Based on interviews during the recertification survey conducted 11/21/2024-12/4/2024, the facility did not ensure a private space for monthly Resident Council Meetings. Specifically, 5 of 5 anonymous residents present at the resident group meeting stated the facility arranged monthly Resident Council meetings in the first floor dining room where uninvited staff were also present. Findings include: The facility policy, Resident Rights, documented all residents had the right to self-determination, confidentiality, and to communicate in person with privacy. The facility policy, Resident Council, dated 2/2021, documented staff, visitors, and other guests may attend resident council meetings if they were invited by the respective resident group. The resident council group was provided with space, privacy, and support to conduct meetings. During a resident group interview on 11/21/2024 at 1:59 PM, 5 of 5 residents stated the monthly Resident Council meetings were not held in a private space. The meetings were held in the first floor dining room and staff, usually the Director of Social Work and the Director of Activities, were always present because the residents were told they had to be supervised. The Director of Social Work and the Director of Activities were not invited to attend the meeting by the members. The Resident Council members were not aware they could request a private space for meetings without staff present. During an interview on 12/3/2024 at 10:11 AM, the Director of Activities stated the Resident Council meetings were always the third Thursday of the month and were held in the first floor dining room. The residents were not allowed to be in the dining room unattended, so they had to attend the Resident Council meetings. They had to miss care conference meetings on the resident council meeting days because they had to be present for the resident council meeting. During an interview on 12/3/2024 at 1:28 PM, the Director of Social Work stated they attended the Resident Council meetings as a second person and the meetings were run by the Director of Activities. Staff needed to be present for resident supervision during Resident Council meetings therefore the meetings could not be held without staff present. 10NYCRR 415.5(c)(1-5)

Based on record review and interviews during the recertification survey conducted 11/21/2024-12/4/2024, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for 3 of 3 residents (Residents #28, #38, and #223) reviewed. Specifically, Residents #28 and #38 remained in the facility after discontinuation of Medicare Part A services with benefits remaining and the facility did not provide timely Notice of Medicare Non-Coverage (Centers for Medicare and Medicaid Services-10123) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (Centers for Medicare and Medicaid Services-10055) as required; and Resident #223 was discharged from the facility and was not provided timely Notice of Medicare Non-Coverage (Centers for Medicare and Medicaid Services-10123) as required. Findings include: The Center for Medicare and Medicaid Services form instructions for the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage Center for Medicare and Medicaid Services-10055, expiration date 1/31/2026, documented a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (form 10055) must be issued by providers to beneficiaries in situations where Medicare payment was expected to be denied. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage must be delivered far enough in advance that the beneficiary or representative had time to consider the options and make an informed choice prior to services ending. The 9/19/2024 facility document, [Skilled Nursing Facility] Beneficiary Notices New [Skilled Nursing Facility Advanced Beneficiary Notice] [October] 2024, documented effective delivery of the notice occurred when the beneficiary had both received the notice and comprehended its contents. The notice was issued no later than two days before termination of services. Telephone contact was confirmed by written notice, mailed on that same day via certified mail, and return receipt requested. When notices were returned by the post office, proof of the date mailed was retained. 1) Resident #28 had diagnosis including epilepsy (seizure disorder) and dementia. The 7/24/2024 Minimum Data Set assessment documented the resident had intact cognition, it was a Skilled Nursing Facility Part A Prospective Payment System (a method of reimbursement used by Medicare that pays a predetermined amount for a service) discharge assessment and the resident had a Medicare-covered stay with a start date of 5/20/2024 and an end date of 7/24/2024. The resident remained in the facility. The Notice of Medicare Non-Coverage for Centers for Medicare and Medicaid Services-10123 letter documented Resident #28's effective end date of services was 7/24/2024. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage Center for Medicare and Medicaid Services-10055 letter did not have options selected regarding the discussion with the representative. There was a hand printed note on both documents that the resident's representative provided verbal acknowledgement on 7/23/2024 one day before the end of services. There was no documented evidence the telephone contact with resident's representative was confirmed by written notice mailed on the same date. During an interview on 12/3/2024 at 9:14 AM, Resident #28's representative stated therapy had discussed the progress Resident #28 made. They stated they did not recall being provided anything in writing regarding Resident #28's services but recalled a verbal conversation. They stated the facility had great verbal communication, but paperwork was a short fall. 2) Resident #38 had diagnosis including dementia and spinal stenosis. The 10/25/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, it was a Skilled Nursing Facility Part A Prospective Payment System (a method of reimbursement used by Medicare that pays a predetermined amount for a service) discharge assessment and the resident had a Medicare-covered stay with a start date of 10/7/2024 and an end date of 10/25/2024. The resident remained in the facility. The Notice of Medicare Non-Coverage for Centers for Medicare and Medicaid Services-10123 letter documented Resident #38's effective end date of services was 10/25/2024. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage Center for Medicare and Medicaid Services-10055 letter did not have options selected regarding the discussion with the representative. There was a hand printed note on both documents that the resident's representative provided verbal acknowledgement on 10/23/2024. There was no documented evidence the telephone contact with resident's representative was confirmed by written notice mailed on the same date. During an interview on 12/3/2024 at 8:45 AM, Resident #38's representative stated that they were not provided information regarding skilled nursing coverage for Resident #38. If they had been given the information, they would have appealed the decision, but they had been working to get coverage for Resident #38. They were made aware they could have appealed the decision after the time frame had passed. 3) Resident #223 had diagnosis including right knee effusion and encounter for orthopedic aftercare. The 8/19/2024 Minimum Data Set assessment documented the resident had intact cognition, it was a Nursing Home Discharge and return was not anticipated, and the resident had a Medicare-covered stay with a start date of 8/5/2024 and an end date of 8/19/2024. The 8/15/2024 at 2:30 PM discharge summary completed by Licensed Practical Nurse Unit Manager #16 documented Resident #223 was discharged home from the facility on 8/19/2024. The 8/16/2024 at 12:39 PM progress note completed by the Director of Social Work #24 documented that they met with Resident #223 and reminded them of their discharge plans, and the resident needed to hang in there a couple more days because they were being discharged on 8/19/2024. There was no documented evidence the Notice of Medicare Non-Coverage for Centers for Medicare and Medicaid Services-10123 was provided to the resident. During an interview on 12/3/2024 at 11:56 AM, the Director of Social Work #24 stated they were responsible to ensure the delivery of the beneficiary notice letters to the resident or the resident's representative was completed. They stated they did not have receipt of a certified letter for Resident #28, they just held on to the letters until the representative visited again. The Director of Social Work stated Resident #38's representative was not mailed a letter, but the letter was left on the nightstand in the resident's room for the representative. They did not have a note documenting whether they received the letter or not. They stated if they had to send something certified they would give it to Administrative Assistant #28 for them to send, or they would stop by the U.S. Post Office on their way home. They stated they only sent beneficiary notices via certified mail if the family was out of state, and they knew they would not be in to see the resident. Even when they sent items certified they did not keep the receipt, as they did not know they had to. The Director of Social Work stated Resident #223 was a resident-initiated discharge. They were told that any resident-initiated discharge did not need beneficiary notification regardless of the length of stay remaining. They stated if a resident requested to go home, they did not have to do anything because the resident asked to leave. Resident #223 was a planned discharge. They met as a team to ensure the resident services were in place and they picked a day that was agreeable with the resident for discharge. Resident #223 spoke with staff with interest to discharge home on 8/15/2024, and the resident did not discharge out of the facility until 8/19/2024, the last covered day of services. The Director of Social Work stated it was important for resident or representative to get the beneficiary notices, so they knew they were getting cut from services and were aware of the appeal process. They stated they did not receive any formal training on how to do beneficiary notices. 10 NYCRR 483.10(g)(18)

Based on observations, record review, and interviews during the recertification survey conducted 11/21/2024-12/4/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 1 of 1 resident (Resident #31) reviewed. Specifically, Resident #31 did not have an individualized person-centered care plan that addressed dementia with behavioral symptoms or use of psychotropic medications (medications used to treat mood disorders). Findings include: The facility policy, Psychotropic Medication Policy and Procedure, dated 3/2017, documented the facility ensured appropriate use, evaluation and monitoring of psychotropic medication use; nursing monitored psychotropic drug use daily noting any adverse effects such as increased somnolence (sleepiness) or functional decline; and the facility's goal was to determine the underlying cause of behavioral symptoms so appropriate treatment of environmental, medical, and/or behavioral interventions could be utilized and met the needs of the individual resident. The facility policy, Behavioral Health Services, dated 5/2017, documented sufficient support was provided to residents that needed Behavioral Health Services and support may include implementation of non-pharmacological interventions as appropriate. The facility policy, Resident Care Planning dated 3/2020, documented designated staff of all disciplines were responsible for the evaluation of the Interdisciplinary Resident Care Plan; the registered nurse reviewed and revised the care plan as appropriate; the resident's problem/needs were discussed by all disciplines; interdisciplinary approaches and specific measurable goals for care were determined or refined by the appropriate discipline; and each discipline entered changes in the care plan problems/needs, approaches, goals and outcomes when the condition of the resident changed. Resident #31 had diagnoses including dementia, anxiety, depression, and unspecified mood disorder. The 11/20/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, mood symptoms nearly every day, required maximum assistance for most activities of daily living, preferred listening to music, reading books magazines or newspapers, spending time outdoors, and doing things with groups of people, and received antidepressant, antianxiety, and antipsychotic medications daily. Psychotropic drug use was triggered as a Care Area Assessment and a care plan was necessary. There was no documented evidence of a Comprehensive Care Plan that included the use of psychotropic drug use including antidepressants, antianxiety, or antipsychotic medications or resident centered interventions that managed behaviors. Physician orders documented the following: - on 7/1/2024 Seroquel 25 milligrams (an antipsychotic) once daily at bedtime for mood disorder. - on 7/23/2024 citalopram (an antidepressant) 10 milligrams once daily for depression. - on 8/13/2024 Ativan (an antianxiety) 0.5 milligrams three times a day for anxiety. - on 8/15/2024 Ativan increased to 1 milligram three times a day for anxiety. - on 8/19/2024 Seroquel 25 milligrams increased to three times a day. - on 8/19/2024 Ativan reduced to 0.5 milligrams three times a day for anxiety. - on 8/19/2024 citalopram increased to 20 milligrams once daily for depression. - on 9/11/2024 Rexulti 0.5 milligrams (an antipsychotic) once daily; increased to 1 milligram daily on 9/20/2024; and increased to 2 milligrams daily on 9/27/2024 for unspecified mood disorder. The Medical Director/Attending Physician's Comprehensive Reviews documented: - on 9/9/2024 the resident had been more agitated and irritable and was constantly yelling out. - on 9/12/2024 the resident was more irritable and was yelling out all the time. - on 11/27/2024 the resident appeared more irritable and had increased agitation. Psychologist #52 progress notes documented: - on 9/10/2024 at 12:42 PM the resident continued to almost constantly yell out. - on 10/29/2024 at 1:05 PM the resident continued to have episodes of yelling, being difficult to redirect, uncooperative and agitated. - on 11/25/2024 at 3:00 PM the resident continued to have behaviors, especially yelling out. November 2024 nursing progress notes documented Resident #31 had observed behaviors on 11/6/2024, 11/8/2024, 11/10/2024, 11/14/2024, 11/16/2024, 11/17/2024, 11/19/2024, 11/21/2024, 11/24/2024, 11/26/2024, and 11/28/2024-11/30/2024. Resident #31 was observed: - on 11/21/2024 at 2:13 PM lying in bed and repeatedly making a woo hoo sound followed by a grunting noise. - on 11/26/2024 at 9:00 AM sitting in front of the television in the common area repeatedly moaning and yelling out loudly indiscernible words that