Based on observation and interview conducted during the recertification and abbreviated (NY00378520) surveys from 6/25/25 to 7/2/25, the facility did not ensure residents were provided food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, when a test tray was sampled the tuna salad was not cold to taste, and yogurt was held at 58 degrees Fahrenheit in the kitchen during an observation of the lunch meal service. Findings include: The facility policy, Food Preparation, approved 3/14/05 documented prepared cold foods held on ice or in refrigerators will be kept cold (40 degrees Fahrenheit or below), temperatures will be recorded. During an observation on 6/30/25 at 11:27 AM of the lunch meal service, yogurts, sodas, and desserts were observed on resident's meal trays on racks near the hot steam table in the kitchen. Hot food had not yet been placed on the resident trays at that time. A temperature taken of yogurt by the Food Service Director documented it was at 58 degrees Fahrenheit. At that time, the Food Service Director was interviewed and stated the procedure was to pre-assemble the racks of meal trays with cold food items prior to the start of tray line, and stated they store the meal racks in the walk-in refrigerator until 11:15 AM. Then they are pulled from refrigeration and left in the kitchen until tray line begins. They stated this was done to facilitate timely meal delivery to the units. They stated they followed the procedure today. On 6/30/25 at 12:09 PM lunch meal trays were delivered to Unit 2. The lunch meal for Resident #62 was intercepted prior to delivery to the room at 12:27 PM and was used as a test tray for palatability and temperature. When tasted, the tuna salad was not cold to taste. At 12:32 PM, the tuna salad had a temperature of 57 degrees Fahrenheit; the temperature was taken by the Dietary Operation Manager. During an interview on 6/30/25 at 3:08 PM, Dietary Aide #11 reported cold food items like salads, yogurt, and milk were routinely pulled from refrigeration at 11:00 AM for lunch meal service and they stated the tray line started at 11:30 AM. They expressed concern because cold foods were not kept on ice when they were pulled from refrigeration, and stated they were concerned that cold foods should not be kept out of refrigeration for that length of time. During a follow up visit to the kitchen on 7/2/25 at 3:56 PM to review the documented temperatures of cold food items at lunch, no record of cold food temperatures in the log were documented for any meal. During an interview at that time, Dietary Supervisor #10 stated they did not take temperatures of cold foods or document the temperatures. They stated only the hot food temperatures were obtained before lunch service at 11:30 AM. 10 NYCRR 415.14 (d)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews conducted during an Abbreviated Survey (NY00326823), the facility did not ensure that a resident's care plan was revised with specific interventions/instructions needed to provide effective and person-centered care for 1 of 4 residents (Resident #3) reviewed. Specifically, Resident #3 fell out of the Hoyer lift on 10/22/2023 during a two person assist transfer, allegedly due to a sudden jerking movement. Resident #3 sustained right forehead superficial laceration, upper arm abrasion and a right wrist skin tear and transferred to the hospital. Resident #3's care plan was not updated with interventions to monitor for sudden movements during transfers or to anticipate unsafe movements. The findings are: Review of the facility Policy and procedure titled, Care Plan Review and Revisions dated 04/14/2023 documented the comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Resident #3 was admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis, Major Depressive Disorder and Chronic Pain. The Minimum Data Set (MDS, an assessment tool) dated 09/08/2023, documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 12/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). The facility Accident/Incident Occurrence Report dated 10/22/2023 documented Resident #3 fell out of the mechanical lift during a transfer with two persons assist. Report documented Resident #3 was being transferred from their bed to their wheelchair when Resident #3 made a sudden jerking movement and fell. Resident #3 sustained laceration to right forehead, upper arm abrasion and right wrist skin tear.Residenr #3 was able to move upper extremities,and had no changes in mental status. Report documented Resident #3 denied knowing what occurred and Resident #3's physician and family member were notified. Resident #3 Fall care plan revision dated 10/22/2023 documented interventions applied included immediate local treatment to affected area, head to toe assessment, pain management, physician and family notification, sideline equipment for inspection, change Hoyer lift pad to smaller size and re in- service staff on the use of mechanical device and been vigilant during procedure. There were no documentation of specific interventions addressing/ monitoring for unsafe movements during transfer. During an interview with Staff #4(Registered Nurse) on 12/20/2023 at 12:38 PM, they stated that on 10/22/2023 Staff #3(Certified Nursing Aide) asked to assist with transferring Resident #3 from bed to wheelchair. Staff #4 stated when they were transferring Resident #3 into the chair Resident #3 leaned forward and fell out of the mechanical lift. Staff #4 stated they were so shocked and unsure of how Resident #3 fell. Staff #4 stated they immediately completed an assessment of Resident #3 and notified the physician and family. Staff #4 stated Resident #3 was ordered and transferred to the hospital for evaluation due to a skin tear on the head. During an interview with Staff #3(Certified Nurse Aide) on 01/02/2024 at 5:35 PM, they stated on 10/22/2023 after caring for Resident #3 they asked Staff #4 for assistance with mechanical lift transfer. Staff #3 stated they had Resident #3 in the mechanical lift and were guiding them into the wheelchair. Resident #3 made a sudden jerking movement and fell out of the mechanical lift on the floor. Staff #3 stated Staff #4 immediately attended to Resident #3 while they went to get additional assistance. Staff #3 stated Resident #3 was sent out the hospital for evaluation. Staff #3 stated they could not explain how Resident #3 jerked out of the mechanical lift. After the incident they were re in serviced on the safety/use of mechanical lifts. During a telephone interview on 01/02/24 at 2:02pm with Staff #5(the Assistant Director of Nursing, they stated that the care plan for Resident #3 should have been updated with interventions addressing monitoring for jerking and sudden unsafe movements during transfer. Staff #5 stated they in serviced all staff to be more vigilant of the sudden movements but forgot to update the care plan. 10 NYCRR 415.11 (c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during an abbreviated survey (NY00328308, NY00317607) the facility did not provide adequate supervision/monitoring to prevent accidents for 2 of 4 residents (Resident #1 and Resident #2) reviewed. Specifically, Staff #1(Certified Nursing Aide) was scheduled for monitoring/supervision of residents in the rotunda. Staff #1 left her post without informing the nurse. Resident #1 fell forward out of their wheelchair while sitting in the rotunda with no supervision. Resident #1 sustained a hematoma with lacerations to the forehead and a cut to the bridge of the nose. Resident #1 was transferred to the hospital for further medical evaluation. Resident #2 who was under the supervision of Staff #2(Certified Nurse Aide) fell out of their wheelchair when the wheelchair rolled backwards while outside getting some fresh air. Facility video footage reviewed by the administrator showed Staff #2 on their cell phone with their back towards the resident unsupervised. Resident #2 sustained a hematoma to the left frontal occipital region of the forehead. In addition, Staff #2 picked Resident #2 up and placed them back in the wheelchair before calling for assistance. Findings include: Resident #1 was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Hyperlipidemia and Congestive Heart Failure the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented no Brief Interview for Mental Status (BIMS) score as the resident had severe cognitive impairment. The resident required dependent and substantial/maximal assist for Activities of Daily Living (ADLs). