Based on record review and interview during the abbreviated survey (NY00337472), the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #3) reviewed. Specifically, Resident #3 sustained a head injury from a fall and neurological checks were not performed during the time the resident awaited transport to the hospital. Findings include: The Head Trauma Protocol reviewed 3/2007, documented: - the Registered Nurse Supervisor was responsible for notifying the physician of any resident with head trauma and to follow-up as warranted. - Neurological checks were to be performed per the instructions. The Registered Nurse was to obtain the physician's order to perform neurological checks per the policy (refer to Neurological Check policy). The Neurological Check policy reviewed 3/2007 documented: - any incident involving the head that resulted in an injury would initiate a monitoring schedule for neurological checks. The schedule was to be maintained for a minimum of 24 hours. Following the initial Registered Nurse assessment, monitoring and neurological assessments could be conducted by licensed nursing personnel. - If the medical provider was not in attendance, the Registered Nurse Supervisor was responsible for notifying the physician of a possible head injury and the assessment of the resident. - A neurological assessment was to be completed and documented every 15 minutes for the first hour. If the assessment was within normal limits and there was no evidence of changes, continue with assessment, monitoring and documentation every 30 minutes for the next hour. - The neurological assessment would include but not limited to vital signs, orientation/level of consciousness, pupil check, change in vision or speech, monitoring for nausea and vomiting, seizure activity, assessment of sensory function, change in behavior, checking motor function (ask resident to grip/release hands, push their arms against you, extend and flex both feet against resistance), and complaints of headache. - Documentation in the nursing notes was to include response to and tolerance of assessments and the presence or absence of parameters. Documentation on the neurological check flow sheet was to be completed with each assessment. The sheet was maintained with the corresponding month's medication administration records. Resident #3 had diagnoses including dementia and anxiety disorder. The 1/6/2024 Minimum Data Set assessment documented the resident had moderate cognitive impairment and required supervision for transfers. The resident had no falls since the last assessment. The 3/24/2024 at 4:30 AM Licensed Practical Nurse #16's progress note was documented as a late entry and noted the resident was found on the floor and the Supervisor was notified. Vital signs and neurological checks were done. The resident had a large bump above and next to their left eye with a small cut and a large bump on the side of their knee. The resident was sent to the hospital. The 3/24/2024 Incident Report completed by Registered Nurse Supervisor #15 documented: - at 4:40 AM, the resident was observed by staff to be on the floor in their room near their bed. - The resident had a large hematoma (collection of blood under the skin) to the left forehead and left side of the eye that measured 5 inches by 2 inches, and a hematoma with severe pain to the touch on the lower thigh that measured 2.5 inches by 2.5 inches. - The fall was unwitnessed. - The physician was notified at 5:00 AM and the resident was to be sent to the hospital for evaluation and treatment. -There was no documentation of neurological checks being completed. The resident's blood pressure, pulse, and respirations were noted on the incident report. The 3/24/2024 at 6:07 AM Registered Nurse Supervisor #15's progress note documented the resident was observed lying on their back next to the bed. They had a large hematoma to the left forehead extending down the left side of their eye measuring 5 inches by 2 inches and a hematoma to the left lower thigh area measuring 2.5 inches by 2.5 inches that was very painful to touch. Range of motion on all 4 extremities was at baseline. Neurological checks were at baseline. Ice was applied and acetaminophen was given. The on-call medical provider was notified and gave a new order was received to transfer the resident to the hospital for evaluation and treatment. Emergency Medical Services was called, and the resident left the facility via stretcher without incident. The Emergency Medical Service Patient Care Record documented they arrived to the resident at 6:46 AM. The resident had a fall out of bed, had a bump on their head, and possible hematoma and leg fracture. The resident was transported to the hospital and arrived at 7:21 AM. There was no documented evidence of neurological checks every 15 minutes for the first hour and every 30 minutes the next hour, following the initial assessment (approximately 5:00 AM) until emergency services arrived at 6:46 AM. During an interview on 5/15/2024 at 4:18 PM, Registered Nurse Supervisor #15 stated on 3/24/2024, they were called to the unit to assess Resident #3 following a fall. They called the physician and received the order to send the resident to the hospital and then called the resident's representative at approximately 5:15 AM for hospital of choice. The Supervisor called the Emergency Medical Services company directly. The Supervisor stated after that they went to the office to print the transfer paperwork and brought it to the unit, then returned to their office to do end of shift tasks. Registered Nurse Supervisor #15 was called back to the unit (unsure of the time) due to increased swelling of the area on the resident's head. They reassessed the resident at that time and directed staff to monitor the resident. They then returned to the office and was not made aware that Emergency Medical Services had not arrived to transport the resident. Approximately 45 minutes later, the Supervisor was on the unit and observed the resident was still in their room. They immediately called Emergency Medical Services again and they arrived shortly after. During an interview with Licensed Practical Nurse #16 on 5/23/2024 at 7:43 AM, they stated after a fall with head injury, neurological checks were done for 24 hours. They were to be recorded on a paper neurological flow sheet for 24 hours. The Licensed Practical Nurse was not sure of the time intervals to complete the neurological checks and would refer to the neurological check sheet. When Resident #3 fell, Registered Nurse Supervisor #15 responded to the unit and did an initial assessment and neurological check. Licensed Practical Nurse #16 stated they monitored the resident while waiting for Emergency Medical Services to arrive and did not complete a neurological check flow sheet due to the resident being sent to the hospital. They stated they documented neurological checks in the progress notes and on the incident report. During the time they waited for Emergency Medical Services, they did not notify the Registered Nurse Supervisor when they did not arrive but when the Supervisor came back to the unit, the Licensed Practical Nurse stated Emergency Medical Services had not arrived and the Supervisor called them again. During an interview with the Director of Nursing on 5/23/2024 at 11:52 AM, they stated post-fall protocol for residents who hit their head included initiation of neurological checks immediately. Neurological checks should be completed and documented every 15 minutes for the first hour, every 30 minutes for the next hour, and then every hour, and ongoing increments for a full 24 hours. If the resident was being sent to the hospital, the neurological checks should be completed per the protocol until Emergency Medical Services arrived. Neurological checks included vital signs, pupil reactions, hand grips, sensory function, and mobility/gait and should be fully documented for each increment of time according to the neurological flow sheet. The Registered Nurse who completed the initial assessment should document the first neurological assessment and subsequently, it could be the Registered Nurse or unit nurse. Documentation of the neurological assessment in progress notes without any details was acceptable as long the assessment was fully documented on the neurological flow sheet. If there was no flowsheet, the Director of Nursing expected the assessment to be documented in the progress note. The Director of Nursing was not aware that there were no neurological checks in the resident's record and stated it should have been documented to ensure monitoring of the resident's condition prior to emergency services arrived. 10 NYCRR 415.12

Based on observation, record review, and interviews during the recertification and abbreviated (NY00290651, NY00310705, and NY00312631) surveys conducted 1/8/2024-1/12/2024, the facility did not ensure residents were treated with respect and dignity for 3 of 5 residents (Residents #26, #38, and #110) reviewed. Specifically, Resident #26 had soiled clothing and an unclean wheelchair; Resident #38 was assisted with eating by registered nurse #9 and licensed practical nurse #10 who stood over them while feeding; and certified nurse aide #17 was observed speaking loudly about Resident #110's colostomy care and could be heard by anyone in the vicinity. Findings include: The facility policy, Accommodation of Resident Needs revised 9/2008 documented staff should call the resident by their first or last names and not honey, sweetie, dear; introduce yourself and explain all procedures to the resident and allow them to tell you what their needs are; review the care plan before providing assistance and always give the Resident a means to call for assistance by placing a call bell or tap bell within easy reach. The undated facility admission agreement packet documented as a resident of the facility, residents have the right to a dignified experience, self-determination, respect, full recognition of their individuality, consideration and privacy for personal needs and communication with and access to persons and services inside and outside of the facility. 1) Resident #26 had diagnoses of dementia with psychosis, Parkinson's Disease (a progressive neurological disorder), and depression. The 11/07/2023 Minimum Data Set assessment documented the resident had moderate cognitive impairment, required partial/moderate assistance of 1 for bathing and upper body dressing, substantial/maximum assistance of 1 for lower body dressing, and used a walker and a wheelchair. The comprehensive care plan, initiated 8/22/2022, documented Resident #26 had an activities of daily living deficit related to confusion, impaired balance, limited mobility, and Parkinson's Disease. Interventions included limited assistance of 1 for bathing/dressing and limited assistance of 1 for personal hygiene. Resident #26 was observed: - on 1/8/2024 at 10:23 AM sitting in their wheelchair dressed in a blue shirt, gray pants, and a gray hooded sweatshirt. There was a white stain on their shirt, a red food substance stain on the left sleeve of their jacket, and the left side of their wheelchair armrest and seat cushion had food stains. - on 1/9/2024 at 1:45 PM dressed in a green shirt, blue pants, and a white jacket. The left jacket sleeve had a red food substance on it and the left wheelchair armrest and seat cushion had food stains. - on 10/10/2024 at 10:00 AM sitting in their wheelchair. The left arm rest and seat cushion had food stains. During an interview on 1/10/2024 at 12:00 PM certified nurse aide #3 stated housekeeping was generally responsible for cleaning wheelchairs but if staff noticed a dirty chair, they should either wipe it down with bleach wipes or they could take the chair into the tub room and use the spray hose on it. They stated Resident #26's wheelchair was dirty and it was not dignified for the resident to sit in an unclean wheelchair. During an interview on 1/12/2024 at 9:14 AM licensed practical nurse #4 stated housekeeping usually cleaned wheelchairs but there was no set schedule. It was not dignified for Resident #26 to sit in a dirty wheelchair or to wear soiled clothing. Licensed practical nurse #4 stated staff should change the resident's clothes when they were soiled and should wipe down the wheelchair. During an interview on 1/12/2024 at 9:25 AM registered nurse #5 stated they were the charge nurse and was familiar with Resident #26. They stated Resident #26 required intermittent assistance with care and could feed themselves. Registered Nurse #5 stated the resident should be provided a clothing protector if they wanted one and it was not dignified for them to have clothing soiled with food. They expected staff to change the resident's clothing if it was soiled. The resident should sit in a dirty wheelchair as it was undignified. During an interview on 1/12/2024 at 9:56 AM the Director of Nursing stated they expected staff to assist Resident #26 with changing clothes when they were soiled and expected staff to wipe down dirty wheelchairs. They stated it was not dignified for a resident to remain in soiled clothing or to sit in a dirty wheelchair. 