Based on record review and interviews during the abbreviated survey (NY00371419), the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care person-centered care plan, and the resident's choices for 2 of 3 residents (Resident #1 and 7) reviewed. Specifically: -Resident #1 had a feeding tube (a device that delivered liquid nutrition into the stomach or intestine through a surgically created opening in the abdomen) and had physician orders to verify placement and check residuals. There was no documented evidence that placement and residuals were checked for 4 months. The resident developed new onset diarrhea and nausea, and there was no documented evidence the resident was assessed to determine if the resident's tube feeding should have been held. Approximately 8 hours later, the resident was found deceased with vomit on their face. -Resident #7 had an order for lorazepam 0.5 milligrams (a controlled substance medication for anxiety) by mouth every day at bedtime and the resident did not receive the medication for 7 days. Findings include: The facility policy, Change in a Resident's Condition or Status, revised 3/2020, documented if a significant change in the resident's condition occurred (new, change worsening), a comprehensive evaluation/assessment of the resident's condition was conducted and documented. The facility policy, Tube Feedings, revised 7/2020, documented gastric (stomach) tubes were used to supply nutrition and hydration to residents unable to take liquid or food by normal means. Tube placement was verified every shift and prior to administration of each feeding. Tube placement was checked using at least two of the following techniques: monitor and evaluate for bloating, nausea, or abdominal pain; check residual (excessive amount of fluid/food remaining in the stomach after feeding through a tube) before feeding was started; and if concerns arose regarding placement or dislodgement, notify physician and obtain x-ray confirmation. When checking for gastric contents, if over 100 milliliters (or an amount specified by the physician), hold feed for 2 hours and notify physician. Feed, flushes and tube placement checks were recorded on the Medication or Treatment Administration Record. Record any unusual symptoms or response to tube feed and report as needed to supervisor. The revised 8/2016 policy, Reordering Medications, documented the purpose was to prevent any missed medication doses due to failure of reordering when necessary. The Unit Coordinator was responsible for overseeing that procedure and assignment of the medication reordering process. The nurse designated for that duty would check the medication in the cart by taking a visual inventory of all resident supplies and reordering when there was a 7-day or less supply remaining. The revised 3/9/2023 policy, Automated Drug Dispensing System, documented the purpose of the automated medication system would be to securely store emergency supplies of controlled substances and other medication needed for use by nursing home residents in the event the immediate administration of the medication was necessary, and that no alternative treatment was available. The Automated Drug Dispensing System was a locked, automated medication storage cabinet with programmable-metered drawers with controlled and limited access. Features included, but not limited to, computerized inventory tracking, controlled password mediated access and recorded drug utilization. The procedure for the Automated Drug Dispensing System included: -the Automated Drug Dispensing System would be monitored continuously using the pharmacy interface. Any action involving the Automated Drug Dispensing System would be logged by the pharmacy and upon request generated in a detailed, comprehensive report. -Class 3A pharmacy licensed facilities should be responsible for maintaining a separate record of the administration of controlled substances from the Automated Drug Dispensing System. -Initially, authorized facility staff would be provided with a personal sign-on code and a default password to allow sign-in. -All staff nurses would have station privileges that included the ability to remove, waste and witness medications from the Automated Drug Dispensing System. -All controlled substances would be stored in an individual compartment allowing the nurse access to only that medication per transaction. -The pharmacy would work closely with the Director of Nursing to resolve all stock-related problems. The revised 6/2024 policy, Medication/Treatment Administration: Documentation, documented medications and treatments were checked against the prescription order before they were administered and would be administered per physician orders. If medications or treatments were not available, nursing was to inform the nursing supervisor immediately, the emergency medication kit was used, and the medical provider was notified, and immediate medication delivery was requested. 1) Resident #1 had diagnoses including dysphagia (difficulty swallowing), malnutrition and other artificial openings of the gastrointestinal tract. The 10/18/2024 Minimum Data Set assessment documented the resident's cognition was intact, they were independent with rolling left and right and they had a feeding tube. The 9/11/2024 physician #18's note documented the resident was recently re-admitted after hospitalization on 8/26/2024 with mental status changes, hypotension (low blood pressure) and septic shock (life threatening condition where blood pressure drops dangerously low from infection). The resident developed dysphagia that required a feeding tube placement on 9/9/2024. The tube was working well and Jevity (liquid nutrition for long term tube feeding) should be continued. The 9/11/2024 physician order documented to verify placement of feeding tube before each feeding, medication administration or flush, and record the amount of residual. The 9/11/2024 comprehensive care plan documented the resident had a feeding tube and would remain without complications such as gastrointestinal distress, nausea/vomiting/diarrhea, abdominal distention and increased residuals through next review. Interventions included Jevity at 60 cubic centimeters per hour continuously for a total of 1440 cubic centimeters per day. Medications were to be flushed with 60 cubic centimeters of water before, during and after each administration, and residuals and signs and symptoms of intolerance checked every shift and as needed. The 1/23/2025 at 8:24 PM Licensed Practical Nurse #7 note documented the resident had large amounts of loose stools multiple times and they complained of not feeling well. The note documented the resident's family was updated. There was no documented evidence the resident was assessed by a qualified professional. The 1/24/2025 at 5:33 AM Licensed Practical Nurse Supervisor #8 note documented the resident was found expired, the provider was notified and orders obtained to release the body. The 9/11/2024 through 1/23/2025 Medication Administration Record did not contain any documentation related to checking and recording the resident's residuals before each feeding, before medication administration or before flushes per physician order. The resident's 1/24/2025 death certificate documented the resident's immediate cause of death was acute cardiopulmonary arrest due to multiorgan failure as a consequence of Diabetes Mellitus. During a telephone interview on 2/20/2025 at 11:34 AM, Certified Nurse Aide #9 stated they worked the night shift and was notified by the outgoing shift the resident was sick and they had an emesis basin. Most residents on the floor had a gastrointestinal illness with loose stools at that time. They checked on the resident at midnight and 2 AM and they were asleep. Around 4 AM, Registered Nurse #10 went in the resident's room to change out the tube feeding equipment and found the resident had expired. Registered Nurse #10 brought Certified Nurse Aide #9 to the resident's room, and they observed the resident's head hanging near the side of the bed with arms stretched towards the waste basket on the floor. The emesis basin was on the floor, and they observed a large amount of vomit. Registered Nurse #10 notified Licensed Practical Nurse Supervisor #8 who came to the unit. During an interview on 2/21/2025 at 10:40 AM, Licensed Practical Nurse #7 stated when a resident had a change in condition, it was documented on the 24-hour report, the supervisor was notified, and the supervisor evaluated the resident. On 1/23/2025, the resident was not feeling well and had not been feeling well since they returned from the hospital. The only change for them was the loose stools. The resident did not give any specifics about how they felt. They believed there was a gastrointestinal illness affecting other residents on the unit at the same time. They stated they did not recall if the resident was nauseous and did not recall if aides reported the resident was nauseous. They believed they reported loose stools to the supervisor or the other nurse on the unit and did not recall who they were. They did not recall if the resident was evaluated. They stated they did not notify the provider. They did not check a residual for the resident as it was not on the Medication Administration Record. They did not give the resident a basin and nobody reported to them the resident was given a basin. Vomiting would have been a change in condition and if they were made aware, the resident's tube feed would have been held and the provider made aware immediately. During a telephone interview on 2/25/2025 at 11:35 AM, Certified Nurse Aide #11 stated they provided care to the resident on the evening shift on 1/23/2025. On 1/23/2025, the resident was not acting themselves. They were in bed all day and that was not their normal. The resident said they did not feel well. The resident required one assist with incontinence care and could roll on their own when prompted. However, on 1/23/2025, when they prompted the resident