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had severe cognitive impairment. The resident required dependent and substantial/maximal assist for Activities of Daily Living (ADLs). The comprehensive care plan (CCP) initiated 10/25/2023 documented that Resident #1 was high risk for falls related to dementia, muscle weakness, unsteady gait, impaired safety awareness and incontinent of bowel and bladder. Interventions included to anticipate and meet resident's needs, follow fall protocol, and ensure the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair. The facility security camera footage was reviewed on 12/12/2023 and Resident #1 is seen siting in their wheelchair in the rotunda with a bed side table in front of them. There were approximately 14 other residents seen on video in the rotunda with the Staff #6(Recreation Therapist) engaged in a BINGO activity. Resident #1 moved their leg and leaned over the bed side table sliding out of the wheelchair and onto the floor. Facility Accident/Incident Occurrence Report dated 11/16/2023 documented Resident #1 had a fall in rotunda at 2:02 PM and sustained superficial laceration to forehead and nasal bridge, hematoma to forehead, bruising and bleeding to nose. Ice was applied to forehead and nasal bridge, wounds cleaned. Wounds cleaned with normal saline bacitracin applied and covered with dry pressure dressing. Neuro checks initiated immediately until Emergency Medical Service arrived. Physician and Resident #'s1 family notified. An interview was conducted with Staff #1(Certified Nursing Aide) on 12/12/2023 at 12:04 PM and they stated they were assigned rotunda duty on 11/16/2023 from 1:30 PM to 2:00 PM. Rotunda duty is to monitor and supervise the resdients in the rotunda. Staff #1 stated when they started their rotunda duty, the residents were having a BINGO activity and one of the activity staff was in the rotunda calling out the BINGO numbers. Staff #1 stated they were prepping for a colonoscopy the next day and needed to go to the restroom. Staff #1 stated they did not inform anyone they were leaving their post to the restroom. As they were exiting the restroom, they heard someone scream and when they got to the rotunda, Resident #1 was on the floor. Staff #1 stated they had a meeting with the floor nurse and Staff #4(Assistant Director of Nursing) after the incident and was suspended for 2 days. Staff #1 stated they were in serviced on the importance of rotunda duty and communicating when they need to leave their post as well as ensuring they are alert and aware of residents where abouts while on duty. An interview was conducted on 12/12/2023 at 1:15 PM with Staff #6 (Recreation Therapist and they stated they were in the rotunda conducting a BINGO game with the residents when Resident #1 fell. Staff #6 stated they were calling out the numbers and all of a sudden they looked up and Resident #1 was on the floor. Staff #6 stated they went over and grabbed the wheelchair because the chair was on top of the resident. Staff #6 stated the nurse came to assist. They then realized there was no aide in the rotunda. The routine is that there is an aide assigned to the rotunda to monitor/supervise the residents but there was no aide at the time of the incident. An interview was conducted with Staff #4(Assistant Director of Nursing) on 12/12/2023 at 1:37 PM and they stated they were notified of Resident #1's fall in the rotunda by Staff #3 (Registered Nurse). Staff #4 stated during their investigation, Staff # 1 stated they left their post at the rotunda without making other staff members aware. Staff #4 stated the rotunda duty was put in place as a precaution to prevent resident falls. Staff #1 was suspended during the the investigation and retrained on rotunda duty and its significance. Resident #2 was admitted on [DATE] with diagnoses including Chronic Kidney Disease, Essential Hypertension and Heart Failure. The Minimum Data Set (MDS, an assessment tool) dated 10/06/2023, documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 08/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). Review of Resident #2 Incident/Accident Report dated 05/31/2023 documented, at approximately 2 PM a nurse was called to assist with Resident #2 as the resident had a fall while outside in front of the building. Hematoma observed to left side of forehead. Ice pack applied with first aid rendered. No major injuries noted. Residdent was assessed by physician. Neuro checks ordered and x-rays to head and bilateral hips ordered. Staff #2 assigned to monitor resident reported Resident #2 fell while they were outside in front of the building. Resident #2 stated staff accidently wheeled them onto a rough surface that caused wheelchair to turn and fall. Facility Investigation concluded: based on review of facility camera system (CCTV), staff interview and Resident #2's account of the incident, the fall could have been avoided. Review of Employee Disciplinary Notice dated 05/31/2023 given to Staff #2 stated on 05/31/2023 at approximately 1:50 PM a rapid response was called. Upon responding, Staff #2 was observed with Resident #1 in wheelchair and hematoma noted to left frontal occipital region. Staff #2 was asked what happened in which they stated that the sun blinded them while they were pushing Resident #2 outside and Resident #2 fell. During an interview with Resident #2 they stated they should know there was a curb there and I fell. Upon reviewing the facility camera system (CCTV), it was observed that Staff #2 was on their phone with their back turned to Resident #2. Resident #2 was unsupervised when the wheelchair wheeled backwards, and Resident #2 fell and sustained injury-hematoma. Staff #2 also picked Resident #2 up and placed them back in the wheelchair before calling for assistance. There was a violation of providing safe care and usage of cellular device while providing care. This action indicated gross misconduct and negligence with impaired judgment that has the propensity to harm other residents. Staff #2 was terminated and last day of employment with the facility was 05/31/2023. During an interview on 12/20/2023 at 11:31 AM with Staff #2 they stated they took Resident #2 outside on 05/31/2023 to get some fresh air. Staff #2 stated the lock on Resident #2's wheelchair was broken and Resident #2's chair went off the sidewalk and Resident #2 fell. Staff #2 stated they were assisted by a painter that was working outside the building to pick up the resident and put them back into their wheelchair. Resident #2 had a bruise on the side of their head but kept stating that they were okay. Staff #2 stated they reported the fall to the nurse and the resident was assessed. Staff #2 stated they were called down to department head' office and the facility camera footage was reviewed with them. Staff #2 stated they wrote a statement on what happened and were fired for using their phone. Staff #2 stated they understood why they were fired. Prior to the incident, they were trained on what to do when a reisdent falls but they panic during the incident and moved the resident before they were assessed by a nurse. During an interview on 12/20/2023 at 11:41 AM with Staff #4, they stated the previous Director of Nursing conducted the investigation for Resident #2's fall on 05/31/2023. Staff #4 stated Staff #2 was terminated after the investigation was concluded. Staff are trained on fall prevention and staff must notify a nurse immediately after a fall and not touch/move the resident. During an interview on 12/20/2023 at 12:26 PM with Resident #2, Resident #2 had in both hearing aids but would not respond to surveyor. Resident #2 continued to asked surveyor who they were multiple times but was not responsive to questioning. During an interview on 12/20/2023 at 1:13 PM with Staff #10(Administrator), they stated they were notified by Staff #7(previous director of nursing) of the investigation regarding Resident #2's fall. Staff #10 stated they usually do not fire staff before the conclusion of an investigation but in this case all the department heads came together and reviewed the investigation and agreed to terminate Staff #2. Staff #10 stated the facility videos were not been saved at the time of the incident so they did not have the footage available at the time of the onsite investigation for the surveyor to review. Presently all facility video footages are been stored on a flash drive for review when needed. 10NYRCC 415.12(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews conducted during an abbreviated survey (NY00317051) the facility failed to ensure that the medical care of 1 of 5 residents (Resident #1) reviewed for Physician services was appropriately supervised by a physician. Specifically, Resident #1 was identified as needing a change in the way medications were being administered and the corresponding Physician order to formally effect the change was not issued. Findings include: Facility Medication Administration Policy and Procedure Dated 11/15/2022 was reviewed and documented Medications are administered as ordered by the Physician. It indicated Crush medications as ordered, do not crush medications with do not crush order. Resident is [AGE] years old admitted to the facility on [DATE] with diagnoses that include but not limited to Stroke, Seizure Disorder, Dysphagia and Quadriplegia. The Quarterly MDS (MDS, an assessment tool) dated 3/11/2023 documented Resident #1 had severely impaired cognition and had total dependence of one staff for eating, dressing, personal hygiene, and required extensive assist of two staff for transfers and toileting. A Review of Resident #1 Nursing care plan for nutritional problems dated 3/10/23 documented staff to monitor/document/report as needed any signs of dysphagia: pocketing, choking, coughing. The resident has nutrition problem r/t mental and medical status Care Plan dated 3/10/23. Diet not listed on the care plan. A Review of Resident # 1 Nursing care plan for oral/dental problems dated 7/6/2022 documented staff to administer medications as ordered, diet as ordered, consult with dietician, and change if chewing/swallowing problems are noted. Review of the Physicians order dated 2/21/2023 documented the resident's diet order as soft bite size texture, regular thin liquids. ST Progress Note dated 3/8/23 documents patient seen for final ST and discharge. At this time, it appears patient has reached maximum potential, continue diet recommended on 02/21/2023 from bedside swallow evaluation; soft and bite sized textures, thin liquids, aspiration precautions, and one to one feeding. Nursing Progress Note dated 3/12/23 documented s/p IV fluids for poor intake, consumed about 75% of meals, Resident was given PO medications in food and consumed 100% of medications. Physician Comprehensive Progress Note dated 3/16/23 documented Dysphagia, currently on soft pureed diet, tolerating well, continue aspiration precautions. ST evaluation as needed with the goal that the resident will be able to swallow safely by 12/31/23. Review of Physician orders dated 6/28/2019 to 5/13/2023 revealed no order for Resident # 1's medication to be crushed. Review of