drowned out the sound from the television. Other residents were hushing the resident saying, No, don't do that. - on 12/2/2024 at 9:34 AM in their room sitting in a chair hollering indiscernible words repeatedly. - on 12/2/2024 at 1:14 PM lying in their bed moaning loudly. - on 12/3/2024 at 8:33 AM, sitting in their chair across from the nurses' station with their eyes closed, moaning. The resident's care instructions active as of 12/3/2024 documented behavior monitoring and interventions. There were no documented resident centered non-pharmacological interventions for behavioral symptoms. During an interview on 12/2/2024 at 1:13 PM, Certified Nurse Aide #42 stated if a resident had behaviors, they tried toileting and repositioning the resident. The resident care cards (care instructions) did not provide much information on behaviors or any specific interventions to try. Resident #31 was declining and yelled out a lot, more now than in the past two weeks. There were not any specific interventions for the resident's behaviors. They thought the resident liked stuffed animals and had a favorite television show but could not remember what one. During an interview on 12/2/2024 at 1:36 PM, Licensed Practical Nurse #35 stated there was information on the care plans regarding behaviors and different ways to calm and redirect a resident. Any new or worsening behavior could be a clue that something was just not normal. Resident #31 appeared broken when they first arrived, was very upset, cried, and had been on a constant decline. They once could say they wanted a drink, to go home, or to go to bed but their communication had declined since admission. Their overall behaviors had worsened. They were spitting out food, yelling and crying and it was difficult to not know what was causing their behaviors. They had reported the physical decline and behaviors to the supervisors and managers many times. During an interview on 12/2/2024 at 1:59 PM, Licensed Practical Nurse Assistant Unit Manager #38 stated they reviewed the care plan in preparation for care conference and any needed changes or updates would be brought to the Nurse Manager or the Director of Nursing to make. Behavior care plans were generated if there was a specific, recurring behavior and included such things as medications and interventions to try before medicating. High risk medications such as psychotropics should be care planned and include symptoms to report so staff knew how to take care of the resident in case there were a problem. Resident #31 had dementia and a lot of anxiety that was not well controlled. They yelled out and did not really know what they were yelling about. The resident received an antipsychotic, an antianxiety and an antidepressant. They did not have a behavioral or psychotropic medication care plan, or anything specifically tailored to them to manage their behaviors. They should be a care plan, so staff knew how to approach and manage the resident's care. The care plan should include resident preferences as they did not want to give unnecessary medications that could cause a decrease in quality of life. During an interview on 12/2/2024 at 2:45 PM, Registered Nurse Unit Nurse Manager #14 stated care plans should include behaviors, dementia, and high-risk medications such psychotropics. A behavior care plan should have simple diversional interventions as well as resident specific preferences. An individualized care plan was important, so everyone knew how to take care of and approach that resident and to minimize having to medicate the resident. Care plans for high-risk medications were important so everyone knew what needed to be monitored. Resident #31 had dementia, took psychotropic medications, and consistently yelled out. Lately, nothing calmed the resident down. Their medications had been adjusted less than a week ago. They did not have a behavior, dementia, or psychotropic medication care plan but should have because those were significant issues for the resident. During an interview on 12/3/2024 at 1:40PM, the Director of Nursing stated registered nurses generated and updated the care plans and included behaviors and psychotropic medication use. Behavior care plans should include resident specific interventions to curb behaviors which was important for the resident's well-being and psychosocial health. Psychotropic medication care plans included such things as monitoring for changes in activities of daily living status and mood. Resident #31 had dementia and anxiety and was followed by psychology for their behaviors. They hollered out and their medications were adjusted. There was nothing specifically listed in Resident #31's care plan for behavioral interventions or any documentation that nonpharmacological interventions had been tried. The resident was taking psychotropic medications and was not care planned for them. If the resident was not provided with person centered interventions, they could become more depressed, more anxious, and even delirious. 10NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 11/21/2024-12/4/2024, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 of 1 resident (Resident #35) reviewed. Specifically, Resident #35 was not provided meaningful activities that met their interests and preferences. Additionally, Resident #35's room was not personalized with preferred activity items, such as a television or radio. Findings include: The facility policy, General Activity Department Guidelines, effective 2/21/2023, documented the facility provided, based on the comprehensive assessment, care plan, and preferences of each resident, an ongoing program to support residents in their choices of activities. The program of activities met the individual needs of each resident and fulfilled basic psychological, social, and spiritual needs. The activities department was ongoing 7 days a week and included weekends. Quarterly reviews were completed and documented in a progress note. Resident #35 had diagnoses including unspecified dementia. The 2/13/2024 Minimum Data Set assessment (a health status tool) documented the resident had moderately impaired cognition, it was somewhat important to have books, newspapers, and magazines to read, do things with groups of people, and do their favorite activities, it was very important to listen to music, be around animals such as pets, keep up with news, go outside for fresh air when the weather was good, and participate in religious services. The Comprehensive Care Plan initiated 2/12/2024 and revised on 11/27/2024 documented the resident had little or no activity involvement related to disinterest, wishing not to participate, and being highly therapy oriented. The resident preferred to spend time in their room watching news programs and soap operas. Interventions included the importance of social interaction and leisure activity time was explained, participation was encouraged, the resident was invited and encouraged to attend, and the resident was reminded they may leave activities at any time and were not required to stay for the entire activity. The 2/12/2024 admission evaluation by the Director of Activities documented the resident's preferred social setting was 1:1 and self-directed. Music, animals, prayer, and family brought the resident comfort. They preferred to spend their free time doing puzzle books, exercises, and watching TV. Interests/ hobbies included cards, games, exercise, sports, gardening, the outdoors, and puzzles. There was no documented evidence of any on-going activities evaluations. The November 2024 Activities Log documented Resident #35 participated in a manicure on 11/4/2024, watched a movie in the common area on 11/5/2024 and 11/6/2024, and was provided with the daily chronicle reading material on 11/6/2024. There was no documented evidence the resident was invited to or participated in any activities after 11/6/2024. The November 2024 Unit 1 and 2 Activity Calendar documented the following activities: - On 11/21/2024- AM: Resident Council; PM: Fall Craft - On 11/22/2024- AM: Nature Documentary; PM: Happy hour - On 11/23/2024- Coloring, Reading, Television, Phone Calls, Word puzzles, etc. - On 11/24/2024- Spiritual Care - On 11/25/2024- AM: Bingo (floor 2); PM: Thanksgiving craft - On 11/26/2024- AM: Bingo, PM: Music Therapy - On 11/27/2024- AM: Thanksgiving Parade; PM: Bowling - On 11/28/2024 there were no activities listed - On 11/29/2024- AM: Paint N' Sip; PM: Birthday Celebration - On 11/30/2024- AM: Coloring, Reading, Television, Phone Calls, Work puzzles, etc. The following observations were made of Resident #35 in their room in silence. There was no television, radio, books, newspapers, puzzles, or other activities/ personalization in their room other than one picture frame with personal pictures on their dresser: - On 11/21/2024 at 10:40 AM and at 11:31 AM, sitting up in their wheelchair next to the window looking straight ahead at the dresser. - On 11/26/2024 at 9:46 AM and 12:50 PM, sitting up in their wheelchair next to the window looking straight ahead at the dresser. Resident #35 stated they liked to play softball, but at the facility all there was to do was watch television. There was no television in the resident's room. - On 11/30/2024 at 9:29 AM, sitting up in their wheelchair next to the window looking straight ahead at the dresser. - On 12/2/2024 at 1:35 PM, lying on their back in their bed, awake, looking at the ceiling. The dry erase board in Second Floor unit hallway was observed: - On 11/26/2024 at 12:49 PM, the AM activity was listed as independent activity; the PM activity was listed as music, [NAME] and choir. - On 12/02/2024 at 1:36 PM, the AM activity was listed as calendar pass; the PM activity was listed as bingo prizes, taking down fall décor. - On 12/03/2024 at 9:40 AM, the AM activity was listed as let's decorate for Christmas, there was no PM activity listed. During an interview on 12/2/2024 at 1:40 PM, Certified Nurse Aide #42 stated the daily activities were listed on the dry erase board in the hallway and there was an AM and a PM activity. Activities included movies in the common television room and church on the television in the common area on Sundays. There were some 1:1 visits, sometimes games. Resident #35 preferred to stay in their room. Their family brought cards in for them when they were on the First Floor. They had not seen the resident really do anything since moving to the Second Floor. The resident was assessed for what they liked to do when they first came in, they were not sure if they were ever reassessed. It was important for the resident to participate in activities because it got them out of their room, stimulated their brain, and allowed them to meet people. During an interview on 12/2/2024 at 1:50 PM, Certified Nurse Aide #10 stated there were activities during the week but there were not any on the weekends. There used to be weekend activities when there was more activities staff. The activities at the facility were lacking. The daily chronicles were passed out, but nobody helped the residents to read them. There were monthly birthday parties, but they were not actually a gathering, cake was just passed out. Bingo was the only activity on the Second Floor that was done away from the unit activity. All activities on the Second Floor were in the common television area. They had never seen Resident #35 do anything and was often in their room. They picked up their room and made their bed earlier today and there was nothing for the resident to do in their room, not even a television. Resident #35 often yelled out because they did not have anything to do and thought they should have activities that kept them occupied. During an interview on 12/2/2024 at 2:08 PM, Licensed Practical Nurse #35 stated the residents on the Second Floor mostly had dementia, so they only gathered in the common television area for activities. Residents that preferred to be alone were provided with music, movies, and magazines. They knew Resident #35 well. Resident #35 was lonely, and they always wanted someone to talk to them. They, and other staff, tried to make time to sit and talk with the resident. They never saw the resident do much of anything and had never seen them with a puzzle or a book. The activities department did 1:1 visits but they were not sure if the resident had any recently. It was important for Resident #35 to have activities for their social well-being, and this was their home. During an interview on 12/3/2024 at 9:41 AM, the Director of Activities stated they were currently the only activities staff, and they were stretched very thin due to short staffing. There were two activities daily during the week and one was for the First Floor and one for the Second Floor. The First Floor had higher functioning residents so they could do more activities such as crafts, paint n' sip, and card games. Activities were done in the dining room. The Second Floor had more cognitively challenged residents, so they did sensory activities and alphabet games, and the activities on the Second Floor were held in the common television area. There were coloring pages and markers/ crayons in the common television area for the Second Floor residents. Today's activity was decorating the units. There was nobody from activities on the weekends. They expected nursing to follow the calendar on Saturdays and facilitate coloring, reading, watching television, and puzzle books. On Sundays, nursing staff was supposed to put a program called Spiritual Care on the television in the common area. Activities were important for the residents because they got bored, and some did not have any family contact. Resident #35 had regular visits from family, but they did not like to leave their room. They enjoyed 1:1 visits, musical activities, and looking at the birds. They were not sure the last time the resident had a 1:1 visit. 1:1 visits were important for Resident #35's psychosocial well-being. It was not fair Resident #35 did not have social interaction, they did not have a roommate, no décor on the walls, and nothing to do in their room. They should probably get a 1:1 visit daily but there was no activities staff. They thought all rooms should have a television and they did not know Resident #35 did not have one. They could put a radio in their room because the resident liked music. During an interview on 12/3/2024 at 1:28 PM, the Director of Social Work stated activities were important for the residents and kept their minds going, kept them stimulated, and broke up their day. There were not enough activities. The resident did like music activities. The resident benefitted from 1:1 activities such as manicures or just talking with someone and enjoyed watching television. They enjoyed talking with the resident and went in to talk with the resident last week. Before they left, they asked the resident if they wanted to watch television. They were not aware the resident did not have a television in their room and there was not much for them to do in their room. Resident #35 refused a lot of activities, sometimes they came out and sat in the common television area, but they got overstimulated in groups. The resident should still be invited and even just being invited could help their psyche and they would feel like they were not forgotten. 10NYCRR 415.5(f)(1)