2) Resident #38 had diagnoses including Parkinson's disease (a progressive neurological disorder), and dementia. The 12/13/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition and required substantial/maximum assistance for all activities of daily living. The comprehensive care plan revised 10/26/2022 documented the resident had an activities of daily living self-care performance related to Parkinson's disease. Interventions included being fed by staff, providing a sippy cup with handles, and using an insulated mug with a lid. The following observations were made of Resident #38 during meals: - on 1/8/2024 at 12:36 PM, registered Nurse #9 assisted the resident with their meal in their room while standing. - on 1/9/2024 at 8:46 AM, registered nurse #9 assisted the resident with their meal in their room while standing. - on 1/9/2024 at 12:56 PM, registered nurse #9 assisted the resident with their meal in their room while standing. - on 1/10/2024 at 1:14 PM, licensed practical nurse #10 assisted the resident with their meal while standing. A chair was observed within reach. During an interview 1/9/2024 at 3:10 PM, certified nurse aide #12 stated they usually helped Resident #38 with their dinner. They stated they could either sit or stand with the resident when feeding them. The appropriate fashion to feed a resident with dignity was to stand and feed them. During an interview 1/10/2024 at 10:07 AM, certified nurse aide #8 stated the policy was to sit while feeding residents to be at their eye level. The resident's wheelchair was tall, so to keep at their level when assisting with eating, they had to stand. The facility did not provide tall stools or tall chairs to use with Resident #38. Dignified care was to be on the resident's level when assisting with meals. During an interview on 1/11/2024 at 9:32 AM, registered nurse #9 stated they had worked with Resident #38 for years. They did not have a preference on whether a staff member stood or sat down while assisting at mealtime. Registered nurse #9 stated it was important to provide residents with dignity. They stated staff should be at eye level with the resident when they were feeding and sitting would be more dignified. The registered nurse stated they always had to be moving and that was the reason they stood when they assisted the resident with eating. During an interview on 1/11/2024 at 9:55 AM, the Director of Nursing stated the dignified manner of feeding a resident was to sit. The resident should be care planned for their feeding requirements to ensure their dignity was maintained while assisting with mealtime. Staff should be seated when assisting the resident with feeding. 3) Resident #110 had diagnoses of diverticulitis of the intestines (inflamed pouches), colostomy status (a surgical opening from the large intestine to the outside to redirect stool), and gastro-intestinal bleeding. The 12/23/2023 Minimum Data Set assessment documented the resident was cognitively intact, had a colostomy, required assistance of 1 with toileting, and partial/moderate assistance for toileting hygiene. The 12/16/2023 physician order documented colostomy care every shift and as needed and colostomy supplies of a one-piece drainable ostomy pouch (holds stool from the colostomy). The comprehensive care plan initiated 12/27/2023 documented the resident had an activities of daily living self-care deficit related to activity intolerance. Interventions were partial/moderate assistance with toileting. The 1/2024 bowel and bladder elimination for colostomy care documentation was not completed on the evening and night shifts from 1/5/2024-1/7/2024. During an observation on 1/8/2024 at 11:19 AM, certified nurse aide #17 entered Resident #110's room, slammed the door, asked the resident if they wanted their colostomy bag emptied or changed, stated they did not know how to change a colostomy bag and would get someone to assist them in 15 minutes. Certified nurse aide #17 talked loudly and could be heard from the hallway. During an observation and interview on 1/8/2024 at 12:22 PM, Resident #110's colostomy bag was half full of fecal matter and air. The resident stated their ostomy bag exploded or leaked due to staff telling them to wait for it to be emptied and not returning for an hour. The resident stated it resulted in wet pants and the need for a clothing change which embarrassed them. During an interview on 1/10/2024 at 11:38 AM, certified nurse aide #25 stated certified nurse aides received colostomy care training in their classes. They were familiar with the resident and stated staff should check their colostomy bag every hour because it filled fast and would burst due to accumulated gas. Certified nurse aide #25 stated aides were trained to burp the colostomy bags and to empty them. They should not yell loudly about a resident's ostomy, and it would embarrass the resident. They stated the resident knew how to do their ostomy care, but they were in the facility for care and should be assisted. If the certified nurse aide did not know how to perform the task, they should ask the nurse quietly to explain the process to them. During an interview on 1/10/2024 at 1:41 PM certified nurse aide #17 stated they were not assigned to Resident #110 on 1/8/2024 and had answered their call bell. Certified nurse aide #17 stated they had ostomy care training in their class and had no hands-on training and they did not know how to care for a colostomy. They stated they should not have yelled loudly about the resident's ostomy because it could embarrass the resident and they should have asked another aide or a nurse for help. During an interview on 1/11/2024 at 9:22 AM certified nurse aide #24 stated they were familiar with Resident #110, they had a colostomy, and they helped empty it when needed. They stated they learned about ostomy care in certified nurse aide class by reading and return demonstration. They stated due to the Health Information Portability and Accountability Act (protects private health information), staff should not yell out loud that they did not know how to perform the ostomy care, it would embarrass the resident, it was a private matter and when asked, the nurse would always help them. During an interview on 1/11/2024 at 12:14 PM licensed practical nurse #26 stated the nurses were responsible for changing colostomy bags weekly during skin assessments and nurses and certified nurse aides could empty them and document the amount. They stated the certified nurse aides should not be discussing a resident's care loudly and if the aide did not know how to perform the care, they should ask another aide, or the nurse and they would walk them through the steps. During an interview on 1/12/2024 at 11:26 AM, the Director of Nursing stated that if a certified nurse aide was not sure how to perform colostomy care, they should ask the nurse on the unit. The staff should never say they cannot or do not know how to do the care in a loud voice, the resident would lose faith in the staff ability to care for them and this was a dignity issue if the conversation could be heard in the hallway. 10NYCRR 415.3(c)(1)(i)

Based on observation, record review, and interview during the recertification survey conducted 1/8/2024-1/12/2024, the facility did not develop and implement a comprehensive person-centered care plan for each resident to meet medical and nursing needs for 1 of 1 resident (Resident #46) reviewed. Specifically, Resident #46 had a physician order to elevate their legs when out of bed and the order was not implemented. Findings include: The facility policy Baseline Care Plan, reviewed 3/2023, documented the care plan included instructions needed for staff to provide effective and person-centered care and physician's orders. The baseline care plan would be evolved into the comprehensive plan of care by the care team and subsequent assessments. Resident #46 had diagnoses including Alzheimer's disease, hypothyroidism (underactive thyroid gland), and hyperlipidemia (elevated fat levels in the blood). The 12/13/23 Minimum Data Set assessment documented the resident had severely impaired cognition, did not exhibit behaviors, had functional limitation in both legs, and was dependent for most activities of daily living. The 12/14/2027 physician's order active through 1/11/2024 documented to elevate the resident's legs when out of bed as much as possible. The comprehensive care plan, revised 9/17/2019, documented the resident had an activities of daily living self-care performance deficit related to Alzheimer's dementias and limited range of motion. Interventions included the resident was to be in a positioning wheelchair with a foot bucket (a solid one piece footrest to assist with leg support and positioning) when out of bed, was to utilize bilateral soft knee-high offloading boots unless bathing and laundering, and they required maximal assistance of 2 with a mechanical lift. The comprehensive care plan initiated 1/21/2016 documented the resident had impaired circulation related to dependent edema (swelling) and elevated cholesterol. Interventions included to have legs elevated when resting and to inspect the foot, ankle, and calf skin daily for changes. The January 2024 resident's care instruction did not include instructions to elevate the resident's legs. The skin risk assessments dated 11/27/2023 and 12/18/2023 documented the resident had a risk factor of edema. The following observations were made of Resident #46: - on 1/8/2024 at 12:18 PM, their feet were positioned dependent on the positioning wheelchair foot bucket and were not elevated. - on 1/9/2024 at 8:10 AM, their feet were positioned dependent on the positioning wheelchair foot bucket and were not elevated. At 1:05 PM, their right foot was on the foot bucket and their left foot was on the floor, both feet were dependent and not elevated. At 1:41 PM, both feet were dependent in the foot bucket and not elevated. At 2:43 PM, their feet were dependent on the wheelchair foot bucket and not elevated. - on 1/10/2024 at 11:16 AM, both legs were dependent on the foot bucket of the wheelchair and were not elevated. At 1:28 PM, 2:35 PM and 4:57 PM, both legs were dependent on the foot bucket of the wheelchair with the chair slightly tilted so their legs were elevated less than 45 degrees. - on 1/11/2024 at 8:45 AM, eating with their positioning chair slightly tilted back with both legs dependent on the foot bucket of the wheelchair. At 9:59 AM, asleep, positioned with the wheelchair slightly tilted back and both legs were dependent on the foot bucket of the wheelchair. At 12:36 PM, eating with their positioning chair slightly tilted back and both legs dependent on the foot bucket of the wheelchair. During an interview on 1/11/2024 at 1:37 PM, certified nurse aide #14 stated if a resident had an order for their legs to be elevated whenever possible, their legs should be elevated by the staff. They would know if a resident had an order for their legs to be elevated by their plan of care. A resident's legs were considered elevated at 90 degrees or more from a dependent position of their feet flat on the floor or on footrests. They stated they knew Resident #46 was to wear the bilateral soft knee-high offloading boots but was unaware that their legs were to be elevated. During an interview on 1/11/2024 at 1:45 PM, licensed practical nurse #15 stated they would usually elevate a resident's legs in a recliner or in their bed. If the resident was in a wheelchair that reclined, they would tilt the chair backwards and use a pillow to assist with propping the legs. They stated staff would use a pillow or recline Resident #46's wheelchair. At 3:44 PM, licensed practical nurse #15 stated they checked the electronic medical record and Resident #46's order to elevate their legs as much as possible when out of bed was under other order, no documentation. The order did not populate for the nurses to see on the medication administration record or the treatment administration record where the nurses could see the order and record it was completed. During an interview on 1/11/2024 at 3:45 PM, registered nurse Care Coordinator #16 stated they had reviewed the order for Resident #46 to elevate their legs whenever possible out of bed. They stated they believed the order was put in when the resident was in a different kind of wheelchair. The order was discontinued today. They stated nursing staff should follow the orders in the computer and the orders should be put into the computer, so they populated for the nurses to be aware of them and to document on them. 10NYCRR 415.11(c)(1)

Based on observation and interview during the recertification and abbreviated surveys (NY00310705 NY00312631, NY00313972, and NY00328391) conducted 1/8/2024-1/12/2024, the facility did not post on a daily basis at the beginning of each shift, the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, in a prominent location readily accessible to residents and visitors for 4 of 5 days. Specifically, the current daily resident census and nurse staffing schedules were located on the Unit 1 [NAME] nursing office door that was not easily accessible to visitors or residents. Findings include: The daily resident census and nurse staffing information was observed posted on the nursing office door outside of Unit 1 [NAME] across from the elevator: - on 1/8/2024 at 2:21 PM. - on 1/9/2024 at 7:50 AM. - on 1/10/2024 at 12:03 PM. - on 1/11/2024 at 9:27 AM. The posting was not legible, did not include the daily census, and was not readily accessible to residents or visitors. During an interview on 1/8/2024 at 4:00 PM, the Administrator stated the main entrance to the facility was on the ground level near the outpatient clinics; the nursing home was located on floors 1 and 2 and the upper-level entrance had been closed since the COVID-19 pandemic and was not going to be re-opened. During an observation on 1/10/2024 at 12:03 PM, signs that directed visitors to use the ground level entry were posted near the social services office and entrance to Unit 1 West. There were no daily staffing or census posted. During an interview on 1/12/2024 at 11:51 AM staff scheduler #13 stated the staffing schedule was posted per shift outside of Unit 1 West, across from the elevator on the nursing office door on the 2nd level of the nursing home on the 1st floor. They stated it was not always legible and was for the day shift only. They were not aware the daily staffing needed to include all shifts for 24 hours and should be posted in an area visible to all visitors upon entrance. 10 NYCRR 415.13