Nursing Progress Notes dated 3/1/2023 through 5/23/2023 revealed Resident # 's medications were administered crushed or in food. Review of Medication Administration Record (MAR) from 3/1/2023 to 5/23/2023 was completed. There was no physician order for Resident #1's medications to be crushed. During an interview with Registered Nurse unit manager (RNUM # 1) on 5/24/2023 at 10:34 AM, the RNUM stated any resident who required crushed meds should have an order to crush meds. If the nurses notice that residents have difficulty swallowing meds they should report it, get an order to crush the meds, and request for the resident to have a speech therapy evaluation. During an interview with Licensed Practical Nurse (LPN# 2) conducted on 5/24/2023 at 10:42 AM, LPN #2 stated, I gave Resident #1 their medication this morning crushed. LPN # 2 stated they know to crush the medications based on their evaluation of the resident, and they were also told by other nurses on the unit. If I float to another floor, I find the directions on the face sheet, in the medication administration record (MAR), or the care plan. LPN #2 stated that a doctor's order is needed to crush medication. During an interview with LPN #3 on 5/24/23 at 10:55 AM, LPN # 3 stated they worked in the facility for 6 years and if a resident received medications whole that caused choking, they would report the incident and any changes in the resident's condition, and obtain a new order for medication administration to maintain safety. During an interview with Speech Therapist (ST) on 5/24/23 at 01:38, ST stated that after they conduct a swallow evaluation, the Physiatrist signs the recommendations, and orders the diet. ST only makes recommendations based on their evaluations. During an interview with Pharmacy Consultant (PC) on 5/24/23 at 01:50 PM, the PC stated in order to have medications crushed for residents on a modified diet a doctor's note is required. The order is entered in the electronic medical record (EMR), and nurses administer the medications as ordered. The PC stated anyone on a puree diet would have their medications crushed. The PC stated they are required to review residents' medication regimen during the monthly medication regimen review (MRR), and identify residents on a puree diet, notify the physician, and obtain an order to crush their medications. PC sated they will be conducting an in-service on crushing medications because they feel the staff need clarification. During an interview with on the Registered Dietician (RD) on 5/25/23 at 10:55 AM, the RD stated special diet orders for altered texture is guided by the Speech Therapist's (ST) recommendation. RD Stated the ST enters their recommendations for the residents' diet in the EMR, all disciplines are made aware of the diet changes and updates to the care plan. During an interview with LPN #1 (the accused staff) on 5/25/23 at 03:50 PM, LPN # 1 stated they worked with Resident #1 on the day of the incident (3/17/2023) and administered their medications as it was ordered by the MD. LPN # 1 stated they check the medication orders before giving medications and administer them in the form ordered. LPN #1 stated if the resident needs a crush order, they notify the MD. LPN #1 stated they have never witnessed Resident #1 choking on their medication, and Resident # 1 had no episode of choking or other unusual event on their shift on 3/17/23. During an interview with LPN #4 on 5/26/23 at 9:49 AM, LPN # 4 the LPN who worked with Resident #1 on the morning shift following the alleged incident) stated they worked the day shift on the date of the alleged incident, and they did not see any red marks or bruising on the resident's neck. They also did not notice any changes in the resident's psychosocial behavior. I administered medications to Resident # 1 on 3/18/23, they had no difficulty swallowing their crushed medications in applesauce and tolerated their meals that day. During an interview with Resident #1's primary care physician (PCP) on 5/26/23 at 11:45 AM, the PCP stated they were the PCP for Resident #1 for two years. PCP stated Resident #1 takes their medications by mouth and needs to take them crushed. Resident #1 had their diet changed in February to soft and bite size texture with thin liquids. The PCP stated they never evaluated how Resident #1 took their medications. The PCP stated that they rely on the Pharmacist Consultant's oversight of the medications identified to be administer crushed, to ensure that nurses do not crush medications that should not be crushed. The PCP stated Resident #1 had an order to crush their medications. However, the PCP could not show the surveyor in the EMR from February 2023 to 5/24/2023 (the start of the survey) any physician order to crush Resident #1's medications. During an interview with the Director of Nursing (DON) on 5/26/23 at 1:56 PM, the DON stated nurses follow the facility standard for crushing medications, the staff are trained in the International Dysphagia Diet Standardization Initiative (IDDSI, a globally developed intake texture guideline). The DON stated when they identify a resident on a modified diet, such as puree or thickened liquid, the staff know that the resident's medications cannot be administered whole. The DON stated the nurse would reach out to the Physician for a crush med order and notify the nurse manager. The DON stated residents who have difficulty swallowing have a Speech Therapy (ST) consult and are seen by the Dietitian. The DON stated the residents' care plans are updated according to the recommendations from the ST and the Dietician. The DON stated if medications are crushed without an order, the nurse must have identified the need, but did not follow through to get the order. The DON stated that the Physician or the Nurse Practitioner reviews the residents' medication profile every month. 415.15(b)(i)(ii)

Based on observation, record review, and interview conducted during the recertification survey from 03/09/2023 to 03/17/2023, the facility failed to revise a comprehensive care plan for 1 of 4 residents (Resident #52) reviewed for position/mobility. Specifically, Resident #52's care plan failed to address the use of wheelchair elevating leg rests and calf and/or foot board as ordered. The findings are: Resident #52 was admitted to the facility with diagnoses including but not limited to Alzheimer's Disease, Non-Alzheimer's Dementia, and Unspecified Osteoarthritis. A review of the 12/15/2022 Quarterly MDS (Minimum Data Set, a resident assessment tool) documented the resident had severe cognitive impairment; required extensive assist by 2+ staff members for bed mobility and transfers, extensive assist of 1 staff for wheelchair locomotion, and had functional limitation of both upper and lower extremities. A review of Resident #52's Occupational Therapy (OT) Evaluation performed 04/14/2021 to 04/27/2021, documented the referral was made for occupational therapy after nursing observed the resident sliding out from their wheelchair. The OT evaluation concluded recommendations for Resident #52 included a standard wheelchair and elevating leg rests. A review of Resident #52's EMR (Electronic Medical Record) revealed a provider order dated 04/21/2021 for a standard wheelchair, elevating leg rests, calf/foot board, and a wedge cushion. A review of Resident #52's comprehensive care plan dated 12/22/2022 revealed no documentation for the use of elevating leg rests or calf/foot boards on Resident #52's wheelchair. Multiple observations were conducted during the following dates and times: -On 3/8/2023 at 12:32PM, Resident #52 was in the wheelchair, with both feet dangling and intermittently dragging when being pushed from the dining room to the activity room, making no attempt to self-propel. The elevating leg rests or calf/foot board were not on the wheelchair. -On 3/9/2023 at 08:48AM, Resident #52 was in a slouched position, in the wheelchair and noted to be sliding forward and down, holding their abdomen, with both feet extended and dangling above the floor, and not making any attempt to self-propel or reposition. No elevating leg rests or calf/foot board were observed on the wheelchair. - On 3/13/2023 at 10:20AM, Resident #52 was in the activity room, not fully upright in the wheelchair, both feet were dangling and not touching the floor, and no attempt was made to self-propel. No elevating leg rests, or calf/foot board were observed on the wheelchair. During an interview on 03/13/2023 at 10:25AM, Certified Nursing Assistant (CNA # 3) stated they took Resident #52 out of bed and into their wheelchair earlier that morning. CNA #3 stated Resident #52 was supposed to have leg rests and a calf board on their wheelchair and did not report to the nurse that Resident #52's wheelchair was missing leg rests. CNA #3 stated that often times when residents' wheelchairs are sent for cleaning, the wheelchairs come back without leg rests. During an interview on 03/13/2023 at 3:28PM, Registered Nurse Unit Manager (RNUM #1) stated there was no part of Resident #52's care plan that included the use of prescribed elevating leg rests or calf/foot board, and stated nursing is responsible for Resident #52's care plan. RNUM #1 stated the rehab department developed the parts of Resident #52's care plan for mobility and positioning devices and the use of elevated leg rests/calf board should have been included in the care plan. During an interview on 03/13/2023 at 03:46PM, Physical Therapist (PT #1) stated rehab is responsible for developing and maintaining the resident care plans for residents requiring the use of wheelchairs and adaptive equipment. PT#1 stated there was no portion of Resident #52's care plan that included the use of elevating leg rests and calf/foot board and stated resident care plans should include the use of mobility equipment. 483.21 (f)(iii)