. Based on observations, record review, and interviews during the recertification and abbreviated (NY00356968) surveys conducted 11/21/2024-12/4/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 3 of 3 residents (Resident #16, #17, and #30) reviewed; and for 1 of 2 emergency carts (Second Floor dining room emergency cart) reviewed. Specifically, the emergency cart in the dining room on the Second Floor was not checked daily to ensure emergency supplies were available; Resident #30 had a discontinued anti-fungal cream administered by Certified Nurse Aide #34; Resident #16 had three separate orders for as needed acetaminophen (Tylenol, pain reliever/fever reducer); and Resident #17 had two orders for as needed acetaminophen, and Percocet (an opioid pain medication) was administered outside of ordered pain parameters. Findings include: The facility policy, Medication Management, effective 8/2020, documented the facility provided medication management that optimized the therapeutic benefit of medication therapy and minimized or prevented potential adverse consequences. The facility, the attending physician/prescriber, and the consultant pharmacist performed ongoing monitoring for appropriate, effective, and safe medication use. When selecting medications and non-pharmacological interventions, members of the interdisciplinary team participated in the care process and identified, assessed, addressed, advocated for, monitored, and communicated the resident's needs and changes in condition. The facility policy, Pain Assessment and Management Policy, revised 1/20/2009, documented each resident was assessed for pain on admission and on a quarterly basis, significant changes in residents' condition, or when verbal and non-verbal responses indicated the resident may be in pain. Once a resident was identified as needing pain management intervention, an individual program was developed for that resident. When writing an order for pharmacological pain control, the order included the pain intensity based on the resident's perception of their pain and the pain scale tools. For a scale of 1-3 was mild pain, 4-7 was moderate pain, and 8-10 was severe pain. The facility policy, Emergency Cart, effective 4/13/2021, documented the facility kept the emergency cart on each unit properly stocked and maintained. The cart was stored in each dining room on both units. The cart was checked daily for cart tag, back board (used as a hard surface when performing cardiopulmonary resuscitation) and oxygen tank by the day shift licensed practical nurse or registered nurse and the log was signed. EMERGENCY CART: During an observation on 11/26/2024 at 1:08 PM, the Second Floor emergency cart was in the dining room. The top of the cart had a September 2024- November 2024 Checklist. There was no documented evidence the cart was checked on the following days: - 9/1/2024, 9/6/2024, 9/7/2024, and 9/15/2024 through 9/30/2024. - 10/1/2024, 10/3/2024, 10/4/2024, 10/10/2024, 10/11/2024, and 10/27/2024. - 11/10/2024, 11/16/2024, 11/17/2024. During an observation on 12/2/2024 at 2:17 PM, the Second Floor emergency cart was in the dining room. The top of the cart had a September 2024- November 2024 Checklist. There was no documented evidence the cart was checked on the following days: - 11/28/2024, 11/30/2024, and 12/1/2024. During an interview on 12/3/2024 at 11:18 AM, Licensed Practical Nurse #35 stated the emergency cart was checked daily by Licensed Practical Nurse Assistant Unit Manager #38. After they reviewed the logs located on top of the cart, they stated the cart was not checked daily. It was important the cart was checked to make sure all the supplies were there in the event of an emergency. During an interview on 12/3/2024 at 11:58 AM, Licensed Practical Nurse #13 stated the emergency cart was checked daily by the nurses, but the Licensed Practical Nurse Assistant Unit Manager #38 usually did it. The day shift nurses were responsible to ensure the cart was checked. This was not assigned to any specific nurse and sometimes the night shift nurse checked the cart. If the cart was not routinely checked, it might not have the supplies needed in an emergency. During an interview on 12/4/2024 at 9:08 AM, Licensed Practical Nurse Assistant Unit Manager #38 stated the emergency cart was everyone's responsibility. The day nurses checked the cart at breakfast time, but it was not assigned to a specific nurse. The cart was supposed to be checked daily. If it was not checked daily, the needed supplies may not be in the cart during an emergency. They usually checked the cart when they arrived on the unit and there were times it was not checked. During an interview on 12/4/2024 at 9:28 AM, the Registered Nurse Unit Manager #14 stated the emergency cart was checked daily by the overnight nurse. There was only one nurse on the overnight and then either themselves or the Licensed Practical Nurse Assistant Unit Manger #38 checked it in the morning. On the weekends, it was probably not being done, this had been an issue. If the emergency cart was not being checked daily, education needed to be done. If it was not being checked, emergency supplies may be missing, and which could cause harm or delay in care during an emergency. MEDICATION ORDERS 1) Resident #30 had diagnoses including dementia. The 9/27/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, required maximum assistance with most activities of daily living, and received application of ointment other than to feet. A physician order dated 2/15/2024 documented Miconazole nitrate external ointment 2% (anti-fungal medication) apply to gluteal/buttocks, groin, and abdomen every day and night shift for fungal rash for 14 days. The order was discontinued on 2/29/2024. The Comprehensive Care plan did not include an active fungal rash of the buttocks, groin, and abdomen. The December 2024 Medication Administration and Treatment Administration Records did not include the use of Miconazole nitrate external ointment. During an observation on 12/3/2024 at 11:15 AM, the resident was lying in bed. Certified Nurse Aide #34 entered the room and removed the top linens to perform care. The resident had an incontinence brief on and was lying on an incontinence pad. The resident's groin and the back of their thighs had a bright red rash that extended up to their lower back. Certified Nurse Aide #34 washed the resident's groin and buttocks and applied 2% Miconazole cream to those areas. During an interview on 12/3/2024 at 11:36 AM, Certified Nurse Aide #34 stated the resident had a big, red rash and looked like they had been wet for quite some time. They did not know the name of the cream they applied to the resident. They should not apply medicated creams as they were not certified to do so. If the wrong cream was applied, it could cause the area to get worse or cause an allergic reaction. During an interview on 12/3/2024 at 11:54 AM, Licensed Practical Nurse #35 stated Resident #30 had on going skin issues. Miconazole cream was discontinued and should not have been applied. Nurse aides should not have applied any medicated creams because they did not know what the orders were. If the wrong treatment was applied, the resident could develop burning and redness. During an interview on 12/3/2024 at 12:17 PM and 1:16 PM, Registered Nurse #21 stated certified nurse aides should not apply medicated creams and if the wrong cream was applied it could result in an infection or even cause a new skin issue. The resident had a chronic rash, and the current treatment did not include Miconazole 2% cream and it should not have been applied. During an interview on 12/3/2024 at 1:55 PM, The Director of Nursing stated Resident #30 should not have received Miconazole 2% cream as the application of wrong creams could be toxic and make the issue worse. 2) Resident #16 had diagnoses including Parkinson's disease (a progressive neurological disorder), morbid obesity, and sepsis (infection in the blood). The 9/21/2024 Minimum Data Set assessment documented the resident was cognitively intact, did not have pain, and did not receive pain medication. The Comprehensive Care Plan initiated 9/14/2024 documented the resident had pain related to Parkinson's disease. Interventions included pain was monitored and medications were given as needed. Physician orders documented: - on 3/27/2024 acetaminophen 325 milligrams, give two tablets by mouth every 4 hours as needed for pain-mild. - on 4/5/2024 acetaminophen 500 milligrams, give one tablet by mouth every 4 hours as needed for oral pain. - on 9/17/2024 acetaminophen 500 milligrams, give one tablet by mouth every 4 hours as needed for pain. The 10/2/2024 monthly medication review completed by Pharmacist #37 documented Resident #16 had three separate orders for administration of acetaminophen when needed. They recommended physician re-evaluation for necessity of all three orders to eliminate confusion or repeated administration. The Medical Director/ Attending Physician documented a response acetaminophen 500 milligrams one tablet by mouth every 4 hours as needed for oral pain and acetaminophen 650 milligrams by mouth every 4 hours as needed for pain-mild was discontinued. They documented the acetaminophen 500 milligrams by mouth every 4 hours as needed for pain was to be kept. The 10/2024 Medication Administration Record documented: - acetaminophen 500 milligram tablet, give 1 tablet every 4 hours as needed for oral pain with a start date of 4/5/2024 and a discontinue date of 11/29/2024. - acetaminophen 500 milligram tablet, five 500 milligrams by mouth every 4 hours as needed for pain with a start date of 9/17/2024 and a discontinue date of 11/29/2024. - acetaminophen 325 milligrams, give 2 tablets by mouth every 4 hours as needed for mild pain with a start date of 3/27/2024 and a discontinue date of 11/29/2024. There was no documentation of a maximum daily dose for the acetaminophen. The acetaminophen was not administered in 11/2024. During an interview on 11/25/2024 at 11:55 AM, Pharmacist #37 stated they recommended one acetaminophen order at the monthly medication review on 10/2/2024 to eliminate confusion with three orders and eliminate the potential for repeated administration. They followed up on the order on 11/4/2024 and stated although the Medical Director/ Attending Physician agreed with the recommendation on 10/2/2024, it was not documented accurately in the medical record. If there were duplicate orders in the medical record a resident could get too much medication which was a safety concern. During an interview on 11/29/2024 at 12:54 PM, Licensed Practical Nurse Assistant Unit Manager #16 stated when a resident was admitted to the facility the interdisciplinary team reviewed medications for accuracy and appropriateness. When a resident was admitted to the hospital and returned to the facility, the admitting nurse reviewed the hospital discharge medications and compared them to the previous facility medication list and ensured medications were not missed or duplicated. Facility medications prior to the hospitalization were discontinued when the resident was admitted to the hospital or put on hold if they were just being evaluated in the emergency room. They stated there should not have been duplicate orders for medications unless the resident received a medication more than once a day and had two different dosages. It was the administering nurse's responsibility to ensure there were not duplicate orders for the same medication. They were unsure what could happen to a resident if they received multiple doses of a duplicate medication and stated it depended on the medication. During an interview on 12/03/2024 at 12:52 PM, the Assistant Director of Nursing #20 stated medications were reviewed with every physician visit. It was important medications were reviewed when a resident returned from the hospital because there may have been a change in the medication, or the medication could have been discontinued. If there were duplicate orders for the same medication, the resident received the newest order as the electronic record used by the facility did not block out the duplicate orders and allowed those orders to be administered. They were notified on 11/29/2024 by Pharmacist #37 about the duplicate acetaminophen orders for Resident #16 and immediately had them discontinued. They should have been discontinued on 10/2/2024 when recommended by Pharmacist #37 and agreed upon by the Medical Director/ Attending Physician. During an interview on 12/4/2024 at 9:40 AM, Licensed Practical Nurse Assistant Unit Manager #16 stated the monthly medication review process was broken down on their unit. Normally, the monthly medication review paperwork was reviewed and initialed by Licensed Practical Nurse Assistant Unit Manager #16 before it was given to the unit clerk and scanned into the electronic record. The monthly medication review completed on 10/2/2024 for Resident #16 was not initialed, therefore, it was not seen. If orders were not documented properly, it could be a safety concern for the resident. 