to roll, they instead sat up and was not following directions. A second aide had to assist them with the resident's incontinence care that night. They stated they reported to Licensed Practical Nurse #7 the resident was not acting themselves and that they also had diarrhea. They saw Licensed Practical Nurse #7 go into the resident's room sometime around 6 PM. The resident complained of nausea but did not vomit and could not recall if they reported to the nurse. They could not recall if they gave the resident an emesis basin. When they left the shift, the resident was sleeping. They did not report to the oncoming aide because they left early that night around 10:30 PM. During a telephone interview on 2/25/25 at 2:09 PM, Licensed Practical Nurse Supervisor #8 stated they were the supervisor on 1/23/2025 at 7 PM through the night shift on 1/24/2025. On 1/24/2025 at around 4:50 AM, they received a call from Registered Nurse #10 to come to the unit as the resident had expired. They observed the resident lying in bed, head of bed elevated, and laying on their left side. When they rolled the resident to their back, vomit was covering their face. They notified the resident's family member and that was when they first heard the resident had been nauseous that night. Nobody reported to them the resident was nauseous while they were supervisor. If they had known, they would have rounded more frequently on the resident. Because the resident had a tube feeding, the provider should have been notified when nausea started to determine if the tube feed should have been held. On 2/26/2025 at 10:38 AM, Registered Nurse #10 was not reached in an interview. During a telephone interview on 3/4/2025 at 11:11 AM, Assistant Director of Nursing #29 stated once a physician order was obtained, the nurse entered the order into the electronic record by entering the medication, the amount, the frequency and who the ordering physician was. To determine if the order would be placed on the Medication Administration Record or the Treatment Administration Record, the nurse needed to select the Order Type, and the physician order would show up on one of those documents depending on what was chosen. They looked in the electronic record at the resident's 9/11/2024 physician order for verifying placement of feeding tube before each feeding, medication administration or flush, and record the amount of residual. They stated Registered Dietitian #20 entered the order on 9/11/2024 and chose Advance Directives as the Order Type. Choosing Advance Directives as the Order Type would not transfer the order to the Medication or Treatment Administration Record and was the reason the resident's feeding tube for placement or residuals was not checked. Licensed Practical Nurse #21 revised and confirmed the order on 9/11/2024 and they should have caught the error. Checking residuals on residents with feeding tubes was important to determine if the resident was digesting the feed. If too much feed was present in the stomach when checking residual, staff needed to determine if the feed should be stopped. If a resident with a feeding tube had nausea, an assessment was needed to see if there was excessive residual. When Resident #1 had nausea on 1/24/2025, they expected a registered nurse to be notified, and an assessment done. They were not aware the resident was not assessed. During a telephone interview on 3/4/2025 at 12:37 PM, Registered Dietitian #20 stated the purpose of checking residuals was to see how a resident was tolerating a tube feed. If a resident had nausea, they expected a nurse to assess the resident because they would not want to continue feeding someone that was not feeling well. They were trained to enter tube feed orders into the electronic record. A nurse signed off on the order after they enter it. On 9/11/2024, they were not aware they selected Advance Directives for the Order Type when they entered the order for verifying placement and checking residual. During a telephone interview on 3/4/2025 at 12:46 PM, Licensed Practical Nurse #21 stated they were trained on entering physician orders into the electronic record. The purpose of confirming the order was to ensure the order was entered correctly. On 9/11/2024, they recalled changing the Order Type from Advance Directive to the Medication Administration Record and was not sure why the changes were not saved. 2) Resident #7 had diagnoses including malignant neoplasm of the prostate and secondary malignant neoplasm of the bone. The 12/24/2024 Minimum Data Set assessment documented the resident was cognitively intact, had no impairment to upper and lower extremities, used a walker, was independent with most activities of daily living and used an antianxiety medication. The comprehensive care plan revised 12/12/2024 documented: Psychosocial well-being, total severity score 2, absence of mood and behavior problems. Interventions were monitor for mood and behavior change, encourage activities, encourage hobbies of interest, encourage to express emotions in a safe environment, report changes in behavior or psychosocial functioning. There was no documentation regarding the resident's lorazepam for anxiety. Physician orders documented: - on 1/7/2025, lorazepam 0.5 milligrams one tab by mouth at bedtime for anxiety; end date 2/16/2025 (the end date was more than 30 days). -verbal order on 2/15/2025, lorazepam 0.5 milligrams by mouth one time only for anxiety for one day, may pull from Automated Drug Dispensing System, approved by on-call provider. -on 2/15/2025, lorazepam 0.5 milligrams give one tab by mouth one time a day for anxiety. -verbal order on 2/15/2025, lorazepam 0.5 milligrams one tab by mouth one time a day for anxiety for two days. -on 2/16/2025, lorazepam 0.5 milligrams one tab by mouth at bedtime for anxiety, start date of 2/17/2025. The facility Controlled Substance Medication Record for Resident #7's lorazepam 0.5 milligrams, prescription number 2700180, documented the medication was sent to the facility 1/7/2025 with a quantity of 30 pills. The record documented the last dose of lorazepam 0.5 milligrams was administered on 2/6/2025 by Licensed Practical Nurse #12. The vendor pharmacy Patient Usage Report for Resident #7 documented lorazepam 0.5 milligrams was dispensed from the Automated Drug Dispensing System: -on 2/7/2025 by Licensed Practical Nurse #12. -on 2/15/2025 by Licensed Practical Nurse #7. -on 2/16/2025 by Licensed Practical Nurse #12. The facility Pharmacy Narcotic Access Code form documented on 2/16/2025 lorazepam 0.5 milligrams was dispensed from the Automated Drug Dispensing System for Resident #7 by Licensed Practical Nurse #12. It also documented to attach the form to a copy of the printed narcotic order from the facility electronic health system and return to the Director of Nursing's mailbox; must be done, or it was a narcotic error. There was no documented evidence a pharmacy access code was obtained on 2/7/2025 and 2/15/2025 when nurses removed lorazepam 0.5 milligrams from the Automated Drug Dispensing System. The resident's February 2025 Medication Administration Record for lorazepam 0.5 milligrams, give one tablet by mouth at bedtime for anxiety for 2/7/2025 - 2/16/2025, documented: -on 2/7/2025 lorazepam 0.5 milligrams administered by Licensed Practical Nurse #12 from the Automated Drug Dispensing System; no access code obtained from pharmacy prior to removal from system. -on 2/8/2025 code 9 meaning other/see progress notes, by Licensed Practical Nurse #12, awaiting new order (medication not administered). -on 2/9/2025 code 9, by Licensed Practical Nurse #12, awaiting pharmacy (medication not administered). -on 2/10/2025 code 9, by Licensed Practical Nurse #13, med unavailable, reordered (medication not administered). -on 2/11/2025 signature block blank, staff working was Licensed Practical Nurse #12 (medication not administered). -on 2/12/2025 lorazepam 0.5 milligrams marked as administered by Licensed Practical Nurse #17, but medication was not available, and it was not administered. -on 2/13/2025 lorazepam 0.5 milligrams marked as administered by Licensed Practical Nurse #17, but medication was not available, and it was not administered. -on 2/14/2025 lorazepam 0.5 milligrams marked as administered by Registered Nurse #10, but medication was not available, and it was not administered. -on 2/15/2025 code 9, by Licensed Practical Nurse #7 from the Automated Drug Dispensing System; the nurse called the on-call provider who approved a one time lorazepam 0.5 milligrams dose for 2/15/2025 at 7:00PM and 2/16/2025; the resident's primary provider to be notified to obtain a refill of the order. -on 2/16/2025 lorazepam 0.5 milligrams administered by Licensed Practical Nurse #12 from the Automated Drug Dispensing System; protocol was followed, and an access code was obtained for the medication prior to removal from the Automated Drug Dispensing System. - Between 2/7/2025 and 2/16/2025, the resident received their routine lorazepam 0.5 milligrams at bedtime 2/7/2025, 2/15/2025 and 2/16/2025, with an access code to obtain from the Automated Drug Dispensing System only on 2/16/2025. The resident did not receive their routine lorazepam 0.5 milligrams at bedtime for 7 straight days, 2/8/2025 - 2/14/2025. During an interview on 2/20/2025 at 9:00 AM Licensed Practical Nurse #3 stated they had a lot of medications during the morning medication pass that were not available because nurses did not reorder them timely. They usually reordered medications when they got down to two pills in the blister pack. If there was a medication unavailable during the medication pass, they would first check the Automated Drug Dispensing System which was in the utility room on Unit 2. If the medication was not in the Automated Drug Dispensing System, they would call pharmacy to order it. They would then sign off in the electronic medication administration record that the medication was on order, as that is what the facility had told them to do. During an