Based observation, record review, and interview conducted during the recertification survey from 03/08/2023 to 03/17/2023, the facility failed to ensure that residents received care and treatment in accordance with professional standards for one of four residents (Resident #52) reviewed for positioning and mobility. Specifically, Resident #52 was not provided positioning devices for their wheelchair as ordered. The findings include: Resident #52 was admitted to the facility with diagnoses including but not limited to Alzheimer's Disease, Non-Alzheimer's Dementia, and Unspecified Osteoarthritis. A review of the 12/15/2022 Quarterly MDS (Minimum Data Set, a resident assessment tool) documented the resident had severe cognitive impairment; required extensive assist by 2+ staff members for bed mobility and transfers, extensive assist of 1 staff for wheelchair locomotion, and had functional limitation of both upper and lower extremities. A review of Resident #52's Occupational Therapy (OT) Evaluation performed 04/14/2021 to 04/27/2021, documented the referral was made for occupational therapy after nursing observed the resident sliding out from their wheelchair. The OT evaluation concluded recommendations for Resident #52 included a standard wheelchair and elevating leg rests. A review of Resident #52's EMR (Electronic Medical Record) revealed a provider order dated 04/21/2021 for a standard wheelchair, elevating leg rests, calf/foot board, and a wedge cushion. A review of Resident #52's comprehensive care plan dated 12/22/2022 revealed no documentation for the use of elevating leg rests or calf/foot boards on Resident #52's wheelchair. Multiple observations were conducted during the following dates and times: -On 3/8/2023 at 12:32PM, Resident #52 was in the wheelchair, with both feet dangling and intermittently dragging when being pushed from the dining room to the activity room, making no attempt to self-propel. The elevating leg rests or calf/foot board were not on the wheelchair. -On 3/9/2023 at 08:48AM, Resident #52 was in a slouched position, in the wheelchair and noted to be sliding forward and down, holding abdomen, with both feet extended and dangling, and not making any attempt to self-propel or reposition. No elevating leg rests or calf/foot board were observed on the wheelchair. -On 3/13/2023 at 10:20AM, Resident #52 was in the activity room, not fully upright in the wheelchair, both feet were dangling and both toes were not touching the floor, and no attempt was made to self-propel. No elevating leg rests, or calf/foot board were observed on the wheelchair. During an interview on 03/13/2023 at 10:38AM, Licensed Practical Nurse (LPN #4) stated Resident #52 was supposed to have elevating leg rests on their wheelchair and if a component to the wheelchair was missing, staff were to notify the nurse manager or the rehab department. During an interview on 03/13/2023 at 12:06PM, Registered Nurse Unit Manager (RNUM #1) stated that Resident #52 was supposed to have elevating leg rests on their wheelchair and was not made aware by staff of Resident #52's leg rests missing. RNUM #1 stated that if a component of a wheelchair was missing, staff were to escalate the issue to the nurse or the nurse manager, who was supposed to notify the rehab department. During an interview on 03/13/2023 at 03:46PM, Physical Therapy (PT #1) stated sometimes when wheelchairs were washed, the leg rests were lost. PT #1 stated the rehab department was not aware resident #52's wheelchair was missing elevated leg rests and calf board. § 483.25

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the recertification and abbreviated surveys (NY00286859,NY00293521), the facility did not ensure that residents were adequately supervised and the environment remained free from accident hazards for 2 of 3 residents (Resident #63 and #58) reviewed for accidents. Specifically, observation revealed that a closet door in room [ROOM NUMBER]A which had previously fallen on Resident #63 was broken and not on the track. Resident #58 was identified at risk for elopement and exited the building undetected. The findings are: The policy and procedure titled Accident and Incident Report dated 9/19/22, documented it was the policy of the facility to ensure that the resident environment remained as free from accidents/incidents as possible through adequate supervision and individualized interventions for prevention. The purpose was to effectively investigate potential and actual injuries to residents and minimize adverse resident outcomes. Resident #63 was admitted to facility on 1/26/16 with diagnosis of Unspecified Dementia with other Behavioral Disturbance, History of Falling, and Chronic Obstructive Pulmonary Disease. The Quarterly Minimum Data Set (MDS) documented Resident #63 had a Brief Interview of Mental Status (BIMS) score of 5 which indicated severely impaired cognition and the resident required extensive assistance of one person for bed mobility, transfers, eating and toileting. The 11/20/21 nursing note documented that Licensed Practical Nurse (LPN #2) reported a broken closet door accidentally fell onto Resident #63 causing a left eyebrow abrasion with a small amount of bleeding. The broken closet door was removed by maintenance and the family was informed. Observation on 3/13/23 at 9:27 AM and 3/15/23 at 11:07 AM revealed Resident #63's closet door was broken and off the track. During an interview on 3/15/23 at 1:09PM Certified Nurse Assistant (CNA #1) stated they saw the closet door broken today (3/15/23) around 10:00 AM. CNA #1 stated that the closet door was tilted off the track and they forgot to report it to the nurse. During an interview on 3/25/23 at 1:12PM, Registered Nurse Unit Manager (RNUM#1) stated CNA #1 just informed them the closet door was broken in room [ROOM NUMBER] and that they would call maintenance to come and fix the door. During an interview on 3/15/23 at 1:30 PM the Director of Maintenance stated they had not been made aware the closet door was broken in room [ROOM NUMBER]. 2. The 9/18/2017 facility policy and procedure titled Elopement Prevention; Missing Resident, Dr Search documented it was the policy of this facility that residents would be maintained in a safe secure manner and protected from actual harm while encouraging resident rights. Resident #58 was admitted to facility with diagnoses including Dementia, Depression, and Hypertension. The 3/23/2022 Significant Change Minimum Data Set Significant (MDS, an assessment tool) documented Resident #58 had a Brief Interview for Mental Status (BIMS) of 2 which indicated severe cognitive impairment. The 10/28/2020 Elopement Care Plan with revision dates of 9/14/2022, 3/10/2022 documented the resident was an elopement risk related to a history of attempts to leave the facility unattended. Interventions included a wander guard (electronic monitoring device) on the left ankle to be checked every shift, redirect the resident from the elevators and exit doors, engage the resident in purposeful activities, provide structured activities and schedule time for walks. Review of the March 4, 2022, Elopement Assessment documented the resident was at risk for elopement. The 3/30/2022 Accident/Incident Occurrence Report documented at around 9:50 AM the concierge alerted the Director of Nursing (DON) about a person whom they saw sitting outside the building. The DON and Assistant Director of Nursing (ADON) responded to find the resident sitting outside of the front lobby. The March 2022 Physician Orders documented an order for an elopement/wander guard to be placed on the resident and checked every shift for placement and functionality. The March 2022 Treatment Administration Record (TAR) documented the wander guard was checked every shift for placement and that it was in working order. The record documented the wander guard was last checked on the 3/29/2022 night shift. Review of the 3/30/2022 Nursing Progress Note documented the resident was alert, responsive and ambulatory. The resident was found outside the front lobby and was brought back by the staff. The Wander guard was checked and noted to be functioning well and a new wander guard was applied to the left ankle. During an interview on 3/7/2023 at 11:26 AM, Certified Nursing Assistant (CNA #6) stated they worked on the unit that day and the resident was more agitated than normal, CNA #6 stated the resident had a wander guard and did make several attempts to get on the elevator but was redirected when the alarms sounded. CNA #6 stated they told other staff the resident was a little more agitated and to keep an eye on the resident. CNA #6 stated that as they were picking up the breakfast trays they noticed the resident was not in the room, so they started looking for the resident and alerted the rest of the staff and supervisor that the resident was missing. CNA #6 stated a few minutes later they were notified the resident had been found. During an interview on 3/1/2023 at 3:30 PM Licensed Practical Nurse (LPN #2) stated it was around breakfast time and the resident was attempting to get on the elevator but was redirected by LPN # 2 and by CNA #6. LPN # 2 stated the breakfast trays came up, so the staff were able to redirect the resident to sit and eat breakfast. LPN # 2 stated they did notice that the resident got up again and the resident was redirected to their room. LPN # 2 stated since it was breakfast time the staff was busy with serving trays and feeding residents and LPN #2 began passing medications. LPN # 2 stated when the nurse manager asked if the resident had been seen the staff immediately began to search for the resident and were informed within 5 minutes the resident had been found. During an interview on 3/7/2023 at 23PM the front desk concierge stated they were working the front desk during the morning on 3/30/2022. The concierge stated multiple people were entering and leaving the facility at the same time and they did not notice the resident in the group of people exiting the facility, but the alarm did sound. The concierge stated looking back now they did not remember if the code was entered to silence the alarm. The concierge stated they went outside and found the resident sitting on the ground to the left of the main door. The concierge stated they notified the staff. The concierge stated they had been trained on Elopement and was aware of the elopement list with pictures that was kept behind the front desk. During an interview with the DON on 3/7/2023 at 9:45 AM, the DON stated the wander guard system at the front door required the front desk staff to enter a code if the wander guard alarm was activated. The DON stated If the front desk staff heard the alarm, they should go to the door and check that no residents have exited the building prior to entering the code. The DON stated the concierge did state at the time that the resident may have exited the building when he unlocked the door for a group of people who were entering and exiting the building. The DON stated at the time of the event they reviewed the camera and did see the resident leave the floor via the staff elevator and exit the front door of the building. 415.12(h)(2)