3) Resident #17 had diagnoses including chronic pain. The 9/17/2024 Minimum Data Set assessment documented the resident was cognitively intact, had medically complex conditions, received a scheduled pain medication regimen, and received as needed pain medications or they were offered and declined. The Comprehensive Care Plan initiated 7/12/2024 documented the resident was at risk for pain related to depression, disease process, diabetes mellitus, chronic pain, and weakness. Approaches included administer analgesia (pain medication) as per orders. The 9/13/2024 Pharmacist #37 monthly medication review note to Medical Director/Attending Physician documented the resident had several as needed medication orders for similar indications without instructions as to a sequence in which these options should be offered for administration. There were orders for acetaminophen as needed and oxycodone with acetaminophen as needed. On two separate administrations during September, Percocet (oxycodone with acetaminophen) was given with a reported pain of 0 and 3 and was given at least once daily throughout the month. Recommendations included the orders were clarified as to which should be given when using a pain scale or it should be considered that one of them was discontinued. The 9/18/2024 Medical Director/Attending Physician response documented Tylenol (acetaminophen) as needed for pain 1-5, Percocet as needed for pain greater than 5 or breakthrough pain. Make sure max dose of Tylenol daily was not exceeded. Physician orders documented: - On 6/12/2024, give 2 tablets of acetaminophen 325 milligrams every 4 hours as needed for mild pain. - On 9/18/2024, give 2 tablets of acetaminophen 325 milligrams every 4 hours as needed for pain level between 1 and 5, do not exceed maximum daily dose. - On 9/18/2024, give 1 tablet of Percocet 10-325 milligrams (oxycodone with acetaminophen) every 4 hours as needed for pain level greater than 5, do not exceed the maximum daily dose. The November 2024 Medication Administration Record documented: - acetaminophen 325 milligrams give 2 tablets by mouth every 4 hours as needed for mild pain with a start date of 8/12/2024 and discontinue date of 11/29/2024. The acetaminophen was not administered in 11/2024. - acetaminophen tablet 325 milligrams, give 2 tablets by mouth every 4 hours as needed for pain rated 1-5 with a start date of 9/18/2024. The medication was administered on 11/7/2024 for a pain level of 5 by Licensed Practical Nurse #13. The November 2024 Medication Administration Record documented Percocet oral tablet 10-325 milligrams, give 1 tablet by mouth every 4 hours as needed for pain rated greater than 5, do not exceed maximum daily dose for acetaminophen. Percocet was not given according to physician ordered parameters (pain level greater than 5) at the following times: - On 11/5/2024 at 9:09 AM by Licensed Practical Nurse #13 for a pain level of 5 and at 3:14 PM by Licensed Practical Nurse #49 for a pain level of 5. - On 11/6/2024 at 1:04 AM by Licensed Practical Nurse #43 for a pain level of 0. - On 11/7/2024 at 4:39 AM by Licensed Practical Nurse #50 for a pain level of 5. - On 11/9/2024 at 8:59 AM by Licensed Practical Nurse #13 for a pain level of 4. - On 11/10/2024 at 4:15 AM by Licensed Practical Nurse #43 for a pain level of 0. - On 11/13/2024 at 7:56 AM by Licensed Practical Nurse #13 for a pain level of 4. - On 11/14/2024 at 12:40 PM by Licensed Practical Nurse #13 for a pain level of 4. - On 11/15/2024 at 1:40 PM by Licensed Practical Nurse #49 for a pain level of 0 and at 9:08 PM by Licensed Practical Nurse #43 for a pain level of 0. - On 11/16/2024 at 8:37 PM by Licensed Practical Nurse #51 for a pain level of 5. - On 11/18/2024 at 9:00 AM by Licensed Practical Nurse #13 for a pain level of 4. - On 11/19/2024 at 8:45 AM by Licensed Practical Nurse #13 for a pain level of 4. - On 11/22/2024 at 8:18 PM by Licensed Practical Nurse #51 for a pain level of 5. - On 11/24/2024 at 5:22 AM by Licensed Practical Nurse #43 for a pain level of 0. - On 11/28/2024 at 12:35 AM by Licensed Practical Nurse #50 for a pain level of 5. - On 11/29/2024 at 9:12 AM by Licensed Practical Nurse #13 for a pain level of 5. During an interview on 11/29/2024 at 11:39 AM, Pharmacist #37 stated they completed a monthly medication review on all residents for the facility. They had sent a recommendation on 9/13/2024 for clarification of a pain scale to indicate whether Tylenol or Percocet was given to Resident #17. After the facility clarified the order, there was a second Tylenol order. The previous Tylenol order should have been discontinued when the new Tylenol order with the pain scale was entered in September. They had monitored if the medications were being appropriately given based on the pain scale and overlooked the second Tylenol order. They had seen duplicate orders in resident's charts and usually caught them during the monthly medication review and put them in the recommendation to be discontinued, but they missed this one in the past 2 monthly medication reviews. With two active orders, the opportunity existed to chart on both orders and give both orders and the resident could receive the Tylenol at an increased frequency or too much Tylenol, but they did not. They had only received one total dose of Tylenol since the second order was entered. Medications should also be reviewed by the physicians during required routine visits. During an interview on 12/2/2024 at 2:33 PM, Licensed Practical Nurse #13 stated if there were two Tylenol orders, they would not know which one to document on. If they saw a second order, they would go to the Unit Manager for clarification. They always gave Resident #17 Percocet, so they did not get too much Tylenol. They gave Tylenol once when the Percocet was not available at the facility. They should not have given the resident Percocet for a pain level of 4 but the resident always requested the Percocet, so they just gave it to them. They stated they should have followed physician orders because the physician knew what was best for the resident. During an interview on 12/2/2024 at 2:46 PM, Licensed Practical Nurse #43 stated if the resident requested the Percocet, they just gave it. It was important physician orders were followed and the right medication was part of the 6 rights to medication administration. While it was important physician orders were followed, it was the resident's right to get the medication they wanted and if they did not give Resident #17 Percocet, they would report them. It was not appropriate they administered Percocet with a pain level of 0 but Resident #17 wanted Percocet every 4 hours and did not want the Tylenol. They should have called the doctor for a one-time order if the pain level did not indicate the Percocet should be given but the resident requested it. During an interview on 12/4/2024 at 9:08 AM, Licensed Practical Nurse Assistant Unit Manager #38 stated they clarified an order for Tylenol for Resident #17 that included a pain scale per the pharmacy recommendation. They thought the electronic system automatically discontinued the old order when a new order was put in. With two active Tylenol orders the resident could have received Tylenol before it was due or too much Tylenol. Tylenol should be administered for pain 1-5 and Percocet should not be given for pain less than 5. If the pain score was 5, it was unclear to them which medication should be given and they would have to clarify the orders. The nurses that gave the Percocet with a pain level less than 5 were not following the physician orders. It was important physician orders were followed. During an interview on 12/4/2024 at 9:28 AM, Registered Nurse Unit Manager #14 stated when an order was clarified, the new order took precedence, and the old order was discontinued. If a nurse saw 2 orders for the same medication, they hoped they clarified with the physician. Resident #17's Tylenol order was given for pain 1-5 and Percocet for pain greater than 5. If the pain score was 5 or below, Tylenol should be given. The nurses should have followed physician orders, but they knew Resident #17 requested the Percocet. Even if the resident requested Percocet, orders still needed to be followed so there was no harm to the resident. Review of the Medication Administration Record showed the nurses were not following the physician orders and this was a quality-of-care issue. During an interview on 12/4/2024 at 10:00 AM, the Assistant Director of Nursing stated Licensed Practical Nurse Assistant Unit Manger #38 should have discontinued the old Tylenol order when the new order was placed. Nurses should look at the medication orders prior to giving a medication. Pharmacist #37 usually caught duplicate orders during the monthly medication review. The physicians should review the resident's medications with every visit. The Medication Administration Record documented the nurses were not following physician orders per the pain scale. The orders should be followed even if the resident requested Percocet. Percocet should not be given unless the pain level was 6 or above. During an interview on 12/4/2024 at 12:03 PM, the Medical Director/ Attending Physician stated medications were not always reviewed during physician visits. The pharmacist and the nurses reviewed the medications monthly and should have discontinued an old Tylenol order. Percocet should not be given for a pain score of 5 or less. Orders should be followed and if they were not followed, education needed to be provided. This was the protocol, physicians ordered, and nurses carried out the orders. 10NYCRR 415.12

Based on observation and interviews during the recertification survey conducted 11/21/2024-12/4/2024, the facility did not ensure a safe, functional, sanitary, and comfortable environment for staff, visitors, and residents on 1 of 2 units (First Floor), and 1 of 1 resident (Resident #30) reviewed. Specifically, the large shower room on the first floor had a strong smell of feces, the bathroom located in the main hallway by the administrative office had a strong smell of urine, and Resident #30 was observed in a wheelchair that was in disrepair. Findings include: The undated facility policy, Resident Rights, documented all residents were provided a dignified existence. During an observation on 11/23/2024 at 10:16 AM, the large shower room on the First Floor had a strong smell of feces, the toilet was filled with brown liquid, and there were multiple small flying insects in the area. During an observation on 11/24/2024 at 3:17 PM, the First Floor large shower room had a strong urine and feces smell, the floor tiles under the toilet and under the shower bed were discolored. There were small flying insects around the toilet area. The November 2024 First Floor cleaning logs documented the large shower room was cleaned daily. During an observation on 11/26/2024 at 1:29 PM Resident #30 was sitting in their room in their wheelchair. Both arm rests on their wheelchair were missing plastic and the material underneath the plastic was exposed. During an observation on 12/2/2024 at 4:37 PM, the bathroom in the main hallway by the administrative offices had a strong urine smell. There was brown debris on the back of the toilet bowl and the back of the toilet seat rim. During an interview on 12/2/2024 at 1:50 PM, Housekeeper #27 stated housekeeping was staffed from 6:00 AM until 10:30 PM and was responsible for cleaning resident rooms, bathrooms, the nurse's stations, dining rooms, day rooms, and offices. Cleaning included sweeping, mopping, dusting, restocking toilet paper and paper towels, and emptying trash. After the cleaning was completed, they documented the room was cleaned on their daily log sheet. If a room had an odor that smelled like urine, they used a chemical in the toilet and asked the resident if they allowed an air freshener to be sprayed. They had noticed the large shower room had an odor as it was used frequently. When a room smelled like urine it was not homelike. During an interview on 12/2/2024 at 1:57 PM, Certified Nurse Aide #30 stated although anyone could clean a resident area, it was ultimately housekeeping's responsibility. They stated the large shower room was used frequently throughout the day to shower residents and when the door was closed it smelled musty. If a resident was in an area that had an unpleasant odor, it was not homelike. During an interview on 12/2/2024 at 2:09 PM, Licensed Practical Nurse #13 stated when they noted an unpleasant odor, they notified a certified nurse aide and asked them to check the resident for incontinence. They stated they did not go in the shower room often and was not aware of any odor in the shower room. If a resident area had an unpleasant odor, it was not homelike for the resident. During an observation and interview on 12/2/2024 at 2:23 PM, Certified Nurse Aide #31 stated when a resident's wheelchair arms rests were worn and torn, they called maintenance and had them replaced. They could not recall anyone on the unit having arm rests on their wheelchair that were worn or torn. Certified Nurse Aide #31 observed Resident #30's wheelchair and stated the arm rests were missing plastic and exposed the material underneath the plastic. The arm rests should have been replaced. During an observation and interview on 12/2/2024 at 2:29 PM, the Director of Rehabilitation Services #18 stated when wheelchairs were in disrepair, they notified maintenance and completed a work order for repair or replacement. If a resident was in a chair that was in disrepair it was not dignified. During an interview on 12/2/2024 at 2:48 PM, the Director of Housekeeping #32 stated they expected rooms to be clean and free from odor. They reviewed the cleaning logs from each housekeeper every day to see if a room was not cleaned. If a room was not cleaned it was passed on to the next shift to clean. If there was an odor from a resident room they identified where the smell originated. They made rounds daily to make sure all areas were clean and free from odor. If a resident was in an area with an unpleasant odor, it was not homelike. If they noticed a wheelchair was in disrepair they entered a work order in the computer for maintenance to repair. During an observation and interview on 12/3/2024 at 8:12 AM, Director of Maintenance #7 stated work orders were completed electronically and directions were located at the nurse's stations. Work orders were typically completed the same day as they were submitted. If wheelchair arm rests were worn, torn, or in disrepair they were replaced the same day. If a resident had wheelchair arm rests that were worn, torn, or in disrepair the resident could feel embarrassed or uncomfortable. 