Based on observation, record review, and interviews during the recertification and abbreviated (NY00328391) surveys conducted 1/8/2024-1/12/2024, the facility did not ensure a resident who displays or is diagnosed with dementia receives the appropriate treatment and services to attain and or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #45) reviewed. Specifically, Resident #45 who had a diagnosis of dementia, made suicidal statements that were not addressed by the facility. The facility policy Suicide Precautions reviewed 03/2023 documented immediate protective response would be provided, physically and emotionally, to any resident that expressed suicidal plans, thoughts, or attempts. Any employee who became aware that a resident had expressed suicidal thoughts, plans, or attempts would immediately notify the charge nurse on the resident's unit. The resident would be under direct supervision until a plan of care for the resident was determined. The registered nurse Supervisor, Director of Nursing, social services, Administrator, and physician would all be notified. If the resident was on psychiatric services, the provider of those services would be notified. If they were not, an evaluation would be requested. Resident #45 had diagnoses that included depression, anxiety disorder, and unspecified dementia. The 12/20/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not have depression, had no behavioral symptoms, and was on anti-psychotic and anti-depressant medications. The comprehensive care plan revised 04/2023, documented the resident had a history of behavior problems related to their dementia which included being weepy and inconsolable. The resident was to have psychiatric consults as needed. Interventions included to monitor behavior episodes to determine cause and to encourage the resident to express their feelings. The comprehensive care plan, initiated 09/11/2020, documented the resident had impaired cognitive function related to dementia. The interventions included to report any change in mental status or cognitive function. The 12/2/2023 at 9:28 PM licensed practical nurse #36 nursing note documented the resident had been yelling and singing all shift and was impossible to redirect. The resident was also making comments that they wished they were dead, and they were going to jump in front of a bus. The plan was to monitor. There was no documented evidence a nursing supervisor or medical provider were notified of the resident's comments. The 12/5/2023 at 9:10 PM licensed practical nurse #36 nursing note documented the resident was singing/screaming/swearing all shift. The resident was and stated they were going to jump out the window when the nurse asked the resident not to sing. There was no documented evidence a nurse Supervisor or medical provider were notified of the resident's comments. There was no evidence of social services or medical provider notification or interventions regarding the resident's statements of self harm. The following observations were made of Resident #45: - on 1/9/24 at 1:41 PM, singing out loudly a wordless tune in their room. At 1:54 PM, they were still singing wordless tune loudly in their room. - on 1/10/24 at 1:19 PM, singing loudly in their room. At 4:49 PM, they were in the hallway singing Candy, Candy, where are you loudly and appeared distressed. An unidentified certified nurse aide informed the resident that they just had to sit another resident down and then they would take the resident back to their room to call their family. Resident #45 was agreeable and stopped singing. At 5:17 PM, they were singing loudly in their room. During an interview on 1/10/2024 at 4:33 PM, the Director of Social Services stated they should be notified of depressive or suicidal statements or ideations made by residents so they could assess the resident. Resident #45 had been followed in their psychotropic medication monitoring rounds due to an increase in behaviors and a decline in their cognitive status related to dementia. There were no reports from the resident or staff the resident was having increased depression. They stated they were not informed of the statements made by the resident on 12/2/2023 and 12/5/2023. They would have done a safety assessment to ensure the resident was okay. During an interview on 1/11/2024 at 1:37 PM, certified nurse aide #14 stated if a resident appeared more depressed or had made depressive comments, they would inform the nurse and the Nursing Supervisor. During an interview on 1/11/2024 at 1:45 PM, licensed practical nurse #15 stated if a resident had made suicidal or increased depressive statements, they would chart on it and notify the Nursing Supervisor. They would also document that they informed the supervisor and what the supervisor implemented for the resident. The Nursing Supervisor would notify the nurse practitioner or the physician. They stated that if they did not report the statements and the resident ended up hurting themselves, it would be a safety issue. During an interview on 1/11/2024 at 3:45 PM, registered nurse Care Coordinator #16 stated if a resident made a suicidal ideation statement, they expected the nurses or any staff member to bring it to their attention. The facility had resident assistants who could sit with the resident while they assessed the situation, and they brought it to the Director of Nursing and the medical providers. The resident would be assessed to see if an evaluation by a hospital was warranted. They were unaware of any suicidal statements made by Resident #45. During an interview on 1/11/2024 at 4:09 PM, the Director of Nursing stated registered nurse supervisor #39 worked on the evening of 12/2/2023 and registered nurse supervisor #38 worked on the evening of 12/5/2023. They stated the actions put into place if a resident made suicidal ideation statements would depend on the resident and the resident's history. They stated the facility took every resident statement seriously. If the statements were not a normal behavior for the resident, they would immediately put a one-to-one (safety watch) in place and notify the provider. Supervisors were to be notified of any resident that made suicidal ideation statements. During an interview on 1/11/2024 at 4:14 PM, registered nurse supervisor #39 stated if a licensed practical nurse was informed a resident made a suicidal ideation, the nurse should immediately report it to them so the resident could be assessed, and the information passed up the nursing chain of command. They could not recall being notified of any resident in the facility making a suicidal ideation statement. They stated they should have been informed of Resident #45's statements so interventions could be put into place as the resident could have acted on their thoughts. During an interview on 1/11/2024 at 4:22 PM, registered nurse supervisor #38 stated they expected to be contacted immediately if a resident made a suicidal ideation statement so that they could assess the resident and their ability to act on a plan. If a resident had a psychiatric history with previous attempts and would act on a plan, the resident would be placed on one-to-one immediately and the Director of Nursing and medical provider would be contacted. They stated they could not recall being informed of any resident in the facility making a passive suicidal comment. They had never been informed of Resident #45 making statements. They knew Resident #45 could get frustrated with their dementia. They stated they should have been informed and it was important to report those statements so the resident could be investigated and monitored. During an interview on 1/12/2024 at 10:40 AM, licensed practical nurse #36 stated their procedure for a resident that had made a depressive or suicidal ideation statement was to let the supervisor know and document what the resident stated. Sometimes they would talk to the resident to calm them down or contact the resident's family to assist with calming them down, but they did not have a lot of time to sit and spend with a resident. They could not recall if they notified the supervisor on 12/2/2023 and 12/5/2023. They tried to document when they let their supervisor know but that they sometimes let the supervisor know thirty minutes or so after the resident had made the comments so the note may have already been written. They stated they did not believe there were any negative side effects in the delayed supervisor notification because they would sometimes bring the resident out to the nurse's station to be within sight or had a resident assistant sit with the resident. Resident #45 had made some suicidal ideation statements but that it was a behavior that reoccurred at random, so they did not always let the supervisor know. 10 NYCRR 415.12

Based on observation, record review, and interview during the recertification survey conducted 1/8/2023-1/12/2023, the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety in 1 of 1 main kitchen. Specifically, the mechanical dishwasher was not maintained, clean utensils were not properly stored, uncleanable surfaces were present in the walk-in cooler, and the walk-in cooler was soiled. Findings include: The undated facility policy, Kitchen Cleaning documented all kitchen staff were responsible for cleaning and sanitizing the kitchen. Specifically, cooks were responsible for cleaning and maintaining their work area, steamers, fryers, sinks, slicers, stove tops, and general work areas; dietary aides were responsible for cleaning their tray line areas, walk-in cooler, refrigerator and dessert carts and dishwashers were responsible for cleaning the dishwashing area and cleaning/mopping floors. Garbage was removed by maintenance. 1) Mechanical dishwasher The mechanical dishwasher's specifications were not documented on the machine. During an observation on 1/12/2024 at 10:06 AM, dishwashing staff were observed washing, putting away and stacking wet dishes. The dishwashing machine temperatures were observed at 125 degrees Fahrenheit (F) for washing and 170 F degrees for rinsing and temperature logs were not documented at the proper temperatures. The facility's Dishwasher Temperatures log documented the required wash temperature as 150 degrees and the rinse temperature as 180 F degrees or above. The log dated January 2024 documented the following temperatures recorded by dietary aide #33: -1/2/2024: 169 F degrees for washing, 170 F degrees for rinsing; -1/3/2024: 150 F degrees for washing, 172 F degrees for rinsing; -1/4/2024: 154 F degrees for washing, 160 F degrees for rinsing; -1/5/2024: 149 F degrees for washing, 175 F degrees for rinsing; -1/8/2024: 152 F degrees for washing, 173 F degrees for rinsing; -1/10/2024: 147 F degrees for washing, 176 F for rinsing; -1/11/2024: 163 F degrees for washing; 152 F degrees for rinsing. The log dated December 2023 had the following temperatures recorded by various staff: -12/7/2024: 125 F degrees for washing, 172 F degrees for rinsing; -12/8/2024: 115 F degrees for washing, 175 F degrees for rinsing; -12/17/2024: 125 F degrees for washing, 150 F degrees for rinsing; -12/25/2024: 149 F degrees for washing, 170 F degrees for rinsing; -12/26/2024: 146 F degrees for washing, 188 F degrees for rinsing; During an interview on 1/12/2024 at 10:08 AM, dietary aide #33 stated dishes were pre-washed and then put through the dish washing machine. After the dishes went through the machine, they should be left to drip, some to dry, and bowls should be placed face down to let dry. They stated there was a temperature range to look for and they documented the machine's temperature on a log. They stated the dishwashing machine temperatures under 150 degrees for washing and 180 degrees for rinsing were not appropriate. The logs were sent to the Supervisor; but they were not sure if temperature logs for the dishwasher were reviewed. During an interview on 1/12/2024 at 10:18 AM, Dietary Supervisor #34 stated dishes should be left to air dry and not stacked wet. They stated they were not sure of the mechanical dishwasher's required temperatures, but thought they were 100 degrees for washing and 180 degrees for rinsing. They stated they collected the logs, but they did not review them, only saved them in a file. After reviewing the log for January 2024 and December 2023, Dietary Supervisor #34 stated the temperatures recorded below the 150 for wash and 180 for rinse were not acceptable. They stated they should have called maintenance, but they did not know the machine was not at the correct temperature and did not alert maintenance. During an interview on 1/12/2024 at 10:35 AM, the Director of Dietary stated the mechanical dishwasher required temperatures were 165 for wash and 185 or higher for rinse. They stated those temperatures were checked and documented twice daily, but occasionally the night shift did not remember to do so. Staff were supposed to notify supervisors if it was not at the correct temperature, and they would alert maintenance or their vendor. They stated the dietary supervisors were supposed to collect and periodically check the logs. The Director of Dietary stated the temperatures recorded on the logs for December 2023 and January 2024 that were below 150 for wash and 180 for rinse were not acceptable. They stated they were not sure if anything was done or if anyone had contacted maintenance. 2) Utensil storage/Uncleanable surface/Walk-in cooler floor During observations on 1/9/2024 at 11:28 AM, 1/10/2024 at 12:19 PM, and 1/12/2024 at 10:18 AM ice scoops were on top of the ice machine which was soiled with debris. During an observation on 1/9/2024 at 12:11 AM the shelving in the dairy walk-in cooler was very rusty, not smooth, and uncleanable. During observations on 1/9/2024 at 12:13 AM, 1/10/2024 at 12:19 PM, and 1/12/2024 at 10:18 AM the meat and produce walk-in cooler had a small puddle of yellowish liquid under the wire racks on the right side of the cooler. During an interview on 1/12/2024 at 10:18 AM, Dietary Supervisor #34 stated the person assigned as the pot and pan washer was responsible for cleaning the walk-in coolers and those should be swept and mopped daily. They stated they were not sure what the liquid on the floor of the cooler was but should have been cleaned. They stated the ice scoops were stored on top of the ice machines and they thought the top of the ice machines were cleaned weekly. During an interview on 1/12/2024 at 10:35 AM, the Director of Dietary stated the walk-in coolers should be cleaned daily, or as needed, and a spill should not have remained on the floor of the cooler for multiple days. They stated the rusty shelving was not smooth, or easily cleanable. The Director of Dietary stated the ice scoop should not be stored atop the ice machine. 10NYCRR 415.14(h)