Based on observations interviews and record review during a recertification survey (3/8/23-3/17/23), the facility did not ensure that professional standards for food safety and prevention of food borne illness were followed. Specifically, wait staff #1 did not perform hand hygiene between serving residents while passing out food during a lunch meal to prevent cross contamination and infection. The finding are : The facility policy on Hand Hygiene dated 6/9/20 and 8/16/21 states all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The attached table documents hand hygiene to be performed between resident contacts. Observations were made on 3/8/23 in the first-floor dining room beginning at 12:10pm. Wait staff #1 was observed pushing a serving cart of lunch plates with bare hands over to a dining table of 3 residents. Wait staff #1 stopped pushing the cart, touched the resident menu with their hands, touched the meal plate and put their finger in the hole of the lid to remove the lid and place the plate in front of the resident, returned to the cart, got another plate, removed the lid, placed it on the table, pushed the cart around the table touching the handle, adjusted their face mask, touched the resident shoulder, and returned to remove plates from the cart, removing lids and placing them on the table. At 12:24pm an observation was made of wait staff #1 who passed out plates of cake to residents at the tables, scratched their arm, walked to the refrigerator, touched the door handle, took out a soda, brought the soda to the resident table and put the soda on the table then walked to get coffee from the pot, returned to the resident table and for each coffee refill, lifted the resident cup by its handle, refilled the coffee and placed the cup back on the table and proceeded to the next resident. There was no hand sanitizer on the cart or on the walls. A small bottle of hand sanitizer was on each table but never used by wait staff #1. There was no hand hygiene performed by the wait staff #1. During an interview on 3/8/23 at 12:34pm Wait staff #1 stated they did not know they needed to perform hand hygiene and had not had Infection Control training by the facility. During an interview on 3/8/23 at 12:30pm Dietary Supervisor #1 stated hand sanitizer is in the kitchen and on tables and stated staff should be using sanitizer before each pass of clean lunch plates to the resident. They stated staff take a 3-day class before serving residents then competencies are done by a supervisor. The Dietary Supervisor #1 was unable to provide evidence of training records for wait staff #1. §483.60(i)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review during a recertification survey from 3/8/23 to 3/18/2023 the facility did not ensure that Infection Control practices and procedures were maintained. Specifically, 1) Housekeeping staff #1 did not properly distribute clean laundry to residents in a manner that would prevent the spread of infection, 2) Certified Nursing Assistant (CNA) #4 handled linen on a clean linen cart while wearing dirty gloves and 3) the front desk concierge did not handle COVID19 test specimens and maintain the COVID19 testing area in a clean and sanitary manner to prevent the development and transmission of communicable disease and illness. The findings are: 1. On 3/15/2023 at 1:35PM Housekeeper #1 was observed distributing clean laundry from a linen cart in hallway C of the third floor. Housekeeper #1 collected uncovered clean laundry on hangers for Residents #134 #129, #167 and #63 and proceeded to hallway B then entered the room of Resident #129, placed resident #129's clothing articles in their closet and collected dirty hangers from the closet while failing to separate dirty hangers from the clean clothing of other resident's in-hand. Housekeeper #1 then proceeded to the room of Resident #134, #167 and #63 in the same manner delivering clean clothes and collecting dirty hangers. During an interview on 03/15/2023 at 01:48 PM Housekeeper #1 stated that linen is covered for infection control, and that clean linen is supposed to be distributed to one resident at a time, distributing clothing articles directly from the covered clean linen cart to the resident's room but stated they did not perform the proper procedure because they had just a few articles of clothing for the hallway C. Housekeeper #1 stated they distributed the linen's uncovered because the clean linen cart is very large and it is hard to see over the cart, and they did not want to accidentally run-into or injure a resident in the process of linen distribution. During an interview on 03/17/2023 at 09:33 AM the facility's Director of Capital Projects, stated the distribution of clean laundry is done by housekeeping and the covered clean laundry cart should be brought outside of each resident room, and housekeeping should individually distribute clean laundry directly from the covered laundry cart and into the resident's room, one resident at a time. During an interview on 03/17/2023 at 11:55 AM the facility's administrator stated they could not provide a policy for proper linen distribution. 2. On 3/9/23 at 9:25 AM CNA#4 was observed on the fourth floor pushing a Hoyer lift while wearing gloves on both hands. CNA #4 stopped in front of a covered clean linen cart in the hallway and grabbed briefs and sheets with the gloved hands then returned to push the Hoyer lift down the hall and into Resident room [ROOM NUMBER]. During an interview on 3/13/23 at 11:39 AM CNA#4 stated they were not thinking at the time and knows that staff should not be wearing gloves outside a resident room and should not have touched clean linens with gloved hands. During an interview on 3/08/2023 at 10:00AM Registered Nurse Unit Manager #2 stated CNA's should not be touching clean linen carts while wearing gloves. 3. On 3/15/23 10:45AM, an observation was made in the front lobby of Concierge #1 during visitor testing. Concierge #1 was observed assisting two visitors for COVID19 testing in the testing area. The visitors swabbed their own noses but when they could not place the swab in the test cartridge properly, Concierge #1 offered and took the swabs from the visitors with their bare hands and put the swab in the correct position on the test cartridge and placed both tests aside to develop. There was no hand hygiene performed by the Concierge or gloves donned for the procedure. A second observation was made 3/15/23 at 10:54 AM of Concierge #1 assisting another visitor, opened a swab handed swab to visitor who in turn swabbed their nose, then took the swab from the visitor and placed it on the test cartridge . The test cartridge was placed on a lobby end table without a barrier to develop. The Concierge returned to the front desk to log in visitors, touched pens and tabletop surfaces without performing hand hygiene or wiping down test tables and end table after each use. The Concierge did not wear gloves when handling test specimens. During an interview on 3/15/23 at 12:00PM Concierge #1 stated that they were not aware they needed to wear gloves during testing and does clean the testing area tables twice an hour and feels that was good enough. During an interview on 3/17/23 at 8:45 AM the Director of Nursing (DON) stated training, and ongoing updates of Infection Control has been relayed to the Concierge. The DON stated the correct procedure is to have visitors do their own testing and if they need help the concierge should wear gloves and assist visitors. The DON stated test kits should stay on the testing table. They should not be moved to end tables. Tables and test areas needs to be wiped down after each test not twice an hour. 483.80