10 NYCRR 415.5(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 11/21/2024-12/4/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 3 of 4 medications carts (First Floor 1-2 and 3-4 carts and Second Floor 3-4 cart), and 2 of 3 medication rooms (First Floor medication room and Second Floor Omnicell room). Specifically, the First Floor medication room refrigerator temperatures were not consistently monitored; medications in First Floor carts 1-2 and 3-4 were expired; the First Floor room refrigerator had unlabeled multidose vial medications; and the Omnicell (medication storage tower) medication room and the First Floor 1-2 and Second Floor 3-4 medications carts were unlocked. Findings include: The facility policy, Storage of Medications, updated 9/2018, documented medications and biologicals were stored safely, securely, and properly per the manufacturer's recommendations or those of the supplier. The medication supply was only accessible to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication supplies were locked when they were not attended by persons with authorized access. Outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures, were immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if an order existed. All medications were maintained within the temperature ranges noted by the Centers for Disease Control. Refrigerator temperatures were kept 36 to 46 degrees Fahrenheit. The facility maintained a temperature log in the storage area and recorded temperatures at least once a day or in accordance with the facility policy. Certain medications such as multidose injectable vials required an expiration date shorter than the manufacturers date when opened and ensured medication purity and potency. UNLOCKED MEDICATION STORAGE The First Floor 1-2 medication cart was observed unlocked at the nurse's station: - on 11/21/2024 at 11:42 AM with two residents in the area. Licensed Practical Nurse #39 walked from the end of the hall (10 rooms or more away from the cart) and locked the medication cart. - on 11/21/2024 at 1:01 PM with three residents in the area. Licensed Practical Nurse #39 came from inside the supply room where the door was shut, crossed the hall, and locked the cart. - on 11/21/2024 at 1:59 PM with two residents in the area. - on 11/26/2024 at 12:00 PM, outside room [ROOM NUMBER]. Licensed Practical Nurse #39 was near room [ROOM NUMBER]. During an observation on 11/30/2024 at 9:28 AM, the Second Floor 3-4 medication cart was in the hall unlocked. There was no nursing staff present. During observations on 11/25/2024 at 12:50 PM and 1:58 PM the Omnicell room on the Second Floor located off the common area was unlocked with residents sitting just outside the door watching television. During an interview on 11/25/2024 at 1:58 PM, Registered Nurse #21 stated the room with the Omnicell should be always locked. During an observation and interview on 11/25/2024 at 2:58 PM Licensed Practical Nurse # 35 stated the room on the Omnicell room was not considered a medication room, it was a storage room for the Omnicell, and residents were not able to get into the Omnicell. They stated there were medications in the refrigerator including insulin and the Second Floor had wandering residents and the room should be always locked for safety. Only nurses had the key to the room and if residents got medications stored in the room, they could get sick. During an interview on 12/03/2024 at 11:57 AM, Licensed Practical Nurse #40 stated they worked 11/30/2024 and was the only nurse working on the Second Floor. They stated they did not lock the medication cart when it was in the hall. The unit had wandering residents, and they should have locked the medication cart for the safety of the residents. The facility policy was to always lock the medication cart when not attended. EXPIRED MEDICATIONS During a medication storage observation and interview with Licensed Practical Nurse #40 on 11/22/2024 at 7:47 AM, the First Floor 1-2 medication cart had Lispro insulin with an opened date of 10/17/2024 and expiration date of 11/17/2024. Licensed Practical Nurse #40 stated they did not administer the insulin and was not sure if the resident received the insulin after it expired. They stated if the insulin was administered it might not be as effective. During a medication storage observation and interview with Licensed Practical Nurse #15 on 11/26/2024 at 10:48 AM, the First Floor medication cart 3-4 contained lispro insulin labeled as opened on 10/22/2024 and expired on 11/22/2024. Licensed Practical Nurse #15 stated lispro was last administered to the resident on 11/23/2024 by Licensed Practical Nurse #39. During an interview on 11/26/2024 at 10:51 AM, Licensed Practical Nurse #39 stated they worked the First Floor medication cart 3-4 on 11/23/2024. After looking in the electronic medical record they stated they gave the lispro insulin on 11/23/2024 to Resident #69. They went to the First Floor medication cart 3-4 and picked up the insulin dated opened 10/22/2024 and expired 11/22/2024 and stated that was the insulin they administered. They should not have administered the insulin because it was expired and might not be effective. They did not check the expiration date and should have. REFRIDGERATOR LOGS The November 2024 medication refrigerator log for the First Floor medication room had multiple blank spaces for the three times a day temperature documentation. During a medication storage observation and interview on 11/22/2024 at 8:12 AM, Licensed Practical Nurse #39 stated refrigerator temperatures were checked every shift by the nurse on medication cart 1-2 and documented on the medication refrigerator log to ensure temperatures were not too high or too low. If there were no documented temperatures for one entire day, the medication refrigerator was not checked and there was no way of knowing if the temperatures were within range for those timeframes. The refrigerator contained an unlabeled multidose vial of the flu vaccine. Licensed Practical Nurse #39 stated the flu vaccine should have been labeled because it was opened and was only good for 28 days. They stated most nursing staff put a 30 day date on the medication. They stated medications carts should be always locked for the safety of the residents. They worked 11/21/2024 on the First Floor medication cart 1-2 and walked away at times without locking the cart and they should have. It was against policy to leave an unlocked cart unattended and a safety concern if residents got into medications or needles. During an interview on 12/2/2024 at 1:11 PM, Assistant Director of Nursing #20 stated they expected medications to be stored safely and securely. Medications should not be administered when expired and all multidose vials should be labeled with the date they were opened and the expiration date. Medication refrigerator temperatures were monitored every day, every shift and documented on the medication refrigerator log to ensure medications were stored at the proper temperatures. If there was no date documented on the log for 24 hours there was no way to determine if the medications were within the proper temperature range. For the stabilization and efficacy of the medications the refrigerator temperatures had to be done every day and every shift. They stated they had wandering residents on both floors. They were not aware the door to the Second Floor Omnicell room and medication refrigerator was unlocked until they were notified by Registered Nurse #21 on 11/25/2024. They were notified the lock was broken. The door should not have been unlocked as it was a safety concern because the room contained medications. 10NYCRR 483.45 (g)(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the recertification and extended survey conducted [DATE]-[DATE], the facility did not ensure an effective training program for all new and existing staff was developed, implemented, and maintained based on the facility assessment for 4 of 5 staff (Licensed Practical Nurses #13, #16, #39, and #43) reviewed Specifically, there was no documented evidence Licensed Practical Nurses #13, #16, #39, and #43 had general orientation and required training in accordance with the facility assessment. Findings included: The Facility-Wide Self-Assessment completed [DATE], documented staff competency and care area requirements as identified in the Resident Population Assessment included incontinence/toileting program, dementia care, pressure ulcer prevention and treatment, technical skills, and pain management. Annual training requirements per regulatory authority and/or facility policy included job responsibilities and line of authority, facility policies and procedures, and other areas identified as areas of weakness during annual performance review/competency evaluation. The facility Administrator documented a nursing education policy was not available when requested. Nursing Staff Education folders were reviewed: - Licensed Practical Nurse #43, hired [DATE], did not have documented evidence of facility orientation or nursing competency for medication administration or pressure prevention and treatment. - Licensed Practical Nurse #16, hired [DATE], did not have documented evidence of annual nursing competency for medication administration or pressure prevention and treatment. - Licensed Practical Nurse #39, hired [DATE], did not have documented evidence of facility orientation or nursing competency for medication administration or pressure prevention and treatment. - Licensed Practical Nurse #13, hired [DATE], did not have documented evidence of annual nursing competency for medication administration or pressure prevention and treatment. During an interview on [DATE] at 2:41 PM, Licensed Practical Nurse #13 stated the Director of Nursing watched them administer medications when they first started. They stated the facility had in-service education, but they would just have a paper to sign. They were told to read the paper and sign, so they were not sure what the trainings were on. During an interview on [DATE] at 2:46 PM, Licensed Practical Nurse #43 stated they did not recall any formal paperwork or training, they worked alongside another agency nurse who showed them how they did things. They did not recall any formal training. During an interview on [DATE] at 9:09 AM, Licensed Practical Nurse #39 stated they may have received a packet about medication administration, but they did not look at it. They stated no one at the facility showed them how to do medication administration at the facility. They worked alongside another nurse for approximately 2 hours, from 6:00 AM until breakfast and then they were on their own. They stated they did not receive facility education for pain management, dressing changes, or pressure wound prevention. They were not observed by a facility nurse when completing a dressing change. It was important to get education on wound care, because without proper wound care the resident could get an infection, sepsis, or a worsening wound. They should review any specific policies for their facility regarding medication administration, but education for medication administration was not important as they knew medications and how to administer them from previous experience. During an interview on [DATE] at 9:40 AM, Licensed Practical Nurse #16 stated they completed a medication test when they were oriented 10 years ago, and it was not done annually. Medication storage was reviewed during their orientation as well. They stated they thought they were one of the few people that had a good orientation. The last education they had regarding pain management was with a different facility educator that had been gone about 8 years. They did not have competencies related to pressure wound prevention and treatment or medication administration annually. They were not sure if the facility staff and agency staff received the same training, but the facility staff oriented with another nurse on the unit. It was important to have education for medications as nurses should know what they were giving, and that it was administered correctly. During an interview on [DATE] at 9:58 AM, Registered Nurse #21 stated they were responsible for staff education in the facility. The documentation provided was all the training the staff had on file. If an audit or observation was done of a specific staff member it would be in their provided folders. Agency staff had the education they needed coming to the facility, and they spent a day on the unit. There was a checklist for easier flow of training, but it had not been done that way. They did not have a current orientation process when staff were hired. Medication administration observation was done between a newly hired and the floor nurse they were paired with. If the floor nurse noticed an issue, they notified them or the Director of Nursing. They stated they would then observe the nurse and provide re-education if needed. They were not sure if the floor nurses the new hires were paired with had formal competencies completed. They stated that formal competencies for dressing changes were not completed prior to direct resident care. There were no formal checklists or observation tools for medication administration unless they were conducting an audit, or they were made aware of an issue. Of the 5 nurses picked for review, none of them had formal medication administration observations completed. Registered Nurse #21 stated given there were no formal competencies, they could not ensure nursing skill competency prior to direct resident care. Medication administration education was important, so medications were administered appropriately, not expired, and were effective for the resident. It was important to have wound prevention and treatment education, so wounds did not develop. They stated they had a lot of work to do to ensure trainings met the facility assessment. The pieces that were required on the Facility Assessment were covered throughout the year. Depending on when staff were hired, they would not get all the pieces before direct patient care, but they tried to complete in-services within the first year to meet the assessment requirements. During an interview on [DATE] at 11:39 AM, the Administrator stated that all new hires had nursing competencies completed before resident care occurred. There was formal education for all new hires that was department specific, and the facility did in-service education for the mandatory education and areas they thought were needed. It had been a while since they last audited nursing education. 10 NYCRR 415.26

