seroquel 50 milligrams (mg) by mouth once a day and 75 mg at bedtime. Review of the current Medication Administration Records (MAR) dated 9/1/21 to 9/17/21 revealed the resident was still receiving Seroquel 50 milligrams (mg) by mouth once a day and 75 mg at bedtime. Review of the facility Behavior Modifying Agent and Review Committee (BMARC) Follow Up Review dated 8/18/21 revealed that the committee agreed that Resident #95's Seroquel dose should not be reduced, however, there was no documented rational as to why it should not be reduced, and that section was left blank. During an interview on 9/17/21 at 9:55 AM, the Consultant Pharmacist stated that medication reviews were done monthly. They stated that they keep track of when a resident was started on psychotropic medications and when a GDR attempt was needed. The Consultant Pharmacist stated that they believed a GDR must be attempted at least once in the first year of the medication and twice in the second year unless it's contraindicated. During an additional interview on 9/20/21 at 11:50 AM, the Consultant Pharmacist stated that they had no GDR attempt documented for Resident #95. During an interview on 9/20/21 at 8:53 AM, the Director of Social Work stated that Resident #95 should have had a GDR attempt done on her antipsychotic medication. During an interview on 9/21/21 at 11:21 AM, the Nurse Practitioner (NP), stated they were not aware of any GDR attempts on the medication (Seroquel) for Resident #95. During an interview on 9/22/21 at 12:31 PM, the DON stated that GDRs were done by a case-by-case basis with the IDT team. They stated that every resident on psychotropic medications were reviewed at the BMARC August 2021. They were not aware that the BMARC Follow Up Review was missing a reason for the contraindication of a GDR. 415.12 (i)(2)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 9/22/21, the facility did not ensure that the Quality Assessment and Assurance (QAA) 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 QAA Committee identified an issue involving the lack of timely Provider signatures of Physician Orders since November 2020. The facility identified corrective actions which were not effective, and the plan was not revised. The finding is: Refer to F 711 - Physician Services - Scope and Severity E. Review of a facility policy and procedure (P&P) entitled Quality Assurance and Performance Improvement Program (QAPI) Program dated 4/2014 revealed the facility shall develop, implement, and maintain an ongoing, facility wide Quality Assurance and Performance Improvement (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals. Performance Improvement Projects(PIPs) are initiated when problems are identified. PIPs involved systemically gathering information to clarify issues and to intervene for improvements. Review of a facility P&P entitled Quality Assurance and Performance Improvement Program (QAPI) Plan dated 4/2014 revealed objectives of the QAPI Plan were to provide a means to identify and resolve present and potential negative outcomes related to resident care and services; Provide structure and processes to correct identified quality and or safety deficiencies; Establish and implement plans to correct deficiencies, and to monitor the effects of theses action plans on resident outcome; Help departments, consultants, and ancillary services that provide direct or indirect care to residents to communicate effectively, and to delineate lines of authority, responsibility, and accountability. During an interview on 9/15/21 at 8:51 AM, the Acting Administrator stated the QAA Committee met monthly and the Medical Director phoned into the monthly meeting and attended meetings quarterly. During an interview on 9/22/21 at 9:43 AM, the Director of Nursing (DON) stated the facility was in the process of changing Medical Provider Groups due to ongoing issues regarding the lack of timely physician order signatures since November of 2020. Signatures were addressed during face-to-face conversations between the Supervising Administrator and the Providers. The DON stated medications were not current without timely Provider signatures and therefore should not be administered. The Pharmacy Representative identified orders pending for signatures and would email the facility with the number of pages with outstanding signatures from (name of computer system). The Supervising Administrator stated they communicated with the providers over a 2 year period and requested the orders be signed. The DON stated they expected Providers signed orders during each visit and no additional tracking system was implemented. During an interview on 9/22/21 at 10:10 AM, with the DON present, the Supervising Administrator stated the lack of timely physician's order signatures was identified in November 2020. The lack of physician signatures on orders were discussed at the QAA meetings on [DATE] and May 2021. During further interview on 9/22/21 at 11:05 AM, the Supervising Administrator stated themselves and the previous DON kept emailing and having conversations with the providers including the Medical Director. The Supervising Administrator stated the conversations were not documented and the issue was not resolved. 415.27(a,c)(3)(v)