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #135 was admitted on [DATE]. Diagnoses included but are not limited to Atrial Fibrillation (AFib); Hypertension, Diabetes Mellitus (DM), Depression, Adult Failure to Thrive, Weakness, and unsteadiness on feet. Doctor's Orders dated 6/14/19 recommended Restorative Physical Therapy (PT) for 30 days for gait training; ROM/strengthening; balance and coordination; transfer bed/mat mobility; Restorative PT 5 times per week for 4 weeks to improve strength, balance, endurance, transfers and ambulation. PT evaluation 6/14/19 documented AFib, Dementia, and difficulty in walking; resident referred to PT due to a noted decline in function; exhibits new onset of reduced dynamic balance, reduced static balance, decrease in strength, decrease in functional mobility, increase need for assistance from others, decreased coordination; and decrease in ROM; PT 5 times per week for 4 weeks, 6/14-7/11/19. PT Discharge summary dated [DATE] recommended for Resident #135 to safely ambulate with a rolling walker (RW) on level surfaces from 20 feet to 100 feet. Resident #135 was discharged from PT as it was believed that the highest practical level for Resident #135 was achieved. PT recommendation 7/17/19 documented for the patient to continue ambulation on the unit with nursing staff utilizing a RW for up to 100 feet. The CNA Accountability Record for July 2019 and Resident Plan of Care dated 5/9/19 documented Resident #135's need for extensive assistance of 1 person for transfer; and extensive assistance of one person for ambulation; and wheelchair for locomotion. The Director of Rehabilitation (DR) was interviewed on 7/25/19 at 10:02AM and explained that when residents finish rehabilitation, he reports it at the utilization review weekly meeting which had rehabilitation staff, social work staff and nursing staff in attendance. He explained that rehabilitation staff would then communicate to the unit nursing staff about resident therapy progress, expected outcomes, and recommendations. Although the DR reported that nursing staff had been verbally made aware of the rehab recommendation, no evidence was available for review. The CNA responsible for resident care (CNA #3) was interviewed on 7/25/19 at 10:41 AM and reported resident does not have a rolling walker and is not ambulated on the unit. 415.12(a)(2) Based on observation, record review, and interview conducted during a recertification survey, it cannot be ensured that the facility provided the appropriate treatment and services to maintain or improve abilities to complete Activities of Daily Living (ADLs) for 4 of 4 residents (#14, #26, #57 and #135) reviewed for Activities of Daily Living. Specifically, the facility did not ensure that Resident #14 was evaluated for decline in mobility and elimination as identified on the Resident Assessment; Resident #26 received adequate fingernail grooming as her fingernails were very long, thick, and fungal looking; Resident #57 did not remain in bed for long periods of time, without her prescribed stump shrinkers. (stump shrinkers are typically used to reduce or control swelling and phantom pain in the residual limb of amputee patients); and for Resident #135 rehabilitation (Rehab) discharge recommendations were not ordered and implemented to maintain the resident's ambulatory function. The findings are: 1. Resident #14 was admitted on [DATE] with diagnoses including but not limited to Dementia with behavioral disturbance, Ataxia, Hypertension and generalized muscle weakness. The Annual Minimum Data Set (MDS: an assessment tool) dated 4/3/19 documented the resident was severely cognitively impaired for decision making, required extensive assist of two persons for transfer, was dependent with extensive assist of one person for toilet use, had functional limitations of both lower extremities and used a wheelchair for mobility. A subsequent quarterly MDS dated [DATE] documented a decline in Resident #14's ability to transfer to dependent with assist of 2 persons and decline in toilet use to dependent with the assistance of 2 persons. A Care Plan 7/3/19 documented that Resident #14 will have basic needs met with daily staff assistance as evidenced by being odor-free, well-groomed and well-nourished x 3 months. Interventions dated 5/2/19 included transfer with 1 assist; out of bed to wheel chair daily as a two-person transfer using a Sara lift. Review of Doctors Orders dated 7/14/19 noted that Resident #14 is to transfer with one person assist. The Certified Nurse's Aide (CNA) Accountability Record and Resident Plan of Care dated July 2019 documented that Resident #14 requires the total assist of one person transferring and toileting. The Registered Nurse Manager (RN #1) was interviewed on 7/24/19 at 1:49PM and reported when a resident has decline in ADLs the resident is to be referred to therapy. At that time RN#1 reviewed the record and could not produce any documented evidence that the Resident #14 was referred to therapy following decline in ADLs per MDS of 7/4/19. She further stated that she was not aware of resident decline in ADLs. The Unit Registered Nurse (RN #3) was interviewed on 7/24/19 at 1:59 PM and reported she was not aware of Resident #14's decline in ADLs. The Director of Rehabilitation Services was interviewed on 7/24/19 at 2:43 PM and reported that Resident #14 should have been screened secondary to her declining ability to perform ADLs. The primary CNA responsible for Resident #14's care was interviewed on 7/25/19 at 10:47AM and reported that she requires the assistance of 2 people for toileting and transferring. 2. Resident #26 is a [AGE] year-old female admitted on [DATE] with diagnoses that include, Muscle weakness, Hypertension, Shortness of breath, local infection of the skin, and chronic pain. The Quarterly Minimum Data Set assessment completed 4/19/2019 showed that Resident #26 requires extensive physical assistance for dressing, toileting, personal hygiene and bathing. Resident #26's Care Plan dated 10/02/2018 documented her muscle weakness stating that she was unable to perform Activities of Daily Living (ADLs) without self-care assistance. The Resident's goal was to perform ADLs to her optimum level. The interventions include encouraging independence, intervening only when she is unable to complete tasks. Staff are to utilize consistent repetition of task, provide encouragement and positive feedback and pride assistance as needed. Furthermore, she is to be monitored for the need of adaptive devices for personal hygiene, dressing, grooming, toileting and eating. Resident's fingernails were observed multiple times to be very long, thick, and fungal looking during the survey with some fingernails being long and curved. The Certified Nursing Assistant (CNA) assignments and accountability records for July 2019 were reviewed and did not indicate whether resident's fingernails were to be trimmed, filed, and cleaned. On 7/24/2019 at 11:00am, the Unit RN Manager was interviewed stated that it was reported 3 weeks ago that Resident #26 complained about her fingernails. On 7/26/19 at 4:00pm the Resident's Primary CNA was interviewed and stated that Resident #26's finger nails have been long, thick and fungal looking for a long time which was reported to the unit nurse. 3. Resident #57 is a [AGE] year-old female admitted on [DATE] with diagnoses that include bilateral below knee amputation of Lower Extremities related to peripheral vascular disease (PVD), Hypertension, Diabetes Mellitus, PVD, Chronic Obstructive Pulmonary Disease (COPD), Anxiety, Hyperlipidemia Postherpetic polyneuropathy, The Quarterly Minimum Data Set (MDS) assessment completed 5/3/19 showed that Resident #57 requires extensive physical assistance of 1 person for Bed mobility, Locomotion on and off the unit, Dressing, and Personal Hygiene. The Resident also requires extensive physical assistance of 2 persons for transfers and toileting. Furthermore, the Resident needs total physical dependence of 2 persons for Bathing. Review of the Physician's Order dated 8/23/18 and the Care Plan dated 8/23/2018 showed that Resident #57 is always to utilize bilateral Stump Shrinkers to prevent edema; only removing them for care. On 7/18/2019 Resident #57 was observed in bed at both 11:30am and 2:10pm without the Stump Shrinkers applied. On 7/19/2019 at 12:45pm resident was again observed in bed without the Stump Shrinkers applied. On 7/22/2019 at lunch time, she was again observed in her wheel chair, eating lunch without the stump shrinkers applied.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during a recent recertification survey, the facility did not provide the necessary care and services for 1 of 1 resident (#57) reviewed for Activities of Daily Living. Specifically, the facility did not ensure that Resident who had bilateral below knee amputation was utilizing the custom-made prosthesis to enhance the resident's mobility and ambulation or stump shrinkers to prevent lower extremity edema. The findings are: Resident #57 is a [AGE] year-old female admitted on [DATE] with diagnoses that include bilateral below knee amputation of Lower Extremities related to peripheral vascular disease (PVD), Diabetes Mellitus, Chronic Obstructive Pulmonary Disease (COPD) and Anxiety. Her Brief Inventory of Mental Status (BIMS) indicated that her cognitive abilities are moderately impaired with a score of 11. The Activities of Daily Living (ADL) care plan dated 08/18/2017 indicated that resident is unable to perform ADL functions without extensive assistance secondary to Bilateral below knee amputation. The goal was updated 3/7/2018 to include that resident will have basic needs met with daily staff assistance, and well groomed. On 7/18/2019 Resident #57 was observed in bed at both 11:30am and 2:10pm without the prosthesis or Stump Shrinkers applied. On 07/18/2019 at 2:27PM Resident #57 was interviewed and reported that she has bilateral lower extremities prostheses but is not using them because staff have not applied them. The prostheses were observed to be in the corner of Resident #57's room. On 7/19/2019 at 12:45pm resident was again observed in bed without the prosthesis or Stump Shrinkers applied. On 7/22/2019 at lunch time, she was again observed in her wheel chair, eating lunch without the prosthesis or Stump Shrinkers applied. The facility did not initiate a care plan for the use of the prosthesis. There was no recent documentation of attempts made to apply the resident's prosthesis. The Certified Nursing Assistant (CNA) assignments and accountability record for July 2019 that was reviewed did not have prosthesis checked nor specific instructions provided on how to assist Resident #57 in applying the prosthesis. On 7/24/2019 at 1:05PM Physical Therapy supervisor was interviewed regarding reason for why resident's prosthesis not being applied, and he stated that when resident complained of soreness with the previous prosthesis in January 2019, he invited prosthetic technician to measure resident for a new prosthesis. He further stated that resident was trained on how to ambulate with the new prosthesis, Physical therapy supervisor was not able to provide any recent documentation after 2/2/2019 when the therapist documented that goal was discontinued because the resident was currently unable to tolerate the bilateral below knee prosthesis. 