Based on record review, observations, and interviews during the recertification and abbreviated (NY00359606) surveys conducted 11/7/2024-12/4/2024, the facility did not ensure residents had a safe, clean, comfortable, and homelike environment for 2 of 2 nursing units. Specifically, there was no hot water in the facility from 10/29/2024-11/8/2024. Additionally, resident's or resident representatives were not immediatley notified of the lack of hot water. Findings include: The undated facility policy, Safety of Water Temperatures, documented tap water in the facility should be kept within a temperature range to prevent scalding of residents. Water heaters that serviced resident rooms, bathrooms, common areas, and tub/shower areas were set at temperatures of no less than 105 degrees Fahrenheit and no more than 120 degrees Fahrenheit. Maintenance staff conducted daily tap water temperature checks using a calibrated digital thermometer at various locations in the facility and recorded the water temperatures in a safety log. If water temperatures fell outside the specified range, the maintenance department adjusted the water heating or cooling system as necessary and rechecked the temperatures. The October 2024 and November 2024 water temperature logs documented the following temperatures at each of the four tested sites (Unit-1 dining room, Unit-1 north shower room, Unit-2 North shower room, Unit-2 dining room): - on 10/1/2024-10/28/2024 - all temperatures were documented between 117 and 133 degrees Fahrenheit - on 10/29/2024 97 degrees Fahrenheit, 96 degrees Fahrenheit, 96 degrees Fahrenheit, 95 degrees Fahrenheit - on 10/30/2024 75 degrees Fahrenheit, 75 degrees Fahrenheit, 76 degrees Fahrenheit, 75 degrees Fahrenheit - on 10/31/2024 75 degrees Fahrenheit, 75 degrees Fahrenheit, 75 degrees Fahrenheit, 76 degrees Fahrenheit - on 11/1/2024 76 degrees Fahrenheit, 76 degrees Fahrenheit, 75 degrees Fahrenheit, 76 degrees Fahrenheit - on 11/2/2024 no recorded temperatures - on 11/3/2024 no recorded temperatures - on 11/4/2024 73 degrees Fahrenheit, 74 degrees Fahrenheit, 75 degrees Fahrenheit, 74 degrees Fahrenheit - on 11/5/2024 73 degrees Fahrenheit, 75 degrees Fahrenheit, 74 degrees Fahrenheit, 73 degrees Fahrenheit - on 11/6/2024 73 degrees Fahrenheit, 74 degrees Fahrenheit, 75 degrees Fahrenheit, 74 degrees Fahrenheit - on 11/7/2024 73 degrees Fahrenheit, 74 degrees Fahrenheit, 73 degrees Fahrenheit, 73 degrees Fahrenheit - on 11/8/2024 127 degrees Fahrenheit, 124 degrees Fahrenheit, 123 degrees Fahrenheit, 126 degrees Fahrenheit (after new pump installation) During an observation on 11/7/2024 at 12:22 PM, a cooler of water was on the counter at the nurse's station on Unit-1 and the water was measured at 96 degrees Fahrenheit. There were wiping clothes next to the cooler. During an interview on 11/7/2024 at 12:34 PM, Registered Nurse #21 stated the cooler was used for incontinence care and a bath in a bag (a no-rinse, disposable bathing system) was used for providing bed baths to residents. Staff were trained on how to administer the bath in a bag product. The facility's in-service sign in sheets for the bath in a bag procedure documented each unit had been trained on the procedure on 11/7/2024 (approximately 2 weeks after low water temperatures were identified) and was signed by Certified Nurse Aide #44 and Certified Nurse Aide #45. During an interview on 11/7/2024 at 12:49 PM, Certified Nurse Aide #44 stated they were using wash cloths from the cooler to bathe residents prior to this morning when they received the bath in a bag product. They stated some residents were not happy they could not shower in the shower room. During an interview on 11/7/2024 at 12:55 PM, Certified Nurse Aide #45 stated they were using wipes that were warmed in the microwave to wash residents. They were not sure why this product was only available starting 11/7/2027 since the facility had been without hot water since 10/30/2024. Before this they only had the cooler at the nurse's station and a washcloth. They stated residents were not happy they were not being showered because of the lack of hot water and staff were trying to use shower caps so at least the resident's hair was washed. During an observation and interview on 11/7/2024 at 1:32 PM, Maintenance Technician #9 stated they checked the water temperature in the building first thing in the morning with a probe thermometer. They checked the first-floor bathroom outside the dining room, then the small shower room on Unit-1, then the small shower room on Unit-2, and finally the Unit-2 dining room. They stated they were looking for temperatures from 90-120 degrees Fahrenheit and if they were out of range, they notified the Maintenance Director. The temperatures on 10/29/2024 were lower than normal and they notified the Maintenance Director. The stated their vendor came on site on 10/29/2024 and identified a water pump was broken and was supposed to be fixed, but the vendor had not shown up yet. The Unit-1 dining room water temperatures were measured with Maintenance Technician #9. The surveyor measured 74.7 degrees Fahrenheit, and the maintenance technician measured 73.3 degrees Fahrenheit with their thermometer. During an interview on 11/7/2024 at 1:49 PM Resident #20 stated they did not have hot water. They stated they were informed about the issue when the facility announced that residents would not get showers for the week. They stated they were not happy with the situation and would rather shower with cold water than be washed in bed with wash cloths. During an interview on 11/7/2024 at 1:58 PM, Resident #61 stated they did not have hot water for 2 weeks and needed it now. They were told there was no hot water because the facility needed parts. They stated they would love to have a hot shower. During an interview on 11/7/2024 at 2:54 PM, the Assistant Director of Nursing #20 stated residents were informed about the lack of hot water and were upset about the food being served on paper plates. They were not sure if families were notified there was no hot water in the facility. They stated the bath in a bag product could be warmed in the microwave was purchased because of the lack of hot water. They stated the repair was taking so long because it was a specialty part that had to come from Buffalo. During an interview 11/7/2024 at 3:08 PM Director of Nursing #2 stated they received the bath in a bag product on 11/6/2024. Prior to receiving the bath in a bag, they were using disposable wipes and wash cloths that were observed in the coolers on the units. Residents were notified about the lack of hot water when personal hygiene was provided, and some were not happy because they wanted a hot shower. They were not sure why it was taking so long to fix; the Maintenance Director was not working this week and they were the one to follow up with regarding the part, delivery, and installment when they returned. They did not believe families were officially notified about the lack of hot water and they should have been. During an interview on 11/7/2024 at 3:16 PM, the Administrator stated they recently started using bath in a bag as an alternative option for a regular shower due to the lack of hot water in the facility. Residents were told by staff about the loss of hot water as they gave care, and no official announcement was made. Initially the repair was going to take 3-5 days, and only one resident family came to them to discuss the lack of hot water. Families were not notified about the lack of hot water. They stated the residents were only supposed to get a shower once a week so they did not think it was that much of an inconvenience, but they would not like to go 10 days without a hot shower. They did not notify the Department of Health because they never lost water, they just did not have hot water. The Administrator stated the repair was taking longer to fix than expected because the contractor only had one pump available. An email correspondence between the Administrator, the Maintenance Director, and their vendor documented the following: - on 10/29/2024 at 4:50 PM, a quote for the repair was provided to the facility. - on 10/29/2024 at 5:46 PM, the Administrator asked the Director of Maintenance if the pump was replaced today. - on 10/30/2024 at 5:30 AM, the Director of Maintenance stated the vendor needed a part, one was available in Rochester, and the vendor would go get that for a fee or it would not get fixed until Friday (11/1). - on 11/4/2024 at 4:05 PM, the vendor replied they were sorry for the delay, but there was an issue with their payment. - on 11/5/2024 at 8:53 AM, Director of Finance #55 replied that the issue with payment was due to the credit card having been maxed out again. 10 NYCRR 415.29 (f)(6), (j)(1)

Based on observations, record review, and interviews during the recertification survey conducted 11/21/2024-12/4/2024 the facility did not store, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and for 1 of 1 resident (Resident #34) reviewed. Specifically, Resident #34's food was handled directly by staff without the use of gloves. In the main kitchen foods in the kitchen walk-in cooler were not properly labeled; floors had debris and uncleanable surfaces; there were unclean surfaces and equipment; walls were in disrepair; and the dishwasher sanitizer was not maintained at the vendor recommended level. Findings include: The facility policy, General Kitchen Cleaning Policy, dated 2/2019, documented all food contact surfaces would be properly cleaned and sanitized. The undated facility policy, Food Storage, documented food would be kept safe, wholesome, and appetizing; food would be stored at appropriate temperature and by methods designed to prevent contamination or cross contamination; food would be dated as it was placed on the shelves; and all containers or storage bags must be legible and accurately labeled and dated. The undated facility policy, General Food Preparation and Handling, documented food items would be prepared to conserve maximum nutritive value, develop, and enhance flavor and keep from harmful organisms and substances and kitchen surfaces and equipment would be cleaned and sanitized as appropriate. The undated facility policy, Bare Hand Contact with Food and Use of Plastic Gloves, documented single - use gloves would be worn when handling food directly with hands to assure that bacteria was not transferred from the food handlers' hands to the food product being served. Bare hand contact with food was prohibited. 1) Resident #34 had diagnoses including moderate protein-calorie malnutrition. The 9/2/2024 Minimum Data Set assessment documented the resident was cognitively intact and required set up assistance for eating. The 9/6/2024 comprehensive care plan documented the resident was able to feed themself after tray set-up. During a lunch meal observation on 11/21/2024 at 12:32 PM, Certified Nurse Aide #30 spread mayonnaise on Resident #34's sandwich and put the bread back on the remaining sandwich components with bare hands. During an interview on 12/2/2024 at 2:04 PM, Certified Nurse Aide #30 stated they helped Resident #34 put condiments on their sandwich, as the resident needed assistance with that task, and always got a sandwich with lunch. If they helped a resident with their food, they should wear gloves. They stated they could not recall if they helped Resident #34 with their sandwich on 11/21/2024, but they would have worn gloves. It was important to wear gloves due to cross contamination and germs. During an interview on 12/3/2024 at 11:08 AM, Registered Nurse #21 stated they were the facility's infection control nurse. They stated the expectation for hand hygiene and food service was that hands were washed prior to serving food. Staff should wear gloves when handling food. 2) During observations in the main kitchen on 11/21/2024 at 9:45 AM, the walk-in cooler had opened, undated bags of parmesan and Monterey cheeses; opened, undated packages of turkey bologna, genoa salami, and bacon; opened, undated containers of sour cream, dill aioli, and buttermilk ranch dressing; and an undated box of 13 tomatoes that had green, fuzzy material on them. On 11/25/2024 at 11:21 AM, the following observations were made in the main kitchen: - the floor tiles in the dry storage room were chipped and strip molding not fully fastened to the floor. - the second dry storage room had onion skins and other food debris under the wire rack shelving. There were cobwebs and two mouse traps (one dated 12/23) behind the entry door. - the microwave had red food splatter on all interior surfaces. - the wall under the 3 bay sinks had tiles missing exposing the wall studs. - the bag in box dispensing nozzle had a dried substance in it. - the exterior and interior of the drink cooler had dried splatters. - the area around the grease trap was soiled with food debris and dried splatters. During an interview on 11/26/2024 at 10:01 AM, the Food Services Director stated the following: - The evening shift should mop the area around the grease trap daily; clean the refrigerators and interior of microwave daily; and sweep and mop all floors including behind doors daily. They stated it did not look like they had been doing any of that. - Any food that was opened should be dated with the month and day. Once opened it was good for three days except lunch meats and cheese which were good for 5 days. The tomatoes should have been removed from the cooler when the new ones were put in. The bacon should not be left exposed in a box. Expired, moldy, or exposed foods could pick up mold spores and if a resident ate them, it could cause them to become sick. - The tile under the 3 bay sinks was removed while investigating a leak and was never replaced and they thought a repair estimate was obtained months ago. - Most drinks were poured from the bag in box system. At the end of the night, the nozzles were put in a bucket of hot water and soaked for 15-20 minutes. They stated the nozzles had gross, dried brown/pink/fuzzy debris that looked like mold. Clean nozzles were important because the juice that passed through those nozzles was contaminated, and if a resident drank it, it could make them sick. They stated drinks had been poured from those nozzles for lunch that day and because of the moldy nozzle, they directed all drinks for the upcoming meal be re-poured. - They checked the dishwasher sanitizer level every morning using test strips but did not document the result. The 12/5/2007 Ecolab Installation and Operation Manual for the ES Series Door Type, Chemical Sanitizing, Single and Dual Rack Dish Machines documented the minimum chlorine required for Model ES4000 was 50 parts per million. The facility's dishwasher sanitizer level log was not available from the facility. During an observation and follow up interview on 11/26/2024 at 10:48 AM, the Food Services Director cycled the ES400 model dishwasher then tested the water with a chlorine test paper. The result was between 100 and 200 parts per million. They were unsure what it was supposed to be but thought they were told between 100 and 200 parts per million. If the sanitizer was greater than 200 parts per million it could cause sickness, chemical burns, respiratory issues, and make residents sick. If the sanitizer was below 100 parts per million the dishes would not be sanitized, bacteria could remain on the dishes and cause residents to become sick. 10NYCRR 415.14(h)