Based on observation, record review, and interviews during the recertification and abbreviated (NY00310705, NY00312631, NY00313972, and NY00328391) surveys conducted 1/8/2024-1/12/2024, the facility did not ensure sufficient nursing staff was provided for nursing care to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 12 of 12 anonymous residents who expressed concerns regarding lack of sufficient staffing and not receiving care in a timely manner. Specifically, during a confidential group meeting (resident council) 12 residents stated they had long wait times for receiving assistance with care. Additionally, deficiencies related to staffing were identified in the areas of Posted Nurse Staffing Information (F732), Resident Rights (F 550), and Infection Control (F 880). Findings include: The facility policy Staffing of Nursing Personnel dated 6/22/2009 documented all residents' needs were always met in a timely manner. The Director of Nursing set the staffing level for each unit and shift. The staffing levels/rosters were prepared for the nursing supervisor for each shift. If staffing needs fell below the anticipated needs, the nursing supervisor was to contact as many on duty and off duty personnel to find coverage. If adequate nursing personnel was not obtained, the nursing supervisor was to contact the Director of Nursing or Administrator, who might request assistance from other departments. The 10/2023 Facility Needs Assessment documented the facility's average daily bed census was 130, with a total bed capacity of 160. The facility's population served both long-term nursing and short-term rehabilitation. The staff plan included the following positions with the desired number total for the facility, by shift: Resident assistants, desired number for day shift 5; evening shift 4, none desired for night shift. Certified nurse aides, desired number for day shift 15; evening shift 15; and night shift 6. Licensed practical nurses, desired number for day shift 6; evening shift 4.5; and night shift 4. Nurse Care Coordinators, desired number for day shift 5. Nursing supervisors, desired number for evening shift 1.5; and night shift 1. The facility daily staffing schedule documented the following nursing schedule for 1/8/2024 through 1/12/2024 (there were 4 nursing care units; 1W, 1E/1EE, 2W, and 2E/2EE): Day shift/first shift (7:00 AM to 3:00 PM) Monday 1/8/2024 staffing documented the following schedule for 115 residents. - Unit 1W: 2 registered nurses (1 worked 11:00 AM-3:00 PM), 2 licensed practical nurses (1 worked 11:00 AM- 3:00 PM), 2 certified nurse aides, and 1 resident assistant. - Unit 1E/1EE: 1 registered nurse, 2 licensed practical nurses (1 worked 6:30 AM-2:30 PM), 3 certified nurse aides (1 worked 9:00 AM-1:30 PM), and 3 resident assistants. - Unit 2W: 1 registered nurse, 1 licensed practical nurse, 2 certified nurse aides, and 1 resident assistant - Unit 2E/2EE: 1 registered nurse, 2 licensed practical nurses, 2 certified nurse aides (1 worked 6:00 AM-2:00 PM), and 3 resident assistants Evening/second shift (3:00 PM to 11:00 PM) Monday 1/8/2024, staffing documented the following schedule for 115 residents. - Unit 1W: 2 licensed practical nurse (1 worked 3:00 PM-7:00 PM), 1 certified nurse aide, and 2 resident assistants (1 worked 3:00 PM-9:00 PM). - Unit 1E/1EE: 2 registered nurses that split the shift 3:00 PM-7:00 PM, and 7:00 PM-11:00 PM, respectively (acted in the licensed practical nurse role), 1 licensed practical nurse, 1 certified nurse aide (another staff orienting to the certified nurse aide position), and 2 resident assistants (1 worked 3:00 PM-9:00 PM). - Unit 2W: 1 licensed practical nurse, 1 certified nurse aide, and 2 resident assistants - Unit 2E/2EE: 1 registered nurse (acted in the licensed practical nurse role), 2 licensed practical nurses that splint the shift 3:00 PM-7:00 PM, and 7:00 PM-11:00 PM, respectively, 2 certified nurse aides that split the shift 3:00 PM-7:00 PM, and 7:00 PM-11:00 PM, and 2 resident assistants. Overnight/third shift (11:00 PM to 7:00 AM) Monday 1/8/2024, staffing documented the following schedule for 115 residents. - Unit 1W: 2 licensed practical nurses (1 worked in the certified nurse aide role), 1 certified nurse aide (another staff member orienting to the certified nurse aide position from 3:00 AM-7:00 AM), and 1 resident assistant. - Unit 1E/1EE: 2 licensed practical nurses, and 2 certified nurse aides. - Unit 2W: 1 licensed practical nurse, and 2 certified nurse aides. - Unit 2E/2EE: 2 licensed practical nurse (1 worked 11:00 PM-3:00 AM, in the certified nurse aide role), and 2 certified nurse aides. Day/first shift (7:00 AM to 3:00 PM) Tuesday 1/9/2024, staffing documented the following schedule for 115 residents. - Unit 1W: 2 registered nurses, 1 licensed practical nurse, 2 certified nurse aides that split the shift 7:00 AM-8:40 AM, and 8:40 AM-3:00 PM, respectively, (another staff orienting to the certified nurse aide position), and 1 resident assistant. - Unit 1E/1EE: 1 registered nurse, 2 licensed practical nurses, 3 certified nurse aides (1 worked 7:30 AM-3:00 PM), and 3 resident assistants. - Unit 2W: 1 licensed practical nurse, 2 certified nurse aides (1 worked 6:00 AM-2:00 PM, 2 other staff orienting to the certified nurse aide position), and 1 resident assistant. - Unit 2E/2EE: 3 registered nurses (2 registered nurses split the shift 7:00 AM-12:00 PM and 12:00 PM-3:00 PM, and worked in the licensed practical nurse role), 1 licensed practical nurse, 4 certified nurse aides (1 worked 7:00 AM-8:40 AM, and another staff member oriented to the certified nurse aide position), and 3 resident assistants Evening/second shift (3:00 PM to 11:00 PM) Tuesday 1/9/2024, staffing documented the following schedule for 115 residents. - Unit 1W: 2 licenses practical nurse (worked 3:00 PM-7:00 PM, and 2:00 PM-11:00 PM, respectively), 2 certified nurse aides (1 worked 7:00 PM-11:00 PM), and 3 resident assistants (2 worked overtime 4:30 PM-7:30 PM and 3:30 PM-5:30 PM, respectively). - Unit 1E/1EE: 3 licensed practical nurses (2 split the shift 3:00 PM-7:00 PM, and 7:00 PM-11:00 PM), 3 certified nurse aide, and 2 resident assistants (another staff member oriented to the resident assistant position). - Unit 2W: 1 licensed practical nurse, 2 certified nurse aides, and 1 resident assistants - Unit 2E/2EE: 2 registered nurses (worked 3:00 PM-7:00 PM in the licensed practical nurse role), 2 licensed practical nurses worked 7:00 PM-11:00 PM, 3 certified nurse aides (2 worked 2:00 PM-11:00 PM and 7:00 PM-11:00 PM, respectively) and 1 resident assistant. Overnight/third shift (11:00 PM to 7:00 AM) Tuesday 1/9/2024, staffing documented the following schedule for 115 residents. - Unit 1W: 2 licensed practical nurses (1 worked in the certified nurse aide role), 2 certified nurse aides split the shift 11:00 PM-3:00 AM and 3:00 AM-7:00 AM. - Unit 1E/1EE: 2 licensed practical nurses, and 2 certified nurse aides. - Unit 2W: 2 licensed practical nurses (1 worked in the certified nurse aide role from 11:00 PM- 3:00 AM), and 2 certified nurse aides. - Unit 2E/2EE: 2 licensed practical nurses, 4 certified nurse aides (2 worked 11:00 PM - 3:00 AM, and another staff member oriented to the certified nurse aide role), and 1 resident assistant. Day/first shift (7:00 AM to 3:00 PM) Wednesday 1/10/2024, staffing documented the following schedule for 115 residents. - Unit 1W: 2 registered nurses, 2 licensed practical nurses, 3 certified nurse aides, and 2 resident assistants (1 worked 7 AM-1 PM). - Unit 1E/1EE: 1 registered nurse that worked 11 AM-3 PM, 2 licensed practical nurses, 3 certified nurse aides (1 worked 9:00 AM-1:30 PM), and 2 resident assistants. - Unit 2W: 2 licensed practical nurses, 2 certified nurse aides, and 2 resident assistants. - Unit 2E/2EE: 1 registered nurse, 2 licensed practical nurses, 3 certified nurse aides (1 worked 6:00 AM-2:00 PM, and another staff member oriented to the certified nurse aide position), and 3 resident assistants Evening/second shift (3:00 PM to 11:00 PM) Wednesday 1/10/2024, staffing documented the following schedule for 115 residents. - Unit 1W: 1 license practical nurse (with a registered nurse oriented to the licensed practical nurse position), 2 certified nurse aides, 1 resident assistant worked overtime from 4:30 PM-7:30 PM. - Unit 1E/1EE: 1 registered nurse worked in the licensed practical nurse, 2 licensed practical nurses that split the shift 3:00 PM-7:00 PM, and 7:00 PM-11:00 PM), 2 certified nurse aide, and 1 resident assistant (another staff member oriented to the resident assistant position). - Unit 2W: 2 licensed practical nurses that split the shift 3:00 PM-7:00 PM, and 7:00 PM-11:00 PM, 2 certified nurse aide, and 1 resident assistants. - Unit 2E/2EE: 2 registered nurses (1 worked 3:00 PM-7:00 PM in the licensed practical nurse role), 1 licensed practical nurse worked 7:00 PM-11:00 PM, 3 certified nurse aides (1 worked 7:00 PM-11:00 PM), and 1 resident assistant. Overnight/third shift (11:00 PM to 7:00 AM) Wednesday 1/10/2024, staffing documented the following schedule for 115 residents. - Unit 1W: 1 licensed practical nurse, and 2 certified nurse aides. - Unit 1E/1EE: 2 licensed practical nurses, and 2 certified nurse aides. - Unit 2W: 1 licensed practical nurse, 3 certified nurse aides (2 split the shift 11:00 PM-3:00 AM and 3:00 AM-7:00 AM), and 1 resident assistant. - Unit 2E/2EE: 2 licensed practical nurses, and 2 certified nurse aides (another staff member oriented to the certified nurse aide role). Day/first shift (7:00 AM to 3:00 PM) Thursday 1/11/2024, staffing documented the following schedule for 115 residents. - Unit 1W: 2 registered nurses, 2 licensed practical nurses (1 worked 7:00 AM-2:00 PM), 3 certified nurse aides, and 2 resident assistants (1 worked 7:00 AM-2:30 PM). - Unit 1E/1EE: 1 registered nurse, 2 licensed practical nurses, 3 certified nurse aides, and 3 resident assistants. - Unit 2W: 2 licensed practical nurses, 3 certified nurse aides (1 worked 6:00 AM-2:00 PM), and 2 resident assistants. - Unit 2E/2EE: 1 registered nurse, 3 licensed practical nurses, 2 certified nurse aides (1 worked 6:00 AM-2:00 PM, and another staff member oriented to the certified nurse aide position), and 3 resident assistants. Evening/second shift (3:00 PM to 11:00 PM) Thursday 1/11/2024, staffing documented the following schedule for 115 residents. - Unit 1W: 1 license practical nurse, 3 certified nurse aides (2 worked 3:00 PM-5:00 PM and 8:30 PM-11:00 PM, respectively), and 2 resident assistants (1 worked overtime 4:30 PM-7:30 PM). - Unit 1E/1EE: 3 licensed practical nurses (2 split the shift 3:00 PM-7:00 PM, and 7:00 PM-11:00 PM), 2 certified nurse aides, and 1 resident assistant (another staff member oriented to the resident assistant position). - Unit 2W: 2 licensed practical nurses that split the shift 3:00 PM-7:00 PM, and 7:00 PM-11:00 PM, 2 certified nurse aides (1 worked 3:30 PM-7:30 PM, and 1 resident assistants. - Unit 2E/2EE: 2 registered nurses (1 worked 3:00 PM-7:00 PM in the licensed practical nurse role), 1 registered nurse worked in the licensed practical nurse role 7:00 PM-11:00 PM, 1 licensed practical nurse worked 7:00 PM-11:00 PM, 2 certified nurse aides, and 1 resident assistant. Overnight/third shift (11:00 PM to 7:00 AM) Thursday 1/11/2024, staffing documented the following schedule for 115 residents. - Unit 1W: 1 licensed practical nurse, and 3 certified nurse aides (2 split shift 11:00 PM-3:00 AM and 3:00 AM-7:00 AM). - Unit 1E/1EE: 2 licensed practical nurses, and 2 certified nurse aides. - Unit 2W: 1 licensed practical nurse, 2 certified nurse aides (1 worked 3:00 AM-7:00 AM), and 1 resident assistant. - Unit 2E/2EE: 2 licensed practical nurses (1 worked 11:00 PM-3:00 AM), and 2 certified nurse aides (another staff member oriented to the certified nurse aide role). The undated facility census, provided on 1/8/2024 documented 115 residents resided in the facility. The undated resident roster documented that Unit 1W had 11 of 26 residents, unit 1E and 1EE had 15 of 38 residents, unit 2W had 14 of 28 residents, and unit 2E and 2EE had 12 of 36 residents that required assistance of 2 or more for activities of daily living. Staffing for mealtime assistance: During an observation on 1/8/2024 at 11:43 AM lunch trays were delivered to Unit 1EE. Multiple residents were served their trays while seated in the hallway outside their rooms. During an observation on 1/8/2024 at 11:54 