interview on 2/20/2025 at 9:29 AM Licensed Practical Nurse Unit Manager #4 stated if a medication was unavailable on the medication cart, they would first check the Automated Drug Dispensing System. If the medication was not in the Automated Drug Dispensing System they would call pharmacy to order it. During an interview on 2/20/2025 at 12:30 PM Resident #7 stated they recalled not getting their lorazepam 0.5 milligrams at bedtime for several days recently. Nurses told them they needed a refill for the lorazepam, and they were getting locked out with the code when they tried to reorder it. The medical provider never spoke to them about the lorazepam not being available. They had done okay without the lorazepam as they also took melatonin (a supplement that helped indirectly with anxiety by improving sleep). During a phone interview on 2/21/2025 at 9:18 AM Registered Pharmacist #5 from the facility's vendor pharmacy stated Resident #7's lorazepam 0.5 milligrams was last filled by them on 1/7/2025 and the order was good for 30 days. There was a one-time order filled by them on 2/16/2025 by Licensed Practical Nurse #12, who dispensed it from the Automated Drug Dispensing System. When nurses removed a controlled substance from the Automated Drug Dispensing System the protocol was for them to call the pharmacy for an access code first, before removing it from the Automated Drug Dispensing System. Then they would log into the Automated Drug Dispensing System with their login credentials to remove the medication. Nurses could still remove a controlled substance from the Automated Drug Dispensing System without an access code, but that would be considered a medication error. They stated the pharmacy's Client Access Manager told facility staff many times the procedure to follow. During a phone interview on 2/21/2025 at 9:33 AM Registered Pharmacist Director of Operations from the facility's vendor pharmacy stated nurses needed to call the pharmacy first for an access code in order to remove a controlled substance from the Automated Drug Dispensing System. They would look up the dates between 2/7/2025 and 2/15/2025 for Resident #7 to verify when nurses had called for an access code for removing lorazepam 0.5 milligrams and call back. During a follow-up phone interview on 2/21/2025 at 9:46 AM Registered Pharmacist Director of Operations stated they ran a report for Resident #7's lorazepam 0.5 milligrams for the dates 2/7/2025 - 2/15/2025. On 2/7/2025 and 2/15/2025 lorazepam 0.5 milligrams was removed from the Automated Drug Dispensing System, but nurses did not call the pharmacy for an access code first. They sent a discrepancy code form to the facility for those two dates which were supposed to be returned to them within 24 hours, and they never heard back from the facility. They used to send the discrepancy code forms to the Director of Nursing, who was no longer at the facility as of 2/8/2025. They did have an access code for the lorazepam 0.5 milligrams removed from the Automated Drug Dispensing System on 2/16/2025. During a phone interview on 2/25/2025 at 10:40 AM Licensed Practical Nurse #12 stated they worked at the facility the last two years as an agency nurse. They usually passed medications but were sometimes the supervising nurse. They were thrown into the nurse supervisor role without any training. If a resident did not have a controlled substance medication available on the medication cart, they would call the pharmacy for an access code to the Automated Drug Dispensing System. Controlled substances were not indefinite orders; they were only good for 30 days. If controlled substance medications were past 30 days pharmacy would not provide an access code number. When on-call medical providers were called regarding a controlled substance medication order they would not return the call quickly unless it was an urgent situation, such as a resident fall. They knew about Resident #7's lorazepam 0.5 milligrams not being available. They had called the on-call medical provider, but the provider never got back to them. If an on-call medical provider was not familiar with a resident they did not feel comfortable ordering a one-time medication. The pharmacy would not give them an access code for Resident #7's lorazepam 0.5 milligrams on 2/7/2025 because the resident's order was past 30 days. They still dispensed the lorazepam 0.5 milligrams from the Automated Drug Dispensing System and administered it to the resident. They could not remember if they wrote a nursing progress note about notifying the on-call medical provider about Resident #7's lorazepam 0.5 milligrams being unavailable. They received a medication error from the facility on 2/24/2025 for not administering Resident #7 their lorazepam 0.5 milligrams on 2/8/2025, 2/9/2025 and 2/11/2025. They were told by the facility they should have notified the supervisor about the unavailable medication, but they stated they were the supervisor on those dates. They were aware Licensed Practical Nurse #7 put in a two-day order for lorazepam 0.5 milligrams on 2/15/2025 (for administration on 2/15/2025 and 2/16/2025). They were never initially trained on the protocol to follow for removing a controlled substance from the Automated Drug Dispensing System. Recently, Licensed Practical Nurse Unit Manager #4 went over the process of removing a controlled substance from the Automated Drug Dispensing System with them. They and other nurses recently received a random education on removing medications from the Automated Drug Dispensing System because none of them knew the process. They had spoken with Resident #7 and Resident #7's family member about the lorazepam 0.5 milligrams being unavailable and how their hands were tied in attempting to get it without success. Resident #7 had shown no outward appearances of having any adverse effects such as agitation, anxiety or complaining from not receiving their lorazepam 0.5 milligrams. On 2/25/2025 at 12:45 PM, Registered Nurse #10 was not reached in an interview. During a phone interview on 2/25/2025 at 12:50 PM Licensed Practical Nurse #13 stated they were an agency nurse and had only worked two shifts at the facility. If they did not have a controlled substance medication for a resident when they were passing medications, they would normally get a supervisor. They were told they had no access to the Automated Drug Dispensing System because they were an agency nurse. They were familiar with Resident #7 and recalled trying to get their lorazepam 0.5 milligrams on 2/10/2025. They called the Registered Nurse Supervisor (name unknown) and the floor licensed practical nurse (name unknown) but they did not do anything about it. They (the Registered Nurse Supervisor and floor licensed practical nurse) had brushed it off and had commented that they knew the lorazepam 0.5 milligrams had been unavailable. Licensed Practical Nurse #13 spoke with who they thought was the Director of Nursing the next morning about Resident #7's lorazepam 0.5 milligrams, but they did not do anything about it and told them most nurses did not have a log-in for the Automated Drug Dispensing System. They had never been educated on the process for getting a medication from the Automated Drug Dispensing System. For the two shifts they worked at the facility, many residents had medications unavailable because they were not re-ordered. They no longer worked at the facility. During a phone interview on 2/25/2025 at 2:37 PM Nurse Practitioner #14 stated for a controlled substance medication to be reordered the licensed practical nurse or registered nurse would need to send an electronic order to refill, and they would double-check to see if it was a routine order. The order notification would show up on their phone. If they were not notified a resident's medication needed to be reordered, they could not refill it. Routine medication orders were good for 30 days, and with 14-day or as needed medication orders they would re-assess to see if the resident still needed that medication. The nurses had to put the refill order under the primary provider's name for it to be refilled. Resident #7 was their patient, and they were not aware they had not received their routine lorazepam 0.5 milligrams at bedtime for seven days (2/8/2025 - 2/14/2025). They re-ordered Resident #7's lorazepam 0.5 milligrams on 2/16/2025. The on-call medical providers were available from 5:00 PM - 8:00 AM. If they had a day off, they would let the covering medical provider know so that the correct provider's name would be on an order. Medication orders were frequently not reordered timely at the facility. During a phone interview on 2/26/2025 at 9:40 AM Licensed Practical Nurse #17 stated if a medication was unavailable on the medication cart, they would notify the supervisor. They worked many double shifts, and it was very busy. They remembered Resident #7 talking to them about their lorazepam 0.5 milligrams not being available because the nurses did not have an access code to the Automated Drug Dispensing System. They had never been educated on using the Automated Drug Dispensing System and there was no handbook available that Administration told them to refer to. They had no access to the Automated Drug Dispensing System. They could not remember if they had administered lorazepam 0.5 milligrams to Resident #7 on 2/12/2025 and 2/14/2025; it was possible they signed for it when they never really gave it due to its unavailability. They could not remember notifying a supervisor on 2/12/2025 and 2/14/2025. They remembered giving that medication to the resident in the past when they worked evening shifts. They recently received a medication error from the facility for not administering lorazepam 0.5 milligrams to Resident #7 as ordered. Resident #7 showed no signs of distress or anxiety on 2/12/2025 and 2/14/2025. Resident #7's family member frequently took them out on pass. During a phone interview on 2/28/2025 at 10:21 AM Licensed Practical Nurse #7 stated they were passing medications on 2/15/2025 when they noticed Resident #7 did not have their lorazepam 0.5 milligrams. The resident needed an order for the lorazepam 0.5 milligrams as it had not been refilled. They called the on-call medical provider and did not get a call-back right away. They passed the information on to Licensed Practical Nurse Supervisor #8. They eventually got a call-back from the on-call provider and were able to get an order for the lorazepam 0.5 milligrams for 2/15/2025 and 2/16/2025. The resident received their lorazepam 0.5 milligrams before they left their shift on 2/15/2025. Resident #7 had been asking about their lorazepam 0.5 milligrams earlier in the shift and if it had come in yet. They were pleasant about the situation and did not appear to be having any withdrawal symptoms from not having had the lorazepam 0.5 milligrams for several days. The resident was thankful after they received their lorazepam 0.5 milligrams on 2/15/2025. They had not had a training on removing a controlled substance from the Automated Drug Dispensing System and were not aware they needed an access code. 10NYCRR 415.12