Based on observations, record review, and interviews during the abbreviated survey (NY00359606) conducted 11/7/2024, and the recertification and extended surveys conducted 11/21/2024-12/4/2024, the facility did not ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, administration failed to ensure that residents received appropriate quality of care by allowing the following deficient practices to exist, placing residents at risk for serious injury, serious harm, serious impairment, or death, F 689 Accident Hazards and F 700 Bedrails; failed to ensure policies and procedures were properly identified, communicated, and consistently implemented; was not aware of the extent of the deficient practices cited; and did not report equipment failure when the facility did not have hot water for 10 days. Additionally, administration did not provide surveyors with requested and required documents (form CMS-802, Matrix for Providers; staffing schedules; beneficiary notices; key personnel information; and facility assessment) in a timely manner, which impeded the survey process. Findings include: The facility job description, Job Title: Administrator, dated 12/16, documented the Administrator was responsible for being the point person for any inquiries, maintenance concerns, etc. The duties and responsibilities included: being Responsible for overseeing the day-to-day operations of the skilled nursing facility and ensuring compliance with all regulatory agencies governing healthcare delivery and rules of certifying bodies by continually monitoring operations, programs, and the physical plant. They were to keep up to date on changes in the regulatory environment and provide direction to facility staff. The facility policy, Quality Assurance and Performance Improvement Program, dated 12/2023, documented the objective of the Quality Assurance and Performance Improvement Program was to provide a means to measure current and potential indicators for outcomes of care and quality of life. The administrator was responsible for assuring that this facility's Quality Assurance and Performance Improvement program complied with Federal, State, and local regulatory agency requirements. The Quality Assurance and Performance Improvement committee reported directly to the administrator. The Quality Assurance and Performance Improvement plan described the process for identifying and correcting quality deficiencies. Key components of this process included tracking and measuring performance; establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies; systematically analyzing underlying causes of systemic quality deficiencies; developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. Deficient Practice Information: Resident's Free from Accident, Refer to the citation text under F689. The facility failed to ensure the residents' environment remained free of accident hazards for 2 of 2 resident units (First and Second Floors). Specifically, hot water temperatures in resident sinks and common shower rooms on the First and Second Floors exceeded temperatures of the 110 degrees Fahrenheit standard. This resulted in no actual harm with likelihood of serious harm, serious injury, serious impairment, or death that is Immediate Jeopardy and Substandard Quality of Care for all 70 residents residing in the facility. Bed Rail, Refer to the citation text under F700. The facility failed to ensure correct installation, use, and maintenance of bed rails to ensure there was no gap between the bed rail and mattress wide enough to entrap a resident's head or body for 5 of 5 residents (Residents #2, #14, #29, #33, and #46) reviewed. Specifically, Residents #2, #14, #29, #33, #46 did not have routine inspections of their mattress and bed rails for areas of possible entrapment. Additionally, the facility failed to evaluate alternatives to bed rails, failed to review the risks and benefits of bed rails with the resident or resident representative, and failed to obtain informed consent prior to the installation of bed rails. This resulted in no actual harm with likelihood of serious harm, serious injury, serious impairment, or death that is Immediate Jeopardy for all 32 residents with bed rails. Safe, Clean, Comfortable Environment, Refer to the citation text under F584. The facility did not ensure residents had a safe, clean, comfortable, and homelike environment for 2 of 2 nursing units. Specifically, there was no hot water in the facility from 10/29/2024-11/8/2024. During an interview on 11/7/2024 at 3:16 PM, the Administrator stated the families were not notified when the facility was without hot water. The Administrator stated that being without water would require notification, but the facility had interventions to substitute for the lack of hot water in many cases. The facility was without hot water for 10 days. They did not notify the Department of Health, as they thought the lack of hot water would be fixed in a shorter time. They stated they thought they had their bases covered with the interim measures they had in place. During an interview on 11/22/2024 at 5:55 PM, the Administrator stated if the facility was not using the bed measuring tool, they did not know where it was. They purchased a tool when they started at the facility in October of 2020. During an interview on 11/29/2024 at 12:22 PM, the Administrator stated that the previous Administrator had approval from the Board of Directors to buy 20 beds in 2019 or 2020. When the Board of Directors approved the spending, the previous Administrator got 50 of the cheaper beds at the same price as the 20 beds that were originally approved for. The cheaper beds were the beds currently being used in the facility. They stated the beds were meant for home use, not for institutional use. The bed manual outlined the use of half or full rails, which they would not use in their facility. The bedrails used on the beds were purchased as over market devices, not specific to any type of bed. During an interview on 12/4/2024 at 11:39 AM, the Administrator stated there were no current audits for bedrails or water temperatures. Additionally, they stated there were no current audits for hand hygiene, call bell times, activities of daily living, nursing education and competencies, pressure wound prevention, or care plans. Survey Required Documents: The recertification survey team entered the facility on 11/21/2024 at 9:30 AM. During the entrance conference interview on 11/21/2024 at 9:41 AM, the Administrator was provided a hardcopy of the entrance conference documents required for survey and included items that needed to be submitted electronically. Items were grouped together by the time frames they were required. Information required from the facility immediately upon entrance included the complete matrix for new admissions; within one hour of entrance schedules for all staff, separated by department, for the survey time period and a list of key personnel with their location and phone number; within four hours of entrance the Facility Assessment; and within 24 hours of entrance beneficiary notices. The following required recertification survey documents were received: - The facility mealtimes were received on 11/21/2024 at 3:12 PM (over 4 hours late). - The food menus were received on 11/22/2024 at 10:35 AM for the regular menus (over 23 hours late) and 10:39 AM for the therapeutic menus (over 23 hours late). - The infection prevention control program was received on 11/22/2024 at 12:25 PM (over 22 hours late). - The Beneficiary Notice List was received on 11/27/2024 at 5:44 AM (over 4 days late). - The Facility Assessment was received on 11/27/2024 at 8:17 AM (over 5 days late). - The Key Personnel List was received on 11/27/2024 at 8:17 AM (over 5 days late). - The Quality Assurance and Performance Improvement committee information was received on 11/29/2024 at 1:15 PM (over 7 days late). - The Nursing Staff schedule was received on 12/2/2024 at 1:54 PM (over 11 days late). - The Environmental Services schedule was received on 12/2/2024 at 2:28 PM (over 11 days late). - The Nutrition and Food Service schedule was received on 12/2/2024 at 3:42 PM (over 11 days late). On 11/21/2024 at 10:12 AM, an electronic copy of the entrance conference documents for survey was sent to the Administrator outlining all the required documents and items discussed during the Entrance Conference interview. On 11/21/2024 at 1:18 PM, the form CMS-802, Matrix for Providers was requested from the Administrator a second time, as the document provided was a website that could not be opened. Additionally, an electronic mail was sent stating there were several documents missing based on the time frame needed. These included mealtimes, menus, medication administration times, key personnel list, and infection prevent information. On 11/22/2024 at 8:39 AM, an electronic mail was sent to the Administrator stating the following items were still missing or incomplete: - Information Needed from the Facility with one hour of Entrance included menus; medication storage information; schedules for all staff, separated by department, for survey time period; and key personnel list. - - Information needed from the facility within four hours of entrance included infection prevention and control information; Quality Assurance and Performance Improvement plan and committee information; and the Facility Assessment. On 11/26/2024 at 10:43 AM, an electronic mail was sent to the Administrator stating the following items were still missing or incomplete: - Information needed from the facility with one hour of entrance included schedules for all staff, separated by department, for survey time period; and key personnel list. - Information needed from the facility within four hours of entrance included Quality Assurance and Performance Improvement committee information; and the Facility Assessment. - Information needed from the facility within 24 hours of entrance included the beneficiary notice list, as the one sent was blank. On 11/29/2024 at 12:04 PM, an electronic mail was sent to the Administrator stating the following items were still missing or incomplete: - Information needed from the facility with one hour of entrance included schedules for all staff, separated by department, for survey time period. - Information needed from the facility within four hours of entrance included Quality Assurance and Performance Improvement committee information. During an interview on 11/29/2024 at 12:22 PM, the Administrator was reminded about missing Entrance Conference documents during. During an interview with the Administrator on 12/2/2024 at 11:19 AM, the Entrance Conference staffing schedules were requested again. The Administrator stated that staff's timecards were sent. It was explained that the Department of Health surveyors were looking for schedules related to who was in the building and when, not how many hours were worked by the staff. During an interview on 12/2/2024 at 11:20 AM, the Nursing Staff Coordinator #54 stated they had the schedule for the nursing staff for the month and they would scan the documents for the Administrator to send. During a follow-up interview on 12/2/2024 at 1:11 PM, the Nursing Staff Coordinator #54 stated they sent the nursing schedules to the Administrator via electronic mail on 12/2/2024 at 11:21 AM. During an interview on 12/2/2024 at 1:37 PM, the Entrance Conference staffing schedules were requested from the Administrator again. 10 NYCRR 483.70(i)

Based on observation, interview, and record review during the recertification survey conducted from 2/21/23-2/24/23, the facility failed to ensure results of the most recent Federal/State survey and Advocate Agency Information were posted in a place readily accessible to residents, family members and legal representatives of residents for 2 of 7 anonymous residents in attendance at the Resident Council meeting. Specifically, the results of the most recent recertification survey, the New York State Department of Health (NYS DOH) Nursing Home complaint hotline, and Ombudsman contact information were not posted in a location that would allow individuals access without having to ask to see them. This is evidenced by: The facility policy Your Rights and Protections as a Nursing Home Resident dated 8/1/21documented residents had the right to be free from abuse and neglect per federal law. The resident should be able to report abuse to the local Long-Term Ombudsman or the state survey agency. The undated facility Resident Handbook documented each resident had the right to call the Long Term Care Ombudsman or NYS DOH when they felt mistreated in any way, or if property had been removed without authorization. The handbook listed the phone contacts for both the Ombudsman and the NYS DOH complaint hotline. During a NYS DOH facilitated resident group meeting on 2/21/23 at 1:28 PM, one anonymous resident stated they were concerned that the survey results and the Ombudsman information were not available on the unit for access to residents. A second resident was also concerned about accessibility of advocacy information. The residents did not want to have to ask staff to access that information. They were not sure if they had been provided that information on admission, or if they still had their admission packet on hand. Due to privacy concerns they did not like having to be accompanied off the unit to access the information. During an observation on 2/21/23 at 2:36 PM, the Long-Term Care Ombudsman contact and NYS DOH hotline contact were observed on a bulletin board by the 1st floor main hallway elevator, outside the locked Unit 1 entrance. Previous survey results were in a binder in the facility's main lobby, also outside the locked Unit 1 entrance. The unit did not have signs posted with the NYS DOH or Long Term Care Ombudsman contacts. There were no visible signs on Unit 2 documenting the Long-Term Care Ombudsman contact or the NYS DOH hotline numbers. Unit 2 had a locked doorway requiring code accessibility from the main elevators. When interviewed on 2/24/23 at 12:06 PM, registered nurse (RN) #2 stated Unit 1 was locked to prevent residents from wandering and to prevent unacknowledged visitation. The RN stated the Ombudsman contact, NYS DOH hotline contact, and previous survey results should be accessible to each resident without staff assistance. Residents did not have the codes to unlock unit entrance doors. When interviewed on 2/24/23 at 12:19 PM, the Administrator stated Unit 1 was locked to protect residents from wandering and to prevent visitors from entering without facility screening. Residents could not leave the unit without staff assistance as they did not have the code to the door. Staff were expected to help a resident off the unit if asked and to accompany them unless they were being escorted by a family member. Past survey results and Ombudsman information should be accessible to each resident without them asking for help. The Ombudsman info and NYS DOH hotline number was in the admission packet the residents should have received. 10NYCRR 415.3 (1)(c)(1)(v) 10NYCRR 415.3 (c)(2)(i)(b)

Based on observation and interview during the recertification survey conducted 2/21/23-2/24/23 the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one isolated area in the main kitchen (the walk in cooler). Specifically, the flooring of the main kitchen's walk in cooler was not smooth and easily cleanable as required. Findings include: During observations on 2/21/23 at 10:05 AM, and 2/22/23 at 1:00 PM, the walk in cooler floor in the main kitchen was rusted, not smooth, and not easily cleanable. Two large sections of metal panel flooring with a metal transition strip in between had raised edges. The raised front edge was a tripping hazard and allowed food debris underneath. During an interview with the Food Service Director on 2/21/23 at 10:05 AM, they stated the walk in cooler flooring was replaced about a year ago by maintenance. They were not sure why the flooring rusted so quickly. They stated the flooring was difficult to clean and they were not sure that was the right type of metal used for walk in cooler floors. During an interview on 2/22/23 at 3:00 PM, the Director of Facilities stated they were not working at the facility when the flooring was installed, and they did not know of any work orders that addressed the flooring. They stated the flooring should not be rusting if it was an appropriate material for a walk in cooler. 10NYCRR 415.14(h)