AM, Resident #107 was being fed by certified nurse aide #8 in their room. The staff member remained standing during mealtime. Upon return to Resident #107's room at 12:06 PM (12 minutes later), the resident's tray was removed from the resident with 50-75% of food remaining on the tray. On 1/8/2024 at 12:26 PM, licensed practical nurse #10 was overheard asking where everyone was, as there was no staff at the nurse's station to help pass lunch trays. During a telephone interview on 1/08/2024 at 2:28 PM, Resident #107's family stated that the resident required assistance with eating and had to be fed as they were unable to feed themselves. They were not sure there were enough staff to assist the resident, as the resident's food was often cold when they had a chance to help them. The family stated that due to the resident's level of assistance, only certain trained staff could assist at mealtime. During an interview on 1/10/2024 at 12:41 PM, certified nurse aide #8 stated that they fed Resident #107 on 1/8/2024. Certified nurse aide #8 stated they were quite rushed on 1/8/2024, as they were the only certified nurse aide for the unit on that day. The person assisting with mealtime feeding should engage the resident and be seated at the level of the resident. During an interview on 1/11/2024 at 9:32 AM, registered nurse #9 stated that the residents on the long-term care units of the first floor used to be transported to the second-floor dining room for every meal before COVID-19. This practice took about 3 hours every meal. They were unsure how many staff members it took to transport the residents to the second floor, but they worked as a team to move residents for meals. All staff assisted with this move daily. They also needed staff to remain on the first floor as not all residents went to the dining room for meals. The facility was no longer able to use the second-floor dining room due to facility restrictions. During an interview on 1/11/2024 at 9:55 AM, the Director of Nursing stated it was difficult to help all the residents that needed assistance during mealtime because at times the number of residents that required assistance was more than the number of staff they had. They assisted Resident #107 for dinner meals at times. During a telephone interview on 1/11/2024 at 4:33 PM, certified nurse aide #8 stated they did not feel there was enough staff no matter how many people they had. They stated they believed the expectation of their job duties had risen. They were expected to do more with less. In addition to being short staffed at times, there were a high number of staff who called in, which made things more difficult. There were approximately 7 residents on the units that needed assistance during mealtimes. They stated staff were very frustrated and angry when the 2 units combined into 1 unit, because there was not enough staff for all the residents, but they worked together to help one another and made things work. Staffing for activities of daily living During an interview on 1/8/2024 at 10:14 AM, Resident #52 stated that call bells could be turned off by staff at the desk and were not answered. They stated they had an incontinent episode due to long call bell wait time. They activated their call bell for assistance to the bathroom, they could hear the call bell turn off and had to reactive it several times. This incident occurred during the overnight shift. There were occasions they were unable to get assistance to exit the bathroom for 45 minutes due to call bell wait times. This was painful and uncomfortable due to placement of wounds and the shape of the toilet. During a confidential group meeting on 1/8/2024 at 1:58 PM, 12 residents reported the evening shift typically had 2 certified nurse aides, while the overnight shift typically only had 1 certified nurse aide for 42 residents. Residents stated they waited 2-3 hours for assistance, especially, if they did not get what they needed in the window of time between supper and getting other residents to bed. Residents were left on the toilet for 15-20 minutes because the certified nurse aide was assisting someone else. The aides did not always have two people to operate the resident mechanical lifts on the overnight shift. They did not like to wait an extended period because the aide was assisting someone with a bath. All department heads attended the resident council meetings, except for nursing. A review of resident council minutes from June 2023 to January 2024, documented there was not a category in the meeting minutes to discuss nursing care concerns. Areas of discussion in the meetings included dietary, administration, social work, and activities. During an interview on 1/8/2024 at 2:27 PM, the Ombudsman stated the concerns from the former Ombudsman for the facility included call lights and staffing. During an interview on 1/8/2024 at 3:52 PM, licensed practical nurse #40 stated the registered nurse supervisor #39 had to come to unit 2EE to help with medication administration, because they were short staffed for nurses this shift. During an interview on 1/9/24 at 7:58 AM, licensed practical nurse #18, stated they were the only nurse on the unit for 26 residents, and they usually only had 1 licensed practical nurse and one certified nurse aide. They should have had 2 licensed practical nurses and 2 certified nurse aides. They stated to prevent the spread of infection, the COVID section of the unit (where current COVID-19 positive residents were located) should have had their own nurse and aide. During an interview on 1/9/2024 at 8:23 AM, resident assistant #41 stated they were the resident assistant for Unit 1E, and there was another resident assistant for 1EE, but normally they were the only resident assistant covering both units. During an interview on 1/9/2024 at 8:43 AM, certified nurse aide #6 stated all staff had to remain in the facility until the next shift showed up. No call ins were accepted without medical notice. They stated this was a no mandate facility, but this was how the facility ensured they had staff for the residents. They were not technically mandated, but they also could not leave. On 1/9/2024 at 9:07 AM, certified nurse aide #8 was overheard stating they worked 3 units all alone on Sunday. On 1/9/2024 at 12:38 PM, during the lunch meal, an unidentified certified nurse aide was overheard stating to registered nurse #45, they had to shave a resident, still had 3 baths to give, and 2 rooms to move. During an interview and observation on 1/9/24 at 12:44 PM, certified nurse aide #21 stated they did not have an assigned unit and was floated to the COVID-19 unit (unit 1 West) today. The unit used to have 7 residents and now it had 26 residents with the same number of staff. With the new admission and the COVID-19 resident rooms it could get very confusing. All the resident care was behind today, staffing was tough, and they had a certified nurse aide go home at the start of the shift for health reasons. This left them alone until another aide got there and now, they were trying to catch up on their care. The unit assignment was doable with two aides but not one aide. They had 3 late baths to do after lunch. During an interview on 1/9/2024 at 12:48 PM, certified nurse aide #21 stated they worked 72 hours in the last 5 days because they had staff call out of work. They felt bad leaving the residents without enough help. They stated they had several residents that required two staff for mechanical lifts and sit to stand lifts, and if they did not have enough staff, the resident would have to wait for care. They should always have at least two certified nurse aides on a unit with 26 residents. During an interview on 1/9/2024 at 3:02 PM, certified nurse aide #12 stated 1E/1EE was considered one unit. They had two licensed practical nurses, three certified nurse aides, two resident assistants, and an additional staff member orienting to the position of resident assistant. Certified nurse aide #12 stated this was not a common staffing roster, they never had this many staff members on the evening shift. They stated the previous night they worked a double, which meant they were the only certified nurse aide for both 1E and 1EE. The overnight shift was lucky if they had a second certified nurse aide working. There was a list of residents that got up in the morning on the overnight shift. If the resident on the get-up list needed a mechanical lift or required assistance of two, the certified nurse aide would either ask for help from the licensed practical nurse on shift or had to go to another unit to ask for a certified nurse aide to help. During an interview on 1/10/2024 at 11:28 AM, certified nurse aide #42 stated they worked full time day shift on the 1E/1EE units which had a low census lately, and they were moved to the 1W unit for the day. Typically, they worked solo on the east unit, during the week, and had one additional staff member on the weekends. Second and third shift typically had one certified nurse aide for both the east units. The unit had 6-7 residents that required assistance of two, and they had to get assistance from the nurse on the unit to help transfer and move residents. There were times that residents were not toileted in time. The west unit (Unit 1 West) was difficult for them today, as it was not their typical unit, the pace was faster, and the needs of the residents were different. During an interview on 1/10/2024 at 12:00 PM, certified nurse aide #3 stated they had worked in the facility for 8 years. A typical shift would be when they were the only certified nurse aide on the unit with 24 beds. The facility combined 2E and 2EE to try to help with staffing, but they only had 1 certified nurse aide on that unit too. The overnight shift had a list of 6-7 resident that wanted to get up early, so the day shift only had 7-8 residents to get up for the day. The unit had 4 residents that used mechanical lifts, which required 2 staff to operate safely, the shift nurse helped when needed. The certified nurse aide would get the lift set up and if the nurse was busy, they had to go to the other unit to get someone to assist them. During an interview on 1/10/2024 at 1:51 PM, certified nurse aide #17 stated they did not have an assigned unit and worked between units. The nursing office door had a schedule and they reported to the unit they were listed on. They would sometimes get moved to another unit during the shift if someone did not show up for work. The nurse aide was a crucial position, and they needed adequate staff to care for residents. One certified nurse aide was not enough, they should have two resident assistants, two certified nurse aides, and two licensed practical nurses on the rehabilitation and COVID unit. The staffing was low, but they had good staff and worked well as a team. It was important to have adequate staff to ensure the resident needs were met and they were taken care of. During an interview on 1/10/2024 at 4:11 PM, certified nurse aide #43 stated they were assigned 13 residents for this shift. They used chair alarms because several residents stood up and fell. They had chair and bed alarms so they knew if a resident tried to get up, they could hear them. They checked on residents about every 2 hours for bathroom use and knew if a resident tried to get up because the bed alarms would go off. During an interview on 1/11/2024 at 9:05 AM, registered nurse #44 stated their unit was all the COVID residents from the facility, The unit usually only had 15 or 16 residents, so now having 26 residents was a lot. They can get up to 32 residents, but with new admissions, rehabilitation residents, and COVID residents it was a lot to handle. During an interview on 1/11/2024 at 2:27 PM, registered nurse #11 stated they only sometimes had enough staff, but it was tough to get enough staff especially just before and just after the weekend. Mondays and Fridays they had to use mostly float staff to ensure they had enough staff, and it was slower to get the residents' needs met. The staff became upset when they could not do extra things for the residents, such as paint nails, or style a resident's hair. During an interview on 1/12/2024 at 9:43 AM, registered nurse #45 stated Unit 1West was a short term rehabilitation unit and the designated COVID unit. Registered nurse #44 and registered nurse #45 usually worked 7:00 AM- 3:00 PM but tended to stay late to help with resident care and admissions. Staffing on the day shift was 1 licensed practical nurse, sometimes 2 on the larger units, 1-2 certified nurse aides, and a resident assistant when they had 10-15 residents. All the new admissions and readmissions came to Unit 1West for a 10-day quarantine. There was an increase in COVID residents. The facility provided more staff this week because, one aide was acceptable with 13 residents, but not with 26. They had a lot of residents with 2 assist requirements and mechanical lifts. Acuity went up on the unit in general, as the unit provided hospital type acute care to the residents. The last 5-6 years had been more stressful and busier with the quarantines. The census increased and with the COVID outbreak they went up to 2 nurses, but they did not get extra aides. There were many residents that required assistance of two. The best staffing with a census of 26 would be 2 licensed practical nurses, 3 certified nurse aides, and 2 resident assistants, as a minimum for the unit. The 2 registered nurse supervisors on evenings 12:00 PM-12:00 AM tried to help with medication passes on the evening shift. During an interview on 1/12/2024 at 9:56 AM, the Director of Nursing stated they were responsible for managing all of nursing staff, policies, procedures, and staffing issues. The expectation