Based on record review and interview during the abbreviated survey (NY00371419), the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 of 3 residents (Resident #2). Specifically, facility Administration, including the Director of Nursing, did not ensure a complete and accurate investigation was completed following an allegtion of abuse. Additionally, the staff statements provided to the Department of Health (as part of the abuse investigation) were falsified. The staff that provided statements stated they did not author the statements or provide a verbal statement to anyone at the facility, they did not sign the statements, and the signatures on the documents were not theirs. Findings include: The facility policy, Facility Incident/Abuse Investigation and Reporting revised 6/7/2023, documented should a resident be observed with unexplained injuries or suspected/alleged abuse, neglect or mistreatment, the employee notified the supervisor who conducted an assessment. The supervisor/designee initiated an Accident/Injury Report in the electronic record and recorded information in the record. The supervisor notified the Director of Nursing immediately. The Director of Nursing initiated the investigation. In the event the Director of Nursing was not on-site, the supervisor might begin the investigation as directed by the Director of Nursing. The Director of Nursing/designee notified the Administrator immediately. For allegations of abuse, neglect, mistreatment, misappropriate or once suspicion of abuse had been formed, the Director of Nursing Services must notify the Department of Health. Facility employees that have been accused of resident abuse would be suspended or reassigned to non-resident care duties until the results of the investigation had been reviewed by the Administrator. The 11/30/2024 untimed and unsigned Investigative Summary (no Incident Report was provided) documented the resident stated a night shift nurse was rough with them and the resident could not provide details on what rough meant. Staff present did not witness any rough actions by the nurse. Staff reported the resident was unusually confused. At baseline, the resident was alert and oriented to person, place, time, and event. Staff reported the resident was combative and hit the nurse. The resident had some swelling but no bruising to their right wrist and the x-ray was negative. The resident stated they were not afraid. There was no care plan violation, and no abuse found as a result of the investigation. The investigation did not document who the accused nurse was or what action was taken with them (statements identified Licensed Practical Nurse #15). Typed statements dated 11/30/2024, with the employee signatures documented: - From Licensed Practical Nurse Supervisor #8, during the night shift of 11/29-11/30/2024, the resident was very combative and insisted they needed to find their car and pick their family members up. The resident was pacing the unit at 4:00 AM, was redirected to their room, and became combative. Licensed Practical Nurse #15 helped the resident into a wheelchair and got them to their room. The resident was very upset, did not want to return to their room, and attempted to hit Licensed Practical Nurse #15 multiple times. - From Licensed Practical Nurse #17, the resident was wandering the unit throughout the night and was attempting to leave to go to their car. Initially the resident was redirectable. Around 4:00 AM, Licensed Practical Nurse #15 helped the resident into a wheelchair and transported them back to their room. The resident was very confused and combative towards the nurse. The resident attempted to hit staff who were redirecting them. Licensed Practical Nurse #15 was firm in their speech with the resident in attempt to redirect them. - From Registered Nurse #16, they spoke with the resident following their claims the night shift staff were rough with them. The resident could not recall specific details besides providing a basic description of the nurse who was rough with them. Staff members reported the resident was disoriented and combative on the night shift. An assessment was completed and the resident had no complaints of pain or discomfort. During a telephone interview on 2/25/2025 at 2:09 PM, Licensed Practical Nurse Supervisor #8 stated on 11/30/2024 during the night shift: - The resident was up and wandering on their shift. - Licensed Practical Nurse #15 was the unit floor nurse and Licensed Practical Nurse #15 expected all residents to be in their rooms on the night shift. Licensed Practical Nurse Supervisor #8 had counseled the nurse in the past that residents had a right to be up as the facility was their home. -They heard Licensed Practical Nurse #15 say to the resident it was time to go to bed and Licensed Practical Nurse #15 sounded annoyed. They did not witness Licensed Practical Nurse #15 place the resident in the wheelchair. - The resident did not allege abuse or complain of wrist pain on their shift. - During their shift the next day, they heard the resident alleged abuse against a night shift staff and the incident was under investigation. They stated they were surprised that nobody had spoken to them because they were present when the incident occurred. If someone had spoken to them, they would have reported Licensed Practical Nurse #15's inappropriate tone when telling the resident they needed to go to bed. - A copy of the 11/30/2024 statement included in the Investigative Summary, with Licensed Practical Nurse Supervisor #8's name and signature was provided to them. The nurse stated they did not author the statement, or provide a verbal statement to anyone at the facility, did not sign the statement, and the signature on the document was not theirs. During a telephone interview on 2/27/2025 at 11:35 AM, Registered Nurse #16 stated: - On 11/30/2024, they were the supervisor on the day shift. They were asked by the former Director of Nursing to do an assessment on the resident and was not told why the assessment was needed. They were not aware the resident alleged abuse and did not know any details. - A copy of the 11/30/2024 statement included in the Investigative Summary with Registered Nurse #16's name and signature was provided for Registered Nurse #16 to review. Registered Nurse #16 stated they did not author the statement, or provide a verbal statement to anyone at the facility, did not sign the statement, and the signature on the document was not theirs. During a telephone interview on 3/3/2025 at 7:31 AM, former Director of Nursing #2 stated incidents should be reported the supervisor, the Administrator or themselves so a thorough investigation could be completed. The staff that was accused of abuse should be suspended to keep residents safe. All staff on duty when the alleged abuse occurred should provide statements and statements were obtained by the supervisor, the Administrator, or themselves. The Administrator was responsible for completion of the Investigative Summary though they had completed them in the past. The Administrator was responsible to determine if abuse or neglect occurred and the Administrator or themselves reported abuse to the New York State Department of Health. On 11/30/2024, they reported the incident to the Administrator. They were not sure why only 3 nurses provided statements and no certified nurse aides were interviewed. They stated the certified nurse aides should have provided statements. They could not recall if they wrote the Investigative Summary for the incident. The Investigative Summary should have been signed and dated. They were not aware Licensed Practical Nurse #15 worked on 12/1/24 and depending on if the investigation was completed and abuse ruled out, they should not have worked. They could not recall if they obtained statements from Licensed Practical Nurse Supervisor #8 or Registered Nurse #16 and was not aware the statements or the signatures were not from those nurses. They did not think the facility could rule out abuse and neglect if the statements were false. They were not sure why the incident was not reported the New York State Department of Health. During a telephone interview on 3/3/2025 at 10:49 AM, the Administrator stated staff statements were obtained by the supervisor or the Director of Nursing. The Director of Nursing was responsible to complete the Investigative Summary. The Administrator reviewed all the incident documentation once completed and they, the Director of Nursing and corporate ruled out abuse and neglect. They or the Director of Nursing reported abuse to the New York State Department of Health. They stated on 11/30/2024, the Director of Nursing investigated the allegation of abuse and determined from staff statements that abuse had not occurred. Staff stated the resident was not at their baseline and was confused. Staff were concerned the resident would fall. The resident alleged they were pushed in to the wheelchair and staff statements did not support this. They stated they did not write the Investigative Summary for this incident and assumed former Director of Nursing #2 did. Former Director of Nursing #2 should have signed and dated the summary. They believed abuse and neglect was ruled out the same day and why Licensed Practical Nurse #15 returned to work on 12/1/2024. They were not aware staff alleged their statements were forged and stated they had no reason to not believe the staff. They stated abuse and neglect could not have been ruled out if staff statements were incorrect. The facility would need to reopen the case to investigate. The incident was not reported to the New York State Department of Health because the facility initially ruled out abuse and neglect. During a telephone interview on 3/4/2025 at 12:52 PM, Licensed Practical Nurse #17 stated they were not on duty on the night shift on 11/30/2024. They were provided a copy of the statement from the Investigation Summary with Licensed Practical Nurse #17's name and signature for their review. Licensed Practical Nurse #17 stated they did not author the statement, or provide a verbal statement to anyone at the facility, did not sign the statement, and the signature on the document was not theirs. 10NYCRR 415.26(a)