Based on record review and interview during the recertification survey conducted 2/21/23-2/24/23, the facility failed to ensure assessment of residents using the quarterly review instrument specified by the State and approved by the Centers for Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for 35 of 65 residents (Residents #1, 4, 5, 6, 7, 8, 11, 12, 13, 15, 17, 20, 21, 22, 23, 24, 26, 27, 29, 30, 31, 35, 39, 40, 42, 43, 44, 45, 46, 47, 48, 50, 51, 52, and 57) reviewed for resident assessments. Specifically, Residents #1, 4, 5, 6, 7, 8, 11, 12, 13, 15, 17, 20, 21, 22, 23, 24, 26, 27, 29, 30, 31, 35, 39, 40, 42, 43, 44, 45, 46, 47, 48, 50, 51, 52, and 57 had Minimum Data Set (MDS) assessments that were completed later than 14 days following the Assessment Reference Date (ARD). Findings include: The undated facility policy Resident Assessment documented a comprehensive assessment of every resident's needs was made at intervals designated by the Omnibus Budget Reconciliation Act (OBRA) and Prospective Payment Systems (PPS) requirements. The Resident Assessment Instrument (RAI) User's Manual (Chapter 2) provided detailed information on timing and submission of assessments. The first comprehensive assessment must be within 14 calendar days after admission, thereafter a quarterly assessment must be within 92 days from the assessment reference date (ARD) of the previous assessment. A comprehensive assessment included completion of the Minimum Data Set (MDS), completion of the care area assessment (CAA) process, and development of the comprehensive care plan. The results of the assessments were used to develop, review, and revise the resident's comprehensive care plan. 1) Resident #43 had diagnoses including Alzheimer's disease, chronic major depressive disorder, and aphasia (difficulty speaking). The quarterly MDS assessment documented an ARD of 12/29/22 and was not completed as of 2/24/23. 2) Resident #8 had diagnoses including Parkinson's disease (a progressive neurological disease), unspecified dementia, and essential hypertension. The quarterly MDS assessment documented an ARD of 12/21/22 and was not completed as of 2/24/23. 3) Resident #35 had diagnoses including Alzheimer's disease, bipolar disorder, and age-related osteoporosis. The quarterly MDS assessment documented an Assessment Reference Date ARD of 11/28/22 and was not completed as of 2/24/23. During an interview on 2/24/23 at 11:22 AM, the Minimum Data Set (MDS) Coordinator stated MDSs were supposed to be done on admission, quarterly, with a significant change, and annually. The MDS Coordinator stated they were responsible for ensuring the assessments were complete. The MDSs were supposed to be submitted 2 weeks after a significant change and 1 week for all other assessments. The information was gathered from resident and staff interviews, and the resident's chart. The MDS Coordinator stated they had been doing the MDSs at the facility for about a year and half. During a second interview on 2/24/23 at 11:55 AM, the MDS Coordinator stated they had been acting as the Infection Preventionist nurse since November and was in the process of training a new Infection Preventionist. They stated they also helped with discharge planning as the social worker left in January and a new one was to start employment 2/27/23. They were aware of the outstanding MDS assessments. They stated the assessments were late because they helped in other areas and did not have enough time to complete them. The MDSs not being up to date could affect resident care because the comprehensive care plan (CCP) may not be updated appropriately if MDS assessments were not current. They stated if the CCP was not updated it could affect resident care needs. During an interview on 2/24/23 at 12:28 PM, the Administrator stated MDS assessments were supposed to be done in the system by each department for their areas of care. Routine assessments should be done every 120 days and if they were not up to date, the resident care needs may not be current. The Administrator stated facility payment was also affected by the assessments not being completed. They were not aware there were assessments over 120 days old and they expected to be notified by the MDS coordinator or the Director of Nursing about the late assessments. 10NYCRR 415.11(a)(4)

Based on observation, interview and record review during the recertification and abbreviated surveys (NY00252336), the facility did not ensure the resident environment remained free of accident hazards for 1 of 4 residents (Resident #59) reviewed. Specifically, Resident #59 sustained a fall when the bed lock was broken and the bed moved during a transfer. The resident's current bed was observed with a missing wheel lock. Findings include: The maintenance policy for PCREE (Patient Care Related Electrical Equipment) and non-PCREE equipment dated 11/3/17, documented if no manufacturer maintenance recommendations can be obtained this will be noted in the book and an inspection will be done monthly. The 2/19 facility policy Preventative Maintenance and Inspection documented that in order to provide a safe environment for residents, employees, and visitors, a preventative maintenance program had been implemented to keep equipment in a state of good repair and condition. Routine inspections promote safety throughout the facility and aid in keeping equipment in good working order and operating in accordance with the manufacturer's guidelines. Resident #59 had diagnoses including Parkinson's Disease and dementia without behavioral disturbances. The 7/27/20 Minimum Data Set (MDS) assessment documented the resident was cognitively impaired and independent with transfers. The 2/3/20 incident report documented at 11:55 AM, a housekeeper found Resident #59 on the floor in the resident's room. The investigation documented the resident attempted to sit on the bed, the brakes on the bed were not working, and the resident fell. The resident landed on the left knee and hit the left shoulder on the bed resulting in a bruise on the left shoulder. The resident landed on their buttocks on the floor. A maintenance request was made for the bed to be fixed and it was fixed that day. The certified nurse aide (CNA) care instructions active in 9/2020 documented the resident was independent with bed mobility and transfers. During an interview with CNA #15 on 9/23/20 at 11:49 AM, she stated the resident's bed wheels should always be locked prior to transfers. During the interview, the surveyor observed the resident's bed with the CNA. The wheel brakes were locked on 3 wheels and one wheel lock was missing. The bed shifted when pushed. The CNA stated she did not know the lock was missing. If she was aware, she would have notified the Unit Manager. During an interview with licensed practical nurse (LPN) Assistant Unit Manager #23 on 9/23/20 at 12:45 PM, she stated she had not been informed of any issues with the resident's bed wheel locks. The last time the resident had a fall, it was related to brakes not working on the bed and the resident was moved to a new room. The resident's bed was to be locked at all times. During an interview with registered nurse (RN) Unit Manager #24 on 9/23/20 at 12:50 PM, she observed the resident's bed and stated there was a wheel lock missing at the head of the bed. She stated the brakes were to be locked at all times on the bed. During interview on 9/24/20, between 2:05 PM and 2:45 PM, the Maintenance Director stated he was not aware that routine PCREE electric bed maintenance was not being documented. 10NYCRR 415.(h)(1)

Based on observation, interview and record review, the facility did not ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional standards, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication rooms (Unit 1) observed. Specifically, the Unit 1 medication room contained expired floor stock multi-vitamins and laxatives. Additionally, the refrigerator contained medications and batteries that were frozen into a sheet of ice. Findings include: The undated facility policy General Rules Concerning Medications did not address disposal of expired medications or refrigerator care and monitoring. During an observation of the Unit 1 medication room on 9/23/20 at 8:32 AM with licensed practical nurse (LPN) #5, the following floor stock medications were observed: -3 bottles of multi-vitamins all with a manufacturer expiration date of 08/2020; and -3 bottles of 5 mg Bisacodyl laxative capsules all with a manufacturer expiration date of 07/2020. During the observation on 9/23/20 at 8:32 AM, the refrigerator and floor stock shelving was a combined large stainless-steel wall unit. The refrigerator was observed to contain a large sheet of ice that had formed along the back wall and onto the second and third shelves. The second shelf contained several boxes of foiled wrapped acetaminophen suppositories and a small tub of glycerin suppositories that were frozen into the ice and not able to be removed. The third shelf contained multiple boxes of batteries, frozen in the ice, that could not be removed. The battery and suppository boxes were soggy and falling apart. The temperature was observed to be 44 degrees Fahrenheit. There was no temperature log present for 9/2020; the 8/2020 temperature log for days 1-15 had 4 entries only. When interviewed during the observation on 9/23/20 at 8:32 AM, LPN #5 stated nurses were to check for expired medications when they reordered them. He said they probably got missed because the facility did not use those brands anymore. He stated he did not know the policy but would let maintenance know about the ice in the refrigerator. He stated the temperature was to be checked twice daily and overnight staff were to check the temperatures. He stated the temperature log for September would normally be hanging on the bulletin board with the others. During an interview on 9/23/20 at 3:25 PM, registered nurse (RN) Unit Manager #8 stated maintenance was responsible for maintaining the refrigerator and he did not know their process for defrosting. He was unsure if there was a scheduled process, but nursing was supposed to check for expired medications on the night shift. He put the expiration dates on the bottles in black marker so they could be seen easier, and when more were obtained the newer medications were to be placed behind the older ones to rotate the stock. He expected the staff to check the dates every day, so the residents were not given expired medications. 10NYCRR 415.18(e)(1)(4)

Based on observation, interview, and record review during the recertification survey, the facility did not store food in accordance with professional standards for food service safety for 1 of 1 walk-in cooler (main kitchen walk-in cooler). Specifically, the main kitchen walk-in cooler had a coolant unit compressor that was spitting/leaking water onto food containers. Findings included: During an observation on 9/22/20 at 3:00 PM, the main kitchen walk-in cooler had a metal pan that was full of water on the top shelf located under the coolant unit compressor. The coolant unit compressor was spitting/leaking water into the metal pan, and on top of various jars of food. Three paper boxes for individual yogurts on the shelf beneath the metal pan were water damaged/wet. There was a bin of 7 individually wrapped sandwiches and a container of wrapped lettuce (approximately 1/2 pound) with a water puddle on top of it. These items were immediately voluntarily discarded. During an observation on 9/24/20 at 3:00 PM, the main kitchen walk-in cooler had a metal pan on the top shelf located under the coolant unit compressor. The coolant unit compressor was defrosted, and there was a small piece of glass in place to redirect the splash of water toward the pan. Water was dripping out of the metal pan onto empty shelves. During an interview on 9/22/20 at 3:00 PM, the Food Service Director stated he was not aware the metal pan was being used to collect leaking compressor water. He stated no one notified him that the coolant unit compressor was leaking and there were no work orders for the leaking compressor. 10NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification and abbreviated (NY00250230) surveys, the facility did not provide a safe, functional, sanitary, and comfortable environment for residents on 2 of 2 nursing units (Units 1and 2). Specifically, the ice machines, nourishment room countertops and shower rooms were not maintained. Findings include: 1) Ice Machine Maintenance: The ice machine user's manual for the ice machine used on both Units 1 and 2 documented ice machine maintenance and cleaning should be scheduled at a minimum of twice a year. Sanitizing of the ice storage bin should be scheduled for a minimum of four times a year. During an observation on 9/22/20 at 11:20 AM, the Unit 1 nourishment room ice machine tray was discolored with calcium deposits and a black substance. A black substance was also observed around the water spray nozzle on the ice machine. Additionally, the Unit 1 nourishment room counter tops had multiple areas with delamination. During an observation on 9/22/20 at 12:20 PM, the Unit 2 nourishment room ice machine tray was discolored with calcium deposits. During an interview on 9/24/20 at 2:30 PM, the Maintenance Director stated during the month that he had been the Maintenance Director, he had not checked on the maintenance of the ice machines located within the Unit 1 and Unit 2 nourishment rooms. He stated no staff had mentioned to him that the Unit 2 nourishment room countertops were in disrepair. He stated he would expect staff to submit a work order if they had seen any deficient issues. 2) Shower Room Maintenance: During an observation on 9/22/20 at 11:45 AM, the shower room opposite room [ROOM NUMBER] had water accumulated/puddled near the access door to the room. The base of the door frame had exposed rust. The water retention installation on the floor, used to keep the water within the shower section of the room, was damaged/torn. During an observation on 9/22/20 at 12:33 PM, the shower room opposite room [ROOM NUMBER] had water accumulated/puddled around the toilet. There were water stain marks which indicated water would run along the shower water retention installation and then run along the back wall toward the toilet area. During an interview on 9/24/20 at 2:30 PM, the Maintenance Director stated during the month he has been the Maintenance Director, no staff members have ever brought the shower room issues to his attention. He would expect staff to submit a work order if they had seen any deficient issues. 10NYCRR 415.29