for resident care was that staff should provide assistance with bathing, morning care, grooming, assistance with meals, toileting, transferring, and walking for those that could walk. During an interview on 1/12/2024 at 11:26 AM, the Director of Nursing stated staffing for the long-term care units was done based on a set number of a full unit and what the unit would like to have on their unit. The rehabilitation unit had a frequently changing census, the staffing needs for that unit changed on a day-to-day basis. The rehabilitation unit normally had 12-15 residents but had an influx of admissions and currently had 24 but could hold up to 32 residents. That unit had not been at full census in 3 years, because they did not have the staff. Safe staffing for the acuity of the rehabilitation unit with 24-26 resident was 2 licensed practical nurses, 2-3 certified nurse aides, and a resident assistant, during the day. The evening would have 1 licensed practical nurse and 2-3 certified nurse aides with the current census. The long-term care units were 24 bed units, they had 1 licensed practical nurse on each extension, and 2-3 certified nurse aides between the 2 units. The aides work between units, as the goal was to have more certified nurse aides. The staffing sheets had blanks where they would like to have those positions filled. They had a nurse aide class finish in mid-December. It was important to have enough staff to provide the best care and quicker response to the residents, and to meet the needs of the resident. Most of the registered nurses stayed late and passed medications in the evening or picked up extra time on the night shift. There had been times when they had 1 aide and 1 nurse, due to calls in, staff not showing up for their shift, sickness, or preapproved time off. If there was one aide, the nurse should help the aide. They should call the nursing supervisor to help if they were available. They could call staff from another unit to help with the residents who required assistance of 2. This was not ideal staffing, but they worked together. New certified nurse aides worked with an experienced certified nurse aide for approximately 2-3 weeks but could be adjusted if they needed more help. During an interview on 1/12/2024 at 11:51 AM, scheduler #13 stated the staffing needs were determined by the actual staffing sheets that were created by the Director of Nursing. Unit 1 [NAME] needed more staff currently because they had all the new admissions and had more residents than normal. The staffing needs right now for each unit were 2 licensed practical nurses, 3 certified nurse aides, and 2 resident assistants for days. The evening shift was to be scheduled with 1 licensed practical nurse, 2 certified nurse aides, and 1 resident assistant. The evening shift was the shortest shift and needed more coverage. They would call staff to come in on days off or stay late. They handled call ins by pulling staff from another unit and if they did not have enough staff, they would call staff on their day off to see if they would come in. If they were unable to find the coverage, they would go to the Director of Nursing to see if anyone would stay late from day shift or come in early from night shift. During an interview on 1/12/2024 at 1:02 PM, the Administrator stated staffing played a role in facility quality measures. They had an Assistant Administrator that was tracking the staffing. The staffing person tracked what they needed and worked on recruitment. They had an outpour of staff retire and were trying to recruit. They staff for the census, and they would like more staff, but the staff they had was doing well. Recruitment was done with an outside recruitment agency, posters in the laundry mats, and social media connections were used to find the types of staff they needed. 10NYCRR 415.(a)(1)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification and abbreviated (NY00328391) surveys conducted 1/8/2024-1/12/2024, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 staff members (certified nurse aides #17 and #28, and food service worker #18) observed. Specifically, certified nurse aide #17 did not don and doff personal protective equipment as required when entering and exiting rooms with COVID-19 positive residents, did not perform hand hygiene, and placed an unclean face shield on a kitchenette counter; certified nurse aide #28 removed a dinner tray from a COVID-19 positive resident room and placed the tray on top of the dinner cart with unserved meal trays; and food service worker #18 entered the closed COVID-19 area with a lunch cart. Additionally, Resident #45 had extended spectrum beta lactamase resistance (an enzyme produced by bacteria that are resistant to many antibiotics) and was not placed on enhanced precautions as planned. Findings include: The facility policy COVID-19 Management dated October 2023 documented all staff were to adhere to hand hygiene, contact precautions and/or enhanced barrier precautions were to be used when caring for residents with COVID-19. In order to reduce transmission in shared rooms personal protective equipment was to be changed and hand hygiene performed before and after each resident interaction. The undated facility policy Coronavirus- Surveillance Plan for Residents/ Staff documented personnel caring for the resident would need to wear an N-95 mask, disposable gown and goggles, or a face shield. The facility policy Precautions- Droplet - Transmission Based revised 8/2023 documented in addition to standard precautions, anyone caring for the resident should wear a mask, gown, and gloves if they were within three feet of the resident. The infection control staff or nursing staff would place the appropriate Centers for Disease Control transmission- based, isolation signage for droplet precautions outside the resident's room. A cart with personal protective equipment would be placed outside the resident room door for use. The attending physician, infection control nurse or supervising registered nurse may make the determination to place a resident on both, droplet, and contact precautions. When removing food trays from the precaution room, the tray would be wrapped in a clear plastic bag and brought out to the carts. The bag would serve as a barrier as well as a warning for dietary so they would know the tray was from a room on precautions. The facility policy Enhanced Barrier Precautions dated 1/2023 documented enhanced barrier precautions was to be used when providing care for the residents with an infection or colonization (presence of a microorganism on/in a host without interaction between host and organism) with a multi-drug resistant organism, when contact precautions do not apply. Gloves and gowns should be worn when providing high contact care such as bathing, dressing, care of indwelling devices and wound care. The Enhanced Barrier Precautions sign should be placed outside of the resident room. The Infection Control staff education COVID Precautions, Signs, PPE dated November 2023 documented COVID-19 rooms would have three signs, droplet, contact and a sign that stated what the staff must wear inside the COVID-19 positive rooms and COVID-19 exposure room. Additionally, directions prior to entering the COVID positive/exposure room included: perform hand hygiene, remove face mask, and put in trash, perform hand hygiene, before entering room, put on all personal protective equipment that included gown, N95, face shield, gloves. The way to exit the COVID-19 room documented to remove all personal protective equipment properly, N95 mask were to go into a brown paper bag and back on the cabinet; cleanse the face shield with alcohol wipes and perform hand hygiene and put on regular face mask. The education included diagrams with the proper way to don and doff the personal protective equipment. The 12/8/2023 facility line list for COVID-19 documented positive COVID-19 resident rooms included Unit 1 [NAME] rooms 113, 114, 115, and 116. During an observation on 1/8/2024 at 10:29 AM, there was no signage posted on the left side of Unit 1 [NAME] closed double doors that notified visitors this was a COVID-19 cohorted area. Observations on 1/8/2024 of certified nurse aide #17 on Unit 1 [NAME] included: - at 10:58 AM, walking down the hallway with a pen and paper in their hand entering and exiting rooms [ROOM NUMBER] which had signage on the doors for contact, droplet, and enhanced precautions. After exiting room [ROOM NUMBER] wearing a yellow gown, face shield, and a surgical mask and walked toward room [ROOM NUMBER]. They did not enter room [ROOM NUMBER] and walked back to the nursing station area where they took off their yellow gown next to a round table where there were boxes of N95 masks. They removed their face shield, and while holding the used face shield, they walked around with the gown balled up in their right hand. They placed their face shield on the kitchenette counter near the sink/eye wash station and entered the soiled utility room. They came back to hallway without the yellow gown and left the face shield on the kitchenette counter. - at 11:05 AM, the face shield remained on the kitchenette counter next to the eye wash station. - at 11:06 AM, they entered room [ROOM NUMBER] without any personal protective equipment on and the signage outside of the door documented contact, droplet, and enhanced barrier precautions. - at 11:07 AM, they entered room [ROOM NUMBER], a COVID-19 positive room without wearing the posted personal protective equipment and exited the room without performing hand hygiene. - at 11:08 AM, rooms [ROOM NUMBERS] call bells were ringing and were lit up above the door. They entered room [ROOM NUMBER], without personal protective equipment. - at 11:10 AM, they exited room [ROOM NUMBER]. They performed hand hygiene and entered room [ROOM NUMBER] without wearing the personal protective equipment listed on the sign outside the door. - at 11:15 AM, they exited room [ROOM NUMBER], wearing a N95 mask and walked to the dirty utility room. - at 11:25 AM, they went back to room116 where the call bell was on. They stopped in front of the personal protective equipment bin and put on gloves and a yellow gown, then walked to the nurse's station with a yellow gown on and walked back to room [ROOM NUMBER]. They had a N95 mask on and entered the room. - at 11:28 AM, they exited room [ROOM NUMBER], and with the same yellow gown on entered room [ROOM NUMBER]. - at 11:29 AM, they exited room [ROOM NUMBER] without a yellow gown on, wearing the N95 mask and entered room [ROOM NUMBER]. They did not put on new personal protective equipment and did not perform hand hygiene. They exited room [ROOM NUMBER] and they went back into room [ROOM NUMBER], with no gown on and did not complete hand hygiene. They exited room [ROOM NUMBER], and then walked down the hallway while removing their gloves. During an interview on 1/8/2024 at 11:35 AM, Unit 1 [NAME] Secretary #27 stated rooms 113, 114, 115, and 116 were COVID-19 positive rooms. The hallway divider at room [ROOM NUMBER] was placed as it was to create a designated COVID-19 cohorted section of the unit. During an observation on 1/8/2024 at 11:58 AM, the wall outside of room [ROOM NUMBER] had signage that documented to enter the room staff should wear a gown, gloves, an N95 mask, and a face shield. The resident was on contact precautions, droplet, and enhanced barrier precautions. The was no personal protective equipment bin outside of the room. During an observation on 1/8/2024 at 12:00 PM, the face shield that certified nurse aide #17 removed at 10:58 AM was observed on the kitchenette counter near the eye wash station. During an observation on 1/8/2024 at 2:25 PM, certified nurse aide #17 was walking around the unit with their yellow gown on, went to the dirty utility room with a bag of trash, went to the nurse's station to get a new N95 mask and then entered the COVID-19 cohorted area. During an interview on 1/9/2024 at 7:58 AM, licensed practical nurse #18 stated the residents that were new admissions should be on full precautions and quarantine for 10 days and the staff should follow the directions on the signs outside of the door. When there was not a personal protective equipment supply bin outside of the room, they should use the next closet bin. They stated they were not sure what the recent facility COVID-19 protocol included and said it was very confusing. They thought the staff should don a gown and a new N95 mask when they were in the COVID-19 positive rooms. The staff should not be wearing a used yellow gown walking around the units, and they should change their N95 mask when they came out of a COVID-19 room. They should use the hand sanitizer that was on the walls or outside of the rooms in the personal protective equipment bin. They stated they were the only nurse on the unit for 26 residents, and they usually only had 1 licensed practical nurse and one certified nurse aide. They stated to prevent the spread of infection, the COVID-19 cohort section should have their own nurse and certified nurse aide. During an interview on 1/9/2024 at 8:06 AM, resident aide #20 stated they were floated to Unit 1 [NAME] in the morning and did not routinely work the unit. They stated there were COVID-19 rooms on the unit and staff should wear N95 mask and remove the mask when exiting the room, perform hand hygiene, and leave the gown in the bins in the room. The gowns and gloves should be changed between residents to prevent the spread of infection. During an interview on 1/9/2024 at 9:17 AM, the Administrator confirmed there were 2 infection prevention nurses and Unit 1 [NAME] was where the COVID-19 residents were cohorted. During an observation on 1/9/2024 at 12:15 PM, on