Based on observation, interview, and record review during the recertification survey conducted 9/9/2024-9/16/2024, the facility did not ensure each resident had the right to a dignified existence for 2 of 6 residents (Residents #37 and #137) reviewed. Specifically, Resident #37 was not provided with a requested shower prior to attending a significant family event, and Resident #137's urinary collection bag was visible in plain sight. Findings include: The facility policy, Activities of Daily Living, revised 10/2023, documented the facility would provide each resident the necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care. The facility policy, Resident Rights and Responsibilities, revised 4/2/2024, documented the facility functioned on the premise that the service it rendered would demonstrate its belief in the dignity and worth of every individual, and the objective of the facility was to provide the resident with optimal nursing and psychosocial care. 1) Resident #37 had a diagnosis of osteoarthritis, muscle weakness, and right above the knee amputation. The 5/24/2024 Minimum Data Set documented it was very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. The 8/22/2024 Minimum Data Set documented resident was cognitively intact, was frequently incontinent of bowel and bladder, and required substantial assistance with bathing. The Comprehensive Care Plan last reviewed 8/31/2024 documented a self-care performance deficit related to limited mobility, limited range of motion, and above the knee amputation; and a psychosocial well-being problem due to alteration in mood and behavior. Interventions included dependence for bathing and offer choices related to care routine. The 8/30/2024 Social Worker #33 progress note documented the resident was preparing to attend their child's wedding that weekend. During interviews on 9/11/2024 at 9:42 AM and 9/13/2024 at 3:28 PM, Resident #37 stated they asked to receive a shower prior to attending their child's wedding on 8/31/2024. They told staff they were willing to give up their normally scheduled shower on 8/27/2024 in exchange for a shower on 8/31/2024. The resident stated they were told their shower was on Tuesday and if they passed up that shower, they would have to wait until the following Tuesday to receive a shower. They received a bed bath on 8/31/2024 but felt that was not the same as a shower especially since the bed bath was given in the morning and the wedding was not until 3:00 PM. During the interview the resident was tearful and said it was hard to talk about how not having a shower affected their experience at the wedding because they did not feel clean. They stated they had clean clothes on, but their body did not feel clean. The resident did not tell their family because they would be upset, especially their parent. They said in the future they would not ask the staff for a favor when it came to their shower ever again. Every time they received a shower, they thought about the situation and how bad it made them feel. The 8/31/2024 facility staffing form documented four certified nurse aides and two licensed practical nurses were scheduled to work on the second floor (the resident's unit) on 8/31/2024 at 6:45 AM. During an interview on 9/16/2024 at 12:21 PM, Certified Nurse Aide #34 stated each resident had a weekly shower in accordance with the schedule located at the front desk. If the unit had less than four aides working on the day or evening shift, they did not give showers and would instead give a bed bath. An attempt would be made to squeeze that missed shower in prior to their next shower day. They were not working on 8/31/2024, but the plan was the resident would be showered the day before the wedding and that did not happen. It would not feel good to go to a wedding and not feel clean. It was a dignity issue that could cause feelings of sadness and depression. During an interview on 9/16/2024 at 2:12 PM, Licensed Practical Nurse Unit Manager #1 stated showers were given once a week. Staff should try to accommodate resident's preferences by doing such things as switching shower days with another resident. If someone missed their shower an attempt was made to do it on the following shift or day. The number of staff working did not determine if someone received a shower or not. They were not aware of Resident #37 asking for a shower on 8/31/2024, but felt they had the right to have a shower in preparation for the wedding. That was important as the resident probably saw family they had not seen in a while. If they felt unclean it was undignified and could lead to depression. 2) Resident #137 had a diagnosis of benign prostatic hypertrophy (enlarged prostate). The 7/29/2024 Minimum Data Set documented the resident had intact cognition, had a urinary drainage device, and had no refusals of care. The Comprehensive Care Plan last reviewed 8/9/2024, documented the resident had a urinary drainage device related to benign prostatic hypertrophy and a sacral (lower back) wound. Interventions included urinary catheter care every shift and leg bag (a small collection bag attached underneath clothing) to be worn during daytime hours. The 8/12/2024 physician order documented an order to change urinary drainage device once a month and as needed and catheter care every shift. The following observations of Resident #137 were made: - On 9/9/2024 at 10:14 AM, walking in their room carrying their uncovered urine collection bag. The bag was visible from the hallway. - On 9/9/2024 at 12:51 PM, standing in the doorway of their room with their urinary catheter tubing threaded through their left pant leg and the uncovered collection bag hooked on their right pants pocket. The collection bag was visible from the hallway. - On 9/10/2024 at 8:33 AM, the resident had their uncovered urine collection bag hanging on their bed visible from the hallway. During an interview on 9/16/2024 at 12:01 PM, Certified Nurse Aide #34 stated nurse aides provided catheter care and that included changing from a leg bag to large collection bag. Blue dignity bags were used when a resident was out of bed. If someone refused a dignity bag, they reported that to the nurse as the refusals may need to be care planned. They had observed Resident #137 walking around with the collection bag hanging from their pants pocket without a dignity bag. Dignity bags were important to prevent a resident from feeling self-conscious and from feeling as though others would be judgmental towards them. During an interview on 9/16/2024 at 1:24 PM, Licensed Practical Nurse Unit Manager #1 stated they expected urine collection bags to be placed in a dignity bag and any refusals were reported so education and care planning would be done. Resident #137 had a catheter and they had observed the resident walking around the unit without a dignity bag. Dignity bags were important because it could cause the resident to feel bad or embarrassed. 10NYCRR 415.5(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted [DATE]-[DATE] the facility did not ensure that residents were assessed to determine their ability to safely self-administer medication, when clinically appropriate for 3 of 3 residents (Residents #38, #41, and Resident #95) reviewed. Specifically, Residents #38, #41, and #95 had prescription medications at their bedsides without physician orders for self-medication administration or resident assessments to determine their ability to safely self-administer medications. Additionally, Resident #95 had a discontinued prescription medication at their bedside. Findings include: The facility policy, Inhalers, revised 3/2011, documented licensed nurses would administer inhaler medications as indicated and ordered by the physician. Inhalers were stored (labeled) in the medication cart and discarded when empty or expired. The facility policy, Medication/Treatment Labeling and Storage, revised 7/2013 documented medications, when received in the nursing unit, would be placed in the proper storage areas, medication room, clean utility room, treatment cart or medication cart. The facility policy, Self-Administration of Medications, revised [DATE] documented residents had a right to be involved in all aspects of their care including self-administration of medications if the interdisciplinary team deemed it clinically appropriate. The medication would be stored in a locked drawer or locked compartment under proper temperature conditions; and the team leader would ascertain from the resident whether any routine medication(s) were self-administered and document accordingly on the electronic Medication Administration Record, generating a progress note after each self-administered medication. 