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recent recertification survey, it could not be ensured that a resident received the necessary treatments to meet the resident's foot care needs. Specifically, 1 of 1 resident (Resident #185) reviewed for quality of care did not receive the treatment that was recommended by a Podiatrist. The findings are: Resident #185 was admitted on [DATE] and has diagnoses including Heart Failure, Difficulty Walking, and Chronic Pain Syndrome. According to the 6/25/19 Quarterly Minimum Data Set (MDS; an assessment tool) the resident had a Brief Interview Mental Status (BIMS; a test for cognitive functioning) score of 13 out of 15 which indicated mild cognitive impairment. Physician Orders dated 7/5/19 had instructions for pain monitoring every four hours as needed. During an interview with the resident on 7/18/19 at 1:24 PM she stated that she was seen by a Podiatrist a month ago for tingling/burning sensation of her feet which was diagnosed as Neuropathy. The resident stated that she gave a copy of the consultative report to a facility staff member upon return to the facility. The resident further stated that the Podiatrist had recommended for the Primary Care Physician to prescribe topical medications for her symptoms, but she never did receive them. The 6/24/19 Podiatry Care/Evaluation Consultation Report documented the resident was evaluated for burning and tingling sensation in both feet, which had increased in discomfort, especially at night when she was trying to sleep. The consultation report further documented that discussion was made with the resident to possibly use a topical cream before bedtime, that would help with the neuropathy, and possible neurologic consultation. Further review of clinical records revealed no evidence that the facility medical staff reviewed the recommendations of the 6/24/19 Podiatrist consultation. RN # 1 was interviewed on 7/25/19 at 11:24 AM and stated that the resident was seen by the Podiatrist last month, but she did not remember receiving a copy of the consult from the resident. The Nurse Practitioner was interviewed on 7/25/19 at 12:59 PM and stated she did remember receiving a podiatry consult report. The Medical Director (MD), who was the resident's primary physician was interviewed on 7/25/19 at 1:23 PM and stated that he was not aware of the recommendations from the podiatry consult report. 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recertification survey, it cannot be ensured that the facility's staff provided ongoing monitoring of a resident for medication effect, side effects, adverse reaction, or any associated behavioral effects of the medication. Specifically, 1of 5 residents (Resident #106) reviewed for unnecessary medication revealed no evidence of ongoing monitoring for the use of an antipsychotic medication used to treat Hiccups. The findings are: Resident # 106 was admitted to the facility on [DATE] and had diagnoses including Major Depression, Dementia, and Anxiety. According to the 6/6/19 Quarterly Minimum Data Set (MDS; an assessment instrument), the resident had a Brief Interview Mental Status (BIMS, a test for cognitive functioning) score of 6 out of 15 which indicated impaired cognition, a mood score of 7 which reflected trouble concentrating, tiredness, and required staff assistance his with activities of daily living (ADLs). The Physician Orders dated 7/18/19 had an order for Chlorpromazine HCL (an antipsychotic medication) 25mg tablet, 0.5 tablet oral daily at 5pm for Hiccups. The Psychotropic Drug Use Care Plan initiated 6/15/2017 and last updated 7/27/2018 documented the resident was on Chlorpromazine for Status Hiccups that occurred in the evening. Interventions included to monitor for changes in resident's behavior or mood, observe and record the effectiveness of drug therapy, and monitor and report side effects/adverse outcomes of the medication. Clinical record revealed no evidence that the facility's staff provided ongoing monitoring of the resident for medication effect, side effects, adverse reaction, or any associated behavioral effects of the medication. RN #1 was further interviewed on 7/24/19 at 12:02PM and confirmed that Resident #106 was not being monitored regarding the Chlorpromazine medication. She further stated that she was unsure why the resident was not monitored by staff regarding the Chlorpromazine medication. RN #1 stated that she had checked the resident's clinical record from 2018 to present and could not find any nurses note that addressed the resident's hiccups. 415.12 (1)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during a recertification survey, it could not be ensured that the facility provided necessary dental services in a timely manner for 1 of 1 residents (resident #57) reviewed for dental services. Specifically, Resident #57 needed an adjustment to full upper and full lower dentures which was not completed or scheduled. The findings are: On 07/18/19 at 02:05 PM Resident #57 was observed to be edentulous. She was interviewed at that time and reported that she has upper and lower dentures but does not use them because they hurt. Resident #57 was admitted to the facility on [DATE]. A Quarterly Minimal Data Set (MDS: an assessment tool) dated 5/3/19 showed that Resident #57 is a [AGE] year-old male who was admitted with diagnoses that include Hypertension, Diabetes Mellitus and cancer in the situ of the esophagus. The Brief Interview of Mental Status (BIMS) showed that Resident #57 is cognitively intact with a score of 11. Review of Resident #57's Care Plan for Oral Hygiene dated 7/30/2018 had goals that she will have her teeth/dentures functioning properly and clean. Also, the Resident will be free from oral pain and pathology daily. The Interventions included that she will have dental examinations as needed per doctor's orders, monitoring for dental problems such as lesions and pain. Resident oral care daily with assistance. Resident was seen by the Dentist on 8/24/2018 and new Full upper and lower dentures were inserted with instructions indicating that the resident may experience Lisping and/or soreness. The Dentist also recommended to store Resident #57's dentures in water when not in use. The Resident was seen by the Dentist again on 6/19/19 for annual Follow up and indicated that dentures full upper and lower dentures need adjustment. On 7/24/19 at 1:20PM the Unit Charge Nurse was interviewed and stated that she was not aware of the dental consult or recommendations. She confirmed that Resident #57 has not had the dental follow up as recommended nor is it scheduled. 415.17 (a-d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #62 was admitted on [DATE] with diagnoses including but not limited to: Benign Prostatic Hypertrophy (BPH), Urinary Tract Infection (UTI), elevated Prostate Specific Antigen (PSA), Diabetes Mellitus (DM) and Depression. Record review revealed that the resident was hospitalized [DATE] and re-admitted [DATE]. Primary Medical Doctor (PMD) note dated 4/10/19 documented the resident was admitted to the hospital for hypotension, found to have UTI, and treated with antibiotics. A comprehensive 14-day Minimum Data Set (MDS: an assessment tool) dated 4/23/19 documented a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident was cognitively intact; received extensive assistance of one person for toilet use; was always incontinent of bowel and bladder; and had a diagnosis of UTI within the last 30 days. A care plan for Urinary - Incontinent Without Toileting Program dated 11/22/17 documented diagnoses UTI, Acute prostatitis, BPH, elevated PSA, and retention of urine, as evidenced by: incontinence of bladder with impaired memory recall, no ability for retraining or scheduled toileting at this time. Goal was last revised 2/14/19 and stated: Resident will remain comfortable, clean, dry and odor free daily x 3 months. Interventions were last revised 3/7/18 and included: administer perineal care after each episode of incontinence; apply barrier cream with each diaper change; change diaper every 2 hours and as needed; monitor for change in condition and ability for toileting; provide commode at bedside, if approved as safe by rehabilitation. Care Plan Notes/Evaluation were last updated 11/22/18 and documented: Resident remains incontinent of bladder. Incontinent care provided every 2-3 hours and as needed. Continue plan of care. The Unit 3 Registered Nurse Manager (RN #2) was interviewed on 7/25/19 at 2:57 PM and reported the resident does not have a current UTI care plan as those are done as episodics. At that time, RN #2 reviewed the record and revealed no episodic care plan was found to address the hospitalization from 4/2019 including a diagnosis of UTI. In a follow up interview 7/26/19 at 1:33 PM, RN #2 reported that the urinary incontinence care plan should have been updated to address Resident #62's UTI with hospitalization from 4/2019. 