the nurse's station desk on 1 [NAME] there was an electronic mail memo that was dated 1/9/2024 at 10:52 AM, from registered nurse Infection Control Director regarding personal protective equipment requirements for the new admissions. The face shields should be worn in new admission rooms and all face shields should be wiped down between uses. During an observation on 1/9/2024 at 12:32, food service worker #18 entered 1 [NAME] through the closed double doors on the COVID-19 side of the unit. They pushed the cart up to room [ROOM NUMBER] and staff told food service worker #18 they needed to exit and enter the unit on the other side of the unit due to the COVID-19 restricted area. During an observation on 1/9/2024 at 12:36 PM, certified nurse aide #21 was overheard asking the Director of Nursing if they had to completely gown up every time, they entered a room to deliver a meal tray. The Director of Nursing nodded their head yes and was overheard telling the aide every single time you take a tray in the room you need to gown up. During an interview and observation on 1/09/24 at 12:44 PM, certified nurse aide #21 stated they did not have an assigned unit and was floated to the COVID-19 unit today. Unit 1 [NAME] used to have 7 residents and now they had 26 residents with the same number of staff. They stated the required personal protective equipment for the COVID-19 rooms was listed on the signs on the wall and they needed to make sure the room doors were closed. At 12:48 PM, they were wearing a gown, face shield, and a N95 mask holding a lunch tray to bring into room [ROOM NUMBER] W. They stated the staff should remove the gown in the resident rooms, the face shield needed to be sanitized outside of the room with alcohol, and the mask should not be worn in and out of different rooms. At 1:02 PM, during the interview they entered and exited room [ROOM NUMBER], and went to get another lunch tray from the other side of the unit and kept their N95 mask on. They stated they should have taken off the N95 off before getting the meal tray for the roommate (116 D) near the door. Staff should not exit the resident room with a yellow gown on, the gown should be removed prior to exiting the room, and left in the designated bin. It was important to remove the gown and change the mask so not to spread germs from one resident to the next. They had seen staff wearing their yellow gown in the hallway between rooms and would usually remind them, but it was not really their place to tell them what to do. The signs outside of the rooms told the staff what personal protective equipment to wear, and basically the entire unit was on precautions. With the new admissions and the COVID-19 resident rooms it was confusing about what precautions to maintain. During an interview on 1/9/2024 at 3:56 PM, registered nurse Infection Control Director #22 and registered nurse Infection Preventionist #23 stated 1 [NAME] had certain rooms that were designated for COVID-19. The rooms were from 113 to 116. They tried to cohort the COVID-19 positive residents on the left side of the unit. The right side of the hallway was for new admission residents. This was not a new thing for the facility to place the new admission on full precautions for 10 days. They sent an electronic memo to the Unit Managers to let staff know what residents had COVID-19. There was also a new sign on the outside of the 1 [NAME] left side door, notifying staff and visitors that was a COVID-19 area. They stated there was a sign, but it must have fallen off because there was not a sign on the door when entering the COVID side of the unit on Monday (1/8/2024). During an interview on 1/10/24 at 1:27 PM, certified nurse aide #17, stated they just became a certified nurse aide and did their training at the facility. They were in the October 2023 class, and just received their certification a couple weeks ago. They had worked in the facility as a resident aide since June 2023. They stated the residents on COVID-19 precautions were on 1 [NAME] and were in rooms 113-116. The personal protective equipment required for COVID-19 was gloves, gown, a N95 mask, and not a surgical mask. When entering a COVID-19 room a gown should be put on before going in the room and taken off before coming out of room. For residents on enhanced precautions, staff could keep the gown on between residents because the resident did not have COVID-19. The enhanced precautions were just extra precautions. Staff should always wash their hands before putting on gloves and after gloves were removed and any times they were soiled. They should put on their N95 mask before going in the COVID-19 rooms and take it off before leaving the room. It was important to do this to avoid spreading the germs around to other residents. There was a bin in the resident rooms for the gowns to be disposed. They stated they received training about infection control and the expectation for COVID-19 rooms. They stated they were aware that they did not wear the required personal protective equipment in rooms where it was required, and a couple times went room to room with the same gown and mask. They stated it was important to follow the posted steps for personal protective equipment for every room. The gowns should be changed, when walking from the COVID-19 cohort unit to the new admission side/precautions and should not be carried in their hands in the hallway after being worn in a COVID-19 positive room. During an interview and observation on 1/10/2024 at 5:55 PM, certified nurse aide #28 placed a tray that was removed from room [ROOM NUMBER] W (a COVID-19 positive room) on the meal cart of trays that had not been served to residents. During an interview at 5:57 PM, certified nurse aide #28 stated the tray was eaten from and was from a COVID-19 room. They stated they would sometimes put the used meal trays in the cart with the new unserved trays. They said they thought the COVID-19 resident trays could potentially contaminate the unserved trays. During an interview on 1/11/2024 at 12:23 PM, food service worker #18 stated they delivered the food cart on the wrong side of the hallway on Monday and Tuesday. They forgot that side of 1 west was for the COVID-19 residents, and they should not have brought the cart on that side. During an interview on 1/12/2024 at 11:00 AM, the registered nurse Infection Preventionist #22 documented they started in the role October 2023. The first COVID-19 outbreak was in September 2023. Staff had received the bare minimum of infection control training when they were hired. They continued to reinforce education regarding personal protective equipment. They had completed an in-service training in December 2023 about personal protective equipment documentation and the signage that was posted outside of the resident rooms. They stated to prevent the spread of COVID-19 to other residents and staff they encouraged proper personal protective equipment. There was posted signage at each room, so everyone knew what to wear in the rooms. They had not done an education for the staff on the proper donning and doffing of personal protective equipment. Staff should not be walking from resident room to resident room with the same gowns and N95 masks on as that violates their policy. They stated they do the best they can to keep the same staff on the COVID-19 unit to prevent the spread of the infection. During an interview on 1/12/2024 at 11:42 AM, the Director of Nursing stated they educated staff on the importance of hand hygiene and the use of personal protective equipment to prevent the spread of infection. PRECAUTIONS NOT IMPLEMENTED Resident #45 had diagnoses that included urinary tract infection, extended spectrum beta lactamase resistance, and unspecified dementia. The 12/20/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, was taking antibiotics, was frequently incontinent of urine, and required moderate assistance for toileting. The 12/15/2023 progress note by nurse practitioner #29, documented the resident had an extended spectrum beta lactamase resistance urinary tract infection and would be treated with antibiotics. The resident was placed on contact precautions indefinitely due to the extended spectrum beta lactamase resistance infection. Physician orders after 12/15/2023 did not include contact precautions. The comprehensive care plan, revised 12/18/2023, documented the resident had reoccurring urinary tract infections which included an extended spectrum beta lactamase resistance urinary tract infection on 12/16/2023. Interventions included to check and change the resident every two hours, give antibiotics as ordered, and to monitor for signs and symptoms of a urinary tract infection. There was documented evidence contact precautions were added to the care plan after nurse practitioner recommendations on 12/15/2023. Nursing progress notes dated 12/15/2023-12/20/2023 did not document the resident was on contact precautions. Nursing notes dated 12/21/2023 at 1:25 PM and 12/28/2023 at 12:30 PM, documented contact precautions maintained for extended spectrum beta lactamase in the urine. There was no documentation of contact precautions from 12/29/2023-1/8/2024. The resident's room was observed to have no contact precaution signage posted prior to entering the room from 1/9/2024 through 1/11/2024. During an observation and interview on 1/9/2024 at 2:35 PM, licensed practical nurse #30 stated the precaution isolation signs were placed on the wall outside the resident's room to identify who was on precautions. If the precaution sign was above the room number sign outside the door, the resident in the bed by the door was on precautions. If the precaution sign was below the room number sign outside the door, the resident in the window bed was on precautions. During an interview on 1/11/2024 at 3:45 PM, registered nurse Care Coordinator #16 stated the miscellaneous notes were not always reviewed as the providers would usually put in any orders that were needed after seeing the resident and would speak to the Nurse Supervisor directly. If it was not communicated directly or put in an order, any follow up in the miscellaneous note would not be seen. They were unsure how a provider's direction to put someone on indefinite precautions got communicated if it was in a miscellaneous note. They stated that if a resident tested positive for an extended spectrum beta lactamase resistance urinary tract infection, there would be ongoing precautions unless a culture was obtained that stated the resident no longer had extended spectrum beta lactamase resistance. Registered nurse Care Coordinator #16 stated if a resident had previously tested positive for extended spectrum beta lactamase resistance and the resident was not on precautions, there was a risk of spreading extended spectrum beta lactamase resistance to other residents. During an interview on 01/11/2024 at 3:59 PM, Quality Assurance and Safety/Certified Nurse Aide #31 stated an infection control memo went out via email to all managers. They stated the infection control personnel updated the list daily and the precaution information and what it required for each resident would be on that list. They stated the most recent infection control memo that came out did not have Resident #45 included on it for precautions. During an interview on 1/12/2024 at 9:11 AM, nurse practitioner #29 stated if a resident had tested positive for an extended spectrum beta lactamase resistance urinary tract infection the precautions would be indefinite. They stated residents who had tested positive for an extended spectrum beta lactamase resistance were to be on enhanced barrier precautions. It was their understanding that the nurses and Nurse Managers read the miscellaneous note assessments where they recorded their provider notes. They stated the precautions would be put in place automatically by the infection preventionist in the building and they had a morning report daily where they discussed residents on precautions. They were not aware that Resident #45 was not on precautions and the resident should be on precautions indefinitely. 10 NYCRR 415.19(a)(b)

Based on observation, record review and interview during the recertification survey conducted 11/15/21-11/18/21, the facility failed to ensure all residents were provided an ongoing program to support residents in their choice of activities and designed to meet their individual needs based on the comprehensive assessment and care plan and the preferences of each resident for 1 of 3 residents (Resident #10) reviewed. Specifically, Resident #10 was not provided meaningful activities as care planned. Findings include: Resident #10 had diagnoses including glaucoma, legal blindness, and heart failure. The 8/12/21 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and required extensive to total assistance with most activities of daily living (ADLs). The resident considered choice of listening to books on tape, listening to television, and listening to music important. The comprehensive care plan (CCP) initiated 8/18/21 documented the resident was alert and able to make leisure choices, enjoyed listening to books on tape, music, and television (genre not specified). The resident enjoyed 1:1 visits, required assistance to activities, and preferred listening to television or books on tape in their room. The care instructions dated 11/18/21 documented the resident was to be encouraged to participate in a program that accommodated the resident's sensory abilities. The resident's preferred activities were listening to television (genre not specified), religious music or books on tape in their room. The activity progress notes documented there were no activities provided to the resident 28 of 31 days in 10/2021 and from 11/1-11/17/21. The resident was observed: - on 11/15/21 at 2:06 PM lying in bed sleeping. There was no television, music, or talking books playing. - on 11/16/21 at 1:31 PM, sitting by the nursing station. - on 11/17/21 at 9:48 AM, in bed with a drink. The television was off and there was no music or talking books playing. - on 11/17/21 at 12:04 PM lying in bed. The television was off and there was no radio or talking books playing. During an interview with activities nurse #27 on 11/18/21 at 11:22 AM, they stated they knew what the residents' interests were by talking with them. They would talk to the resident, about their father and the residents daughters. The resident would tell them what they liked. The activities nurse stated if they had provided interaction/activities with the resident it would have been recorded. When interviewed on 11/18/21 at 11:00 AM, certified nurse aide (CNA) #25 stated that most of the time the unit CNAs did not do activities with the residents because they did not have time. The resident liked to listen to books on tape; however, the resident had the same 5 books on tape the last year and a half and they did not have any others to play for them. During an interview with the Director of Activities on 11/18/21 at 1:23 PM, they stated they had not been asked to order more books on tape for the resident. If staff knew what the resident's interests were, they would expect them to be provided as much as possible, and they should be documented in the resident's record. If they did not document activities, then nothing was done. 10NYCRR 415.5(f)(1)