1) Resident #95 had diagnoses including chronic embolism and thrombosis (types of blood clots) of the left lower extremity. The [DATE] Minimum Data Set assessment documented the resident had intact cognition and required set-up assist for personal hygiene. The Comprehensive Care Plan initiated on [DATE] documented the resident had independent decision-making skills. There was no documented evidence the resident was care planned to self-administer medications. The [DATE] physician order documented fluticasone propionate suspension (Flonase -nasal spray) 50 micrograms, 1 spray in each nostril once a day for allergies and was discontinued (no discontinuation date documented). The 9/2024 Medication Administration Record did not document an order for Fluticasone propionate suspension. The following observations were made: - On [DATE] at 8:57 AM, a bottle of fluticasone was on the resident's bedside table. Resident #95 stated they self-administered one spray of fluticasone to each nostril most every morning for allergies. - On [DATE] at 11:15 AM, a bottle of fluticasone was on the resident's bedside table. There was no documented evidence the resident was assessed to determine their ability to safely self-administer medications. During an interview on [DATE] at 1:38 PM, Licensed Practical Nurse Unit Manager #1 stated a physician order and assessment was required for a resident to self-administer medications. They were not sure what the assessment consisted of or how often that assessment had to be reviewed. If a resident had a self-administration order it would show up on the medication administration record as such. It would also indicate whether the resident could keep that medication at the bedside. Medications at the bedside should have the date it was opened, and expiration dates should be checked as with any other medication. If a medication was discontinued, it should be removed from the room by whomever acknowledged the discontinuation order. Resident #95 did not have a current order for fluticasone, and they did not know why it was discontinued. If a staff member observed the fluticasone at the bedside, they should check for an active physician order and if the resident could keep the medication at the bedside. This was important because a resident that was taking a medication that was no longer prescribed could get sick and the resident could overdose themselves. 2) Resident #41 had diagnoses including chronic obstructive pulmonary disease (lung disease). The [DATE] Minimum Data Set documented the resident had intact cognition, had bilateral upper extremity contractures, and required set-up assistance for personal hygiene. The Comprehensive Care Plan revised on [DATE] documented the resident had impaired pulmonary function related to chronic obstructive pulmonary disease. Interventions included administer pulmonary medications per physician order. The [DATE] physician order documented Combivent Aerosol 18-103 micrograms/actuation (Combivent inhaler) one puff every four hours as needed for shortness of breath. The physician order did not document the resident could self-administer or keep the medication at the bedside. There was no documented evidence the resident was assessed to determine their ability to safely self-administer medications. The following observations were made: - On [DATE] at 8:52 AM, an unlabeled Combivent inhaler was in a plastic container on the resident's bed. - On [DATE] at 12:01 PM, two unlabeled Combivent inhalers were in the top drawer of the resident's nightstand. One had an imprinted manufacturer's expiration date of 2/2023. - On [DATE] at 1:42 PM, an unlabeled Combivent inhaler was in the resident's shirt pocket. There were two unlabeled Combivent inhalers in the top drawer of the nightstand. - On [DATE] at 10:07 AM, Licensed Practical Nurse #51 entered the resident's room during their medication administration and asked the resident where their Combivent inhaler was. The resident pulled it out of their shirt pocket and stated they had not used it yet. When Licensed Practical Nurse #51 prompted the resident to use it, the resident stated they only used it when they needed it, they did not currently need it, but would take it anyway. The resident took one puff from the inhaler. The nurse requested the resident hand over the inhaler and placed it in the medication cart. During an interview on [DATE] at 1:42 PM, Resident #41 stated they had carried their own inhaler for a couple of years. They used the inhaler usually once or twice during the day, once during the night, and whenever they felt short of breath. The nurses did not bring it to them. They kept their own because if they needed it, they never knew when the nurse was going to make it in to administer it to them. They did not keep track of when they used it, the nurses seldom asked if or when they had used it, and no one had watched them use the inhaler to ensure they used it properly. During an interview on [DATE] at 10:07 AM, Licensed Practical Nurse #51 stated residents had to be assessed before being able to self-administer medications. They thought the assessment was done by a registered nurse and could be found in the evaluation tab of the medical record. They would know if someone could self-administer medications because it would show up on the medication administration record. Inhalers at the bedside would not be locked up because the resident might need to quickly access it. It was unusual for a resident to have multiples of the same medication in their room. Resident #41 kept their Combivent at the bedside and did not have an order for the inhaler be kept at the bedside or be self-administered. During an interview on [DATE] at 1:38 PM, Licensed Practical Nurse Unit Manager #1 stated Resident #41's family had a history of bringing in medications including the Combivent inhaler, and they had talked to the family previously about not doing so. The resident did not have an order to have the inhaler at the bedside. During an interview on [DATE] at 5:03 PM, the Director of Nursing stated Resident #41 had been found with a Combivent inhaler at the bedside in the past and the family had brought them from home. The resident had used too much of the Combivent inhaler in the past and for that reason the physician had deemed it unsafe for the resident to keep medications at the bedside. 3) Resident #38 had diagnoses including asthma, diabetes, and dysphagia (difficulty swallowing). The [DATE] Minimum Data Set assessment documented the resident was cognitively intact, required set up assistance for eating and oral hygiene, and did not reject care. The Comprehensive Care Plan initiated [DATE] documented the resident had impaired pulmonary (lung) function and medications were administered per orders. The [DATE] physician order documented Diabetic Tussin (cough syrup) oral liquid 10 milliliters by mouth twice daily for cough. There was no documented evidence of a self-administration assessment or a physician order for self-administration of medications. During a medication administration observation on [DATE] at 8:24 AM, Licensed Practical Nurse #24 placed Resident #38's ordered medication pills into a plastic medication cup and the Diabetic Tussin (cough syrup) oral liquid 10 milliliter was poured into another plastic medication cup. At 8:30 AM, the nurse knocked on Resident #38's door and entered the room, watched the resident take the pills and left the cough syrup on the resident's bedside tray table. The resident was eating breakfast and did not take the cough syrup. The 9/2024 Medication Administration Record documented the resident's Diabetic Tussin was administered on [DATE] at 8:00 AM. During an interview on [DATE] at 9:00 AM, Resident #38 stated they liked to take their cough syrup after they had eaten breakfast. The nurses usually left the cough syrup at their bedside for them to take after breakfast. During an interview on [DATE] at 9:01 AM, Licensed Practical Nurse #24 stated if a medication was documented as given it meant they watched the resident ingest the medication. They did not watch Resident #38 take the cough syrup and should have to ensure they took it. They should have taken the cough syrup to the resident after breakfast when they were ready to take it. Resident required an order to self-administer medication and they did not have a self-administration of medication order. During an interview on [DATE] at 1:37 PM, the Assistant Director of Nursing stated if a medication was signed for on the Medication Administration Record as administered it meant the nurse watched the resident take the medications. Pre-poured medications should not be left at the bedside for safety reasons and the nurse would not know if the medication was taken if they did not watch. Resident #38 did not have an order to leave medications at their bedside or to self-administer medications. The cough syrup should not have been left at the bedside. During an interview on [DATE] at 5:03 PM, the Director of Nursing stated if a resident wanted to keep medications at their bedside and self-administer them, a physical and cognitive evaluation had to be done by nursing. If approved, the medication could be kept at the bedside. If not approved, there should be no medications in the room. There should not be multiples of the same medication in the room. The medication nurse should ask and ensure the resident had taken the medication as ordered. 