415.11(c)(2)(i-iii) Based on observation, interview and record review conducted during a recertification survey, it could not be ensured that the facility reviewed and revised comprehensive care plans with measurable goals and interventions to determine if interventions remained appropriate to address the residents' needs. Specifically, 1 of 1 residents (Resident # 4) reviewed for oxygen therapy had a Respiratory Care Plan which was not reviewed or revised to address her current respiratory needs; 1 of 5 residents (Resident # 106) reviewed for unnecessary medication/psychotropic drug use had a Care Plan which was not updated to determine if interventions remained appropriate for the continued use of an antipsychotic medication; and 1 of 2 residents (Resident # 62) reviewed for bladder and bowel incontinence had a Care Plan which was not updated to reflect a change in the resident's status regarding recent urinary tract infection. The findings are: 1. Resident #4 was admitted on [DATE] with diagnoses and conditions including Major Depression, Acute Bronchitis, Sleep Apnea and Pulmonary Embolism. According to the 6/29/19 Annual Minimum Data Set (MDS - an assessment tool), the resident had a Brief Interview Mental Status (BIMS - a cognitive functioning assessment tool) score of 15 out 15 which indicated intact cognition and required dependence on Bi-PAP/C-PAP machine at night which provides respiratory support to aid in lung function. The Alteration in Respiratory Care Plan was initiated on 5/10/17 and updated 12/28/17 with interventions not limited to: monitor respiratory status every shift to ensure airway patency, observe for signs of ineffective breathing. The Physician Orders dated 7/1/19 MD included instructions for Resident #4 to receive oxygen at 2 Liters per minute via nasal cannula for Shortness of Breath, Xarelto 20mg tablet oral daily for history of pulmonary embolism, continuous positive airway pressure (C-PAP) at bedtime for Sleep Apnea and oxygen saturation 3 x daily. Further review of the 12/28/17 Care Plan revealed it has not been updated to determine if interventions remained appropriated to meet the resident's respiratory needs. The Registered Nurse Manager (RN # 1) was interviewed on 7/25/19 at 10:29 AM and stated that she was responsible for initiating and updating care plans but offered no explanation as to why the care plan was not updated. 2. Resident # 106 was admitted to the facility on [DATE] and had diagnoses including Major Depression, Dementia, and Anxiety. According to the 6/6/19 Quarterly Minimum Data Set (MDS; an assessment instrument), the resident had a Brief Interview Mental Status (BIMS) score of 6 out of 15 which indicated impaired cognition, a mood score of 7 which reflected trouble concentrating, tiredness and required staff assistance his with activities of daily living (ADLs). The Physician Orders dated 7/18/19 had an order for Chlorpromazine HCL (an antipsychotic medication) 25mg tablet, 0.5 tablet oral daily at 5pm for Hiccups. The Psychotropic Drug Use Care Plan initiated 6/15/2017 and last updated 7/27/2018 documented that the resident was taking Chlorpromazine for Status Hiccups that occurred in the evening. Interventions included to monitor for changes in resident's behavior or mood, observe and record the effectiveness of drug therapy, as well as monitor and report side effects/adverse outcomes of the medication. Review of the Psychotropic Drug Use Care Plan, as indicated above, revealed no evidence that the care plan was reviewed and revised since 7/27/18 to determine if interventions remained appropriate for the ongoing use of the Chlorpromazine to treat Hiccups. RN #1 was interviewed on 7/23/19 at 2:09 PM and stated that Resident #106 had Hiccough at times and remained on Chlorpromazine medication. RN #1 stated that the RN managers are responsible for initiating and updating care plans, but in this case, it was an oversight. RN #1 was further interviewed on 7/24/19 at 12:02PM and confirmed that Resident #106 was not being monitored regarding the Chlorpromazine medication. She further stated that she was unsure why the resident was not monitored by staff regarding the Chlorpromazine medication. RN #1 stated that she had checked the resident's clinical record from 2018 to present and could not find any nurses note that addressed the resident's hiccups.

Based on observation and interview conducted during the recertification survey, it cannot be ensured that the facility practiced proper storage of foods in accordance with professional standards for food safety. Specifically, undated, outdated, and/or expired foods were stored in two refrigerated units. This was observed on both the initial tour and a follow up observation of the kitchen. The findings are: 1. Observations and interviews conducted during the initial tour of the kitchen on 7/18/19 between 9:30am to 10:50am revealed: a) The following undated and outdated foods were stored in the walk-in refrigerator (Unit 1): Ten 10-pound bags of undated, uncooked ground beef; Multiple undated, opened, boxes of defrosted beef patties; An undated, opened, package of cooked diced chicken; An undated, opened, 10-pound box of uncooked bacon; An outdated, full, half-pan of chicken pot pie, labeled with a use by date of 7/13. b) The following undated, outdated and expired foods were stored in the Cooks' prep refrigerator (Unit 2): An undated, quarter-full, number 6 pan of Tuna salad; A quarter-full, quarter pan, of defrosted liquid eggs, dated 7/5/19; An undated, opened, partially used container of pre-cooked hard-boiled eggs, about 90% full, dated 6/25/19 (the product label stated to use within five (5) days of opening). The Food Service Director (FSD) was interviewed at that time and confirmed that the identified food stuffs should not be in the refrigerated units, available for consumption. 2. Observations and interviews conducted during a follow up tour of the kitchen on 7/23/19 at 1:45 PM revealed: a) The following undated and outdated foods were stored in the walk-in refrigerator (Unit 1): One forty (40) pound case of defrosted chicken thighs dated 7/18; One half case (20 pounds) of defrosted chicken thighs dated 7/18; One 10-pound box of defrosted precooked sausage patties dated 7/18/19; One undated, 10-pound box of defrosted pre-cooked sausage links; One undated, opened, package of uncooked bacon. An interview was conducted on 7/24/19 at 9:42 AM with the Dietary Aide (DA) primarily responsible for dating and putting away foods upon delivery as well as retrieving frozen foods. At that time, the DA reported that he dates foods with a marker when they are delivered but does not date foods with a pull date or a use by date. He explained that he was not aware of the need to do so. A follow up interview of the FSD conducted on 07/24/19 at 11:30 am revealed that either he, another supervisor, or the DA are responsible for dating food upon delivery and when retrieving frozen foods. The FSD shared that a dating gun is utilized to note the date on foods upon delivery. He went on to explain that when pulling foods from the freezer for defrosting in the refrigerator, they are dated with the pulled date but he does not identify that date as the pulled date and that foods have not be labelled with a use by date. 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey, the facility did not ensure that one of four residents (Resident #99) reviewed for accidents was provided an assistive device that was properly maintained to prevent accidents. Specifically, the care planning team did not ensure that an electronic device (wander-guard) used by the resident to prevent elopement was maintained in accordance with the manufacture's guidelines to ensure proper functioning at all times when in use. The findings are: Complaint Intake Number: NY00207522 Resident #99 is diagnosed with unspecified dementia without behavioral disturbance and is able to ambulate with a walker. The annual elopement risk assessment dated [DATE] revealed that this resident is cognitively impaired and has poor decision- making capacity. It also revealed that the resident has prior history of elopement attempt from the facility. The care plan dated 8/24/17 noted the resident to be at risk for elopement (i.e. leaving the facility unauthorized and unknown to staff). The interventions to prevent elopement include monitoring the resident's whereabouts, involving the resident in recreation activities, and applying a wander-guard (an electronic device worn by the resident to alert staff when the resident wanders into certain unsafe and unmonitored areas). Review of a nurse's noted dated 9/17/17 revealed that the resident left the building on that date unknown to staff. The report of the investigation conducted by the facility on 9/17/17 revealed that on that date the resident, while wearing a wander-guard bracelet on her ankle, exited the facility at the main entrance without activating the wander-guard system and that staff was unaware that the resident left the building. The facility's staff was alerted when a visitor made them aware that the resident was outside the building. Further review of the investigative report revealed that an inspection of the wander-guard system showed that the tag pick up field from the knee down was weak. The report also showed that the battery for the wander-guard bracelet worn by this resident had an expiration date of March 2016. The Director of Nursing was interviewed on 9/27/17 at 11:03 AM. She stated that prior to this incident, the wander-guard bracelets were not checked for expiration dates and that this oversight was corrected. An interview conducted on 9/28/17 at approximately 3:00 PM with a Sale Representative Manager for the wander-guard company revealed that there is no guarantee that after three years the battery will function and that using it beyond the expiration date put the resident's safety at risk. 415.12(h)(l)