Based on observation, interview, and record review during the recertification survey conducted 11/15/21-11/18/21 the facility failed to ensure drugs and biologicals 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 3 unit medication rooms (Unit 2EE) and 1 of 4 medication carts (medication cart #8) reviewed. Specifically, the Unit 2EE and medication cart #8 had stock medications that were expired or outdated beyond the opened date. Findings include: The facility policy Storage and Maintenance of Medication dated 6/2016 documented medication should be checked regularly for expiration dates and deterioration. Expired medications are removed from use and destroyed. During an observation of the 2EE medication room on 11/16/21 at 9:54 AM, there was a vial of influenza vaccine with an expiration date of 6/30/20 and a handwritten date on the box labeled 12/2, and an open of box of bisacodyl suppositories (laxative) with an expiration date of 11/2020. Medication cart #8 contained an opened bottle of aspirin 325 milligram (mg) with an expiration date of 6/2021 and an opened date of 7/20/21, and an opened bottle of bisacodyl 5 mg with an opened date of 4/1/19 and an expiration date of 3/2021. When interviewed on 11/16/21 at 9:56 AM, licensed practical nurse (LPN) #9, stated they were unsure if there was an assigned person to check for expired meds. The LPN stated each nurse should check the expiration date prior to giving medications. When interviewed on 11/18/21 at 11:26 AM, registered nurse (RN) Unit Manager #8 stated the expectations was that staff would date the medication bottle when opened. The stock vials were good for 30 days after being opened and staff were expected to date the box with open date. The 11-7 shift was expected to check medications in the medication cabinets, the medication carts, and the refrigerator weekly. The RN stated each nurse should check the expiration date of each medication before administration. When a medication was discontinued the nurse should pull the medication and put it in a designated location for pharmacy pick-up. The RN stated the medications that were expired should have been discarded prior to use. When interviewed on 11/18/21 at 12:10 PM, the Director of Nursing (DON) stated the expectation was each nurse should check for expiration dates prior to medication administration and the 11-7 nurse should check twice a week for expired medication in the medication room, the refrigerator, and the medication carts. The medication should be discarded when it expired. The date opened should be written on the vial or the box. Once opened immunization vials should be good for 28 days depending on what it was. 10NYCRR 415.18(d)(e)(2-4)

Based on observation and interview during the recertification survey conducted 11/15/21-11/18/21, the facility failed to ensure each resident received food and drink that was palatable and at a safe and appetizing temperature for 2 of 2 meal trays (lunch and dinner) tested. Specifically, food was not served at a safe and appetizing temperature for a lunch and dinner meal. Findings include: The facility policy for Food Temperatures was requested and was not received. During an interview with Resident #50 on 11/15/21 at 1:42 PM, they stated food was generally served cold. During an interview with Resident #21 on 11/15/21 at 4:45 PM, they stated the food was served lukewarm or ice cold. During the resident group meeting on 11/17/21 at 10:00 AM, 1 anonymous resident stated their hot food items at meals were not always served hot. During an observation on 11/15/21 at 5:17 PM, the meal cart arrived at the Unit 2 Extension. At 5:22 PM, Resident #18 was served, and their dinner tray was used for temperature measurement and taste testing with a replacement provided. At 5:24 PM, the following food temperatures were measured: - coffee 115 degrees Fahrenheit (F) - Spanish rice 130 degrees F - shredded pineapple 56 degrees F - milk 53 degrees F - cranberry juice 56 degrees F - salad 67 degrees F The shredded pineapple, milk, cranberry juice, and salad tasted warm and were not palatable. During an observation on 11/17/21 at 11:46 AM, the lunch trays arrived at the Unit 1 Extension. At 12:03 PM, Resident #21's meal tray was used for temperature measurement and taste testing with a replacement provided. At 12:05 PM the following temperatures were measured: - pork patty 108 degrees F - green beans 107 degrees F - hot water for tea was 125 degrees F - Ensure (oral nutritional supplement) 60 degrees F - pears 57 degrees F - Lactaid (lactose-free) milk 50 degrees F - cranberry Juice was 56 degrees F. The hot food items did not taste hot and cold did not taste cold and were not palatable. During an interview on 11/17/21 at 12:35 PM, the Food Service Director stated the coffee and hot water for tea should be at 140 degrees F when served to the residents. Cold food items should not be above 40 degrees F and hot food should not be below 130 degrees F to 140 degrees F depending on the food items. [NAME] beans and meat patties did not hold temperature well. They stated the dinner and lunch trays were not served at palatable temperatures. 10NYCRR 415.14(d)(2)

Based on observation, record review and interview during the recertification survey conducted 11/15/21-11/18/21, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 2 of 8 unit pantry refrigerators (Units #1 East and 2 West) and 1 kitchen tray line refrigerator observed. Specifically, air temperatures were not maintained for Unit #1 East and 2 [NAME] pantry refrigerators at 40 degrees Fahrenheit (F) or lower. Additionally, the kitchen tray-line refrigerator air and food temperatures were not maintained. Findings include: The facility policy Proper Refrigeration Temperatures dated 11/2011 documents the following: - All dining room and nourishment pantry refrigerators will be maintained to standards set for proper storage of cold foods and beverages. The dietary aide/server will take temperatures of each refrigeration unit in dining room pantries on the day shift and record on the log sheet. The cook will take the temperature of each refrigerator in the kitchen and record on the log sheet. - If a refrigerator temperature is found to be above 42 degrees Fahrenheit (F) or below 34 degrees F, staff will immediately notify the Food Service Manager or the Dietary Supervisor. The Dietary supervisor will temp all items in the cooler and if deemed above 42 degrees F, they will be discarded. A maintenance request for repair will be completed and forwarded to the Maintenance Department. - Refrigerators in the unit kitchenettes are not to be used for potentially hazardous foods (food that requires time/temperature control for safety to limit the growth of pathogens). Daily temperatures of the refrigerator are taken by dietary staff and recorded on the log sheet, which is posted inside the cupboard. If a refrigerator temperature is above 50 degrees F or below 30 degrees F, staff were to notify the Food Service Director or Supervisors, and Maintenance. On 11/15/21 at 11:24 AM, the Unit 2 [NAME] pantry/kitchenette was observed. The refrigerator temperature log was last signed on 10/28/21 and there were no temperatures for 10/29-10/31/21 and 11/1-11/15/21 documented. The refrigerator had a sign that documented no meat or dairy were to be in the refrigerator. Inside the refrigerator, there were multiple individual packets of butter, non-dairy liquid creamer, and a half empty 48-ounce container of applesauce. The thermometer inside the refrigerator door was observed to be 50 degrees F. On 11/15/21 at 5:24 PM, the following temperatures were obtained from a test tray: - Shredded pineapple 56 degrees F - Milk 53 degrees F - Cranberry juice 56 degrees F - Salad 67 degrees F On 11/17/21 at 12:05 PM, the following temperatures were obtained from a test tray: - Ensure (oral nutritional supplement) 60 degrees F - Pears 57 degrees F - Lactaid (lactose-free) milk 50 degrees F - Cranberry juice 56 degrees F. During an interview on 11/17/21 at 11:29 AM, the Food Service Director stated milk, juices, and fruit were moved from the walk-in cooler to another refrigerator near the tray line during meal service. The juices were poured in the morning and placed in the refrigerator for the lunch tray line. The pears were chilled the night before, dished that morning and put on a ladder track in the refrigerator. During the meal, the pears would be moved individually to the other refrigerator near the tray line. The refrigerator door was held open throughout food service. Temperatures of refrigerators in the main kitchen were checked daily in the morning before breakfast service started. The Dietary Department was responsible for checking temperatures in the pantry refrigerators on the units. The temperatures were done at different times of the day. On 11/17/21, the following was observed with the Food Service Director: - At 1:13 PM, the 1 East pantry refrigerator read 56.1 degrees F; the refrigerator contained thickened orange juice measured at 57 degrees F and pineapple chunks measured at 54 degrees F. - At 1:18 PM, a 2 [NAME] pantry refrigerator had a temperature of 50 degrees F. - At 1:34 PM, the trayline refrigerator had a temperature of 54 degrees F. During an observation of the kitchen trayline refrigerator on 11/17/21 at 3:18 PM, there was a temperature log on the side of the refrigerator that was initialed on 11/17 with no time. The tray line Supervisor stated that the trayline refrigerator had been replaced since the previous observation at 1:34 PM. The Supervisor stated they removed the other refrigerator and brought one from upstairs to replace it. Temperatures of items within the refrigerator were measured and included: - red pears 52 F, when re-temped at 3:21 PM, the temperature was 51 F; -a whole chicken salad sandwich 44 F; -garden Salad 43 F; -chocolate pudding was 48 F. During an interview with the Food Service Director on 11/17/21 at 3:21 PM, they stated the refrigerator was replaced with a refrigerator from another department. The Food Service Director stated the other refrigerator was not holding temperatures. They stated the items temped were from the lunch meal and were supposed to be removed after the lunch meal. The Food Service Director stated when the refrigerators were switched, staff must have removed the items from the other refrigerator and put them into the current refrigerator. They stated they should have discarded the items from the refrigerator that was not holding temperatures. The Director confirmed the items were not acceptable temperatures. They stated the cooks took refrigerator temperatures every morning and recorded it on the logs. The refrigerator temperatures were not taken throughout the day. During a follow-up interview on 11/17/21 at 3:33 PM, the Food Service Director stated they were not aware of any temperature issues with the kitchenette refrigerators. The items in those refrigerators should be discarded if the refrigerator was bad or if a food product in a refrigerator was out of temperature range. During an observation of the Unit 2 [NAME] pantry refrigerator on 11/18/21 at 12:00 PM, the refrigerator had a sign reading no meats or dairy in fridge. The thermometer inside the refrigerator read 50 F. Inside the refrigerator there were two 46-ounce (oz) honey thickened waters, one 46-oz nectar thickened cranberry drink, one 46-oz nectar thickened apple juice, one 60-oz orange juice, six 4-oz yogurts, a 1 gallon storage bag with individual butter pads, 1 pudding in a blue bowl dated 11/17/21, a 236 milliliter (ml) white milk and an 8-oz cardboard container of Ensure Plus in the door and two 1 liter opened soda bottles in the back of the refrigerator. The orange juice had a measured temperature of 60 degrees. On 11/18/21 at 12:09 PM, licensed practical nurse (LPN) #26 stated the staff were not supposed to put dairy or meat products in the pantry refrigerators as a precaution in case the refrigerator was not keeping temperature. The LPN stated they were not aware there were dairy items in the refrigerator, they did not know who put them there, and they should not be in there. 10NYCRR 415.14(h)