10NYCRR 415.3(e)(1)(vi)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification and abbreviated (NY00336546) surveys conducted 9/9/2024- 9/16/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 9 residents (Residents #2, #35, #37, and #64) reviewed. Specifically, Resident #2 was not provided with assistance during meals as planned; and Residents #35, #37, and #64 had unclean and untrimmed fingernails. Findings include: The facility policy, Activities of Daily Living, revised 10/2023, documented each resident would receive and the facility would provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Residents would be given the appropriate treatment and services to maintain or improve their ability to carry out activities of daily living including hygiene, mobility, elimination, dining, and communication. Certified nurse aides would follow the [NAME] (resident care instructions) and if the resident refused care or had a change in condition requiring a level of care different from the [NAME], they would alert the licensed nurse or nurse supervisor. The facility policy, Nail Care, revised 10/2011, documented the purpose of nail care was to ensure cleanliness and to prevent infection. Routine nail care was to be done following a bath or shower, and whenever possible. Fingernails of residents who were diabetic were to be trimmed by a licensed nurse. 1) Resident #2 had diagnoses including Alzheimer's disease, dysarthria (difficulty speaking), and feeding difficulties. The 8/21/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment and required moderate assistance with eating (receives some assistance in getting food to their mouth). The Comprehensive Care Plan initiated 3/1/2022 and revised on 8/22/2024, documented a risk for alteration in nutrition related to a self-performance deficit, high blood pressure, weight loss and diabetes mellitus. Interventions included moderate assistance with feeding when in bed, supervision assistance when in their wheelchair, positioned with peers in common area or dining room, and adaptive equipment and straws with meals. The 6/10/2024 Registered Dietitian #4 progress note documented Resident #2 required 1730 kilocalories and 68 grams of protein per kilogram per day. The 7/30/2024 Nurse Practitioner #42 progress note documented they recommended to increase the resident's protein for wound healing. The 9/16/2024 [NAME] documented the resident required adaptive equipment at meals including cups with lids and straws and a divided plate; moderate assistance for eating when in bed; supervision assistance for eating when in their wheelchair and provide verbal cues and encouragement. During an observation on 9/9/2024 at 1:07 PM, Resident #2 was served their lunch meal of stuffed shells, spinach, and a dinner roll on a divided plate; and vanilla ice cream, a Health Shake (nutritional supplement), a brownie, 2 orange juices, diet cola, water, and yogurt. The meal ticket documented the resident required moderate assistance with meals. At 1:13 PM, Resident #2 was provided their meal with cups and lids placed by staff. The staff did not provide further assistance with the meal. At 1:26 PM, Resident #2 had eaten 5% of the stuffed shells, 0-25% of the spinach, 0% of the roll, 0% of the yogurt. 100% of the brownie, 0% of the ice cream, 75% of the orange juice, and 25% of Health Shake. At 1:34 PM, Resident #2 was eating their stuffed shells with their fingers and by 1:40 PM had eaten all the stuffed shells. During an observation on 9/11/2024 at 12:48 PM, Resident #2 was served their lunch in the dining room which included macaroni and cheese, salad, Health Shake, yogurt, water, Magic Cup (frozen nutritional supplement), cola, milk, and orange juice. At 12:59 PM, Resident #2 was eating by themselves holding their fork with both hands and bringing one noodle to their mouth. There was no staff assisting the resident. At 1:21 PM, the resident had not received any feeding assistance from staff. At 1:30 PM, the resident was attempting to eat their Magic Cup with a fork. They set the fork on the napkin and attempted to bring the fork to their mouth. During an interview on 9/16/2024 at 11:16 AM, Certified Nurse Aide #48 stated they reviewed the care plan to know the level of assistance required for each resident including eating assistance. They were familiar with Resident #2 and stated they were independent with eating and could pick up cups and utensils on their own. They stated if a resident's care plan documented they required moderate assistance with eating that meant the resident required cueing only. During an interview on 9/16/2024 at 11:20 AM, Licensed Practical Nurse #32 stated staff reviewed the care plan daily to determine the level of assistance required for care. The resident's level of assistance with feeding recently changed and they now required maximum assistance with eating. They stated if the care plan documented moderate assistance with eating, the resident required assistance with eating and staff should sit with them at all meals. During an interview on 9/16/2024 at 11:28 AM, Director of Therapy #49 stated the therapist determined how much assistance a resident needed for eating after completing an evaluation. This was documented on the care plan. They stated Resident #2 required assistance with eating and staff should sit with the resident and assist with feeding as necessary. 2) Resident #37 had a diagnoses including osteoarthritis and muscle weakness The 8/22/2024 Minimum Data Set assessment documented the resident was cognitively intact; was dependent for personal hygiene and required substantial assistance with bathing. The Comprehensive Care Plan initiated 3/1/2022 and revised 8/31/2024, documented a self-care personal hygiene performance deficit related to activity intolerance, limited mobility, and limited range of motion. Interventions included nail care on bath day and as needed. The 9/16/2024 [NAME] (care instructions) documented maximum assistance with personal hygiene and nail care on bath day and/or as needed. The 8/12/2024 physician order documented weekly skin and nail monitoring every day shift every Tuesday for skin integrity/hygiene. The undated second-floor shower schedule documented Resident #37's weekly showers were scheduled for Tuesdays on the day shift. The following observations of Resident #37 were made: - On 9/9/2024 at 2:24 PM, fingernails were long and jagged. - On 9/13/2024 at 8:41 AM, fingernails were long and jagged with brown debris under the right thumb and index fingers. During an interview on 9/9/2024 at 2:24 PM, Resident #37 stated their nails were too long and they preferred them short. They were told they would be cut the prior weekend, but they were not. During an interview on 9/16/2024 at 12:21 PM, Certified Nurse Aide #34 stated aides could perform nail care. Nails were supposed to be checked on shower days, but dirty nails should be taken care of anytime they were noticed. Well-groomed fingernails were important for dignity. Infections could develop if the resident scratched themself. If someone needed nail care and they refused, they would tell the nurse. They had noticed Resident #37's fingernails were long and needed attention. The resident would let them cut their fingernails. During an interview on 9/16/24 at 2:12 PM, Licensed Practical Nurse Unit Manager #1 stated nail care should be done on shower days and anytime in between if needed. Certified nurse aides could do fingernail care. Resident #37 did not refuse care. Nail care was important because long, dirty nails could cause scratches which could lead to infection, and it was undignified have dirty nails. 3) Resident #35 had diagnoses including Alzheimer's disease, stroke, and diabetes. The 9/6/2024 Minimum Data Set assessment documented the resident was cognitively intact, required supervision or touching assistance with personal hygiene, eating, oral hygiene, shower/bathing, and dressing. The Comprehensive Care Plan initiated 6/21/2024 documented the resident had self-care performance deficit with personal hygiene related to a stroke. Interventions included supervision and diabetic nail care by nurse and/or podiatrist (specializes in foot care). The 9/13/2024 [NAME] (care instructions) documented the resident required diabetic nail care by nurse or podiatrist. The following observations of Resident #35 were made: - On 9/9/2024 at 12:34 PM, in their room with long, unkept fingernails with black/brown debris under the nails. The resident stated their nails were too long, they got in the way, and staff did not trim their fingernails when they asked. - On 9/10/2024 at 9:15 AM, in their room with long, unkept fingernails with black/brown debris under the nails. - On 9/11/2024 at 10:06 AM, in their room with long, unkept fingernails with black/brown debris under the nails. During an interview on 9/13/2024 at 9:32 AM, Certified Nurse Aide #25 stated personal hygiene consisted of hair care, oral care, nail care, and bathing. They had noticed Resident #35's long nails, but certified nurse aides could not trim them because the resident was a diabetic. The nurses were responsible for trimming Resident #35's nails for safety reasons. They stated it was important for the resident's nails to be clean and trimmed to prevent them from cutting themselves or getting an infection. During an interview on 9/13/2024 at 9:38 AM, Licensed Practical Nurse #26 stated the certified nurse aides were responsible for residents' personal hygiene but were not able to trim nails if the resident was a diabetic. They stated Resident #35 never refused care, and they had never cut the resident's nails. They thought it should have been listed on the treatment administration record to remind nurses the resident was a diabetic that required nail trimming, or they would just assume the certified nurse aides were going to do it. They stated it was important for the resident to have clean and trimmed nails to prevent cuts and wounds from developing, and for the resident's dignity. During an interview on 9/13/2024 at 10:41 AM, Registered Nurse Supervisor #27 stated certified nurse aides were responsible for resident's nail care but if the resident was a diabetic the licensed nurse was responsible for trimming them. They stated Resident #35's nails should have been checked daily during care and by the nurse during their weekly skin check. They stated it was important for the resident's nails to be clean and trimmed to prevent them from scratching themselves or others which could lead to infection. 10NYCRR 415.12(a)(3).

Based on observation, record review, and interview during the recertification survey conducted 9/9/2024-9/16/2024, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 of 2 residents (Resident #5) reviewed. Specifically, Resident #5 was not offered meaningful activities that included their interests and preferences. Findings include: The facility policy, Activity Department Programming, effective 1/1/2000, documented the activities department provided activities programs seven days a week and included individual, group, and independent activities. A visitation program designated to reach residents who would not or could not attend other activities was included. Activities reflected the interests listed on the initial assessment form. Resident #5 had diagnoses of bipolar disorder (a type of mental illness), depression, and spinal stenosis (narrowing of the spinal) of the lumbar (lower back) and thoracic (middle back) regions. The 2/22/2024 Minimum Data Set assessment documented the resident was cognitively intact, they felt down or depressed several days, and they felt it was very important to have books, newspapers, and magazines to read, listening to music, and going outside when weather permitted. The Comprehensive Care Plan initiated 4/12/2023 documented leisure time activities of one-on-one visits to reminisce and talk about interests, self-selected daily activities of interest that included reading, watching television, and crocheting in their room. The 2/23/2024 Quarterly Activities Evaluation completed by Activities Director #20 documented the resident did not attend activities but enjoyed one-on-one visits, snack/ beverage carts, crocheting, reading, word searches, visiting with family, and watching television. The 7/1/2024 Quarterly Activities Evaluation completed by Activities Director #20 documented the resident did not attend activities but enjoyed pet therapy visits, one-on-one visits, specialty carts, visiting with family, knitting, and watching television. The 9/4/2024 progress note by Activities Director #20 documented the resident did not attend group activities. The resident preferred their room and privacy and accepted one-on-one visits by staff and visitors. They would benefit from socialization and would continue to encourage the resident to participate in activities that interested them. The September 2024 activity calendar documented the following daily activities: - On 9/9/2024 at 10:30 AM Who am I?, at 1:00 PM one-on-one visits, at 2:30 PM crafty hour, at 3:30 PM cornhole and at 4:30 PM Bingo. - On 9/10/2024 at 10:30 AM Travel to Colorado, at 3:30 PM baking club, at 4:30 PM noodle ball, and at 6:00 PM movie and popcorn. - On 9/11/2024 at 10:30 AM True or False, at 1:30 PM resident council, at 2:30 PM pet therapy visits, at 3:00 PM trivia, at 4:00 PM ice cream cart, at 6:00 PM chair exercises, and at 7:00 PM noodle ball. - On 9/12/2024 at 10:30 AM bingo, at 2:00 PM Catholic mass, at 3:00 PM chocolate milkshake social, at 4:00 PM relax and color, and at 6:00 PM movie and popcorn. - On 9/13/2024 at 10:30 AM trivia, at 1:00 PM one-on-one visits, at 2:00 PM chair exercises, at 3:00 PM bingo, and at 4:30 PM happy hour. The resident's activity attendance records from June 2024- September 2024 did not document the resident attended or was provided with any activities. There was no documented evidence in the activity progress notes of one-on-one visits with the resident since November 2023. During observations on 9/9/2024 at 11:08 AM and 9/10/2024 at 3:23 PM, the resident was observed lying on their back asleep in their bed wearing a hospital gown. During an observation and interview on 9/11/2024 at 9:44 AM, Resident #5 was lying on their back in bed dressed in a hospital gown. They stated they did not like to socialize in a group. They had problems with depression, and enjoyed one-on-one visits, but they only had them one to three times per year. They wanted to have a one-on-one visit once per week and thought it would help their mood. They also enjoyed reading and completing the word puzzle in the daily chronicle. There were no books observed in their room. During an observation and interview on 9/12/2024 at 12:44 PM, the resident was sitting up in bed in a hospital gown working on a word puzzle. The resident stated they enjoyed mystery books and there were no books observed in their room. During an interview on 9/13/2024 at 9:33 AM, Activities Aide #22 stated they documented in the progress notes any activity that was completed. One-on-one visits were done every day with the residents who did not like to attend group activities. Residents that did not want to socialize deserved the same care and respect. Resident #5 enjoyed one-on-one visits and enjoyed reading. They had not provided any books to the resident, but the activities department should have provided books. It was important the resident had reading material and had one-on-one visits for quality of life and for social interaction. Resident #5 was always in their bed, and they often said hello to them when they were going to get their roommate for activities. During an interview on 9/13/2024 at 9:45 AM, Activity Director #20 stated resident's preferences were in their quarterly assessments and carried over to the care plan. Residents who did not attend activities should be provided with one-on-one visits at least weekly. They did not believe Resident #5 liked to read but they provided books to other residents that liked to read. The resident did not like to participate in activities and did get one-on-one visits but sometimes refused them. It was documented in a progress note if a one-to-one visit was completed or refused. They were not sure how long it had been since the resident had a one-on-one visit, but the visits were important for social interaction. The resident enjoyed talking about crocheting. They were responsible for the quarterly assessments and preferences were updated on the care plan. 10NYCRR 415.5(f)(1)

Based on observation, record review, and interview during the recertification survey conducted 9/9/2024-9/16/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents (Resident #120) reviewed. Specifically, Resident #120's physician ordered urinalysis (a laboratory test that examines urine for a variety of conditions) was not obtained timely. Findings include: The facility policy, Radiology and Other Diagnostic Services, revised 11/2016, documented the facility would provide or obtain diagnostic services to meet the needs of its residents pursuant to an order by an appropriate practitioner. The facility was responsible for the quality and timeliness of such services. Resident #120 had diagnoses of unspecified dementia, cerebral infarction (stroke), and hypothyroidism. The 7/10/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, was incontinent of bladder and bowel, did not have a urinary catheter, and did not have a urinary tract infection in the last 30 days. The Comprehensive Care Plan initiated 1/24/2024 and revised 6/10/2024 documented an alteration in bladder function due to dementia. Interventions included bladder scans and straight catheter as ordered; toilet per request, incontinence care/toileting when resident was restless; incontinence care as needed; incontinence briefs medium pull-ups during day and medium briefs at night; monitor for signs and symptoms of urinary tract infection. The 8/15/2024 physician order documented bladder scan every shift and straight cath (inserting a tube into the urinary tract to obtain a urine specimen) if greater than 250 milliliters for bladder distention for 3 days. An 8/29/2024 Physician #54 progress note documented they were asked to follow up with the resident to assess a urinalysis. Lab data was reviewed with nursing, but a urinalysis result could not be found. They were unsure if the resident's urinalysis was drawn or if they just did not have access to the results. An order was placed to do a urinalysis with microscopy with a reflex for culture. The 8/29/2024 physician order documented urinalysis with microscopy (using a microscope) and reflex for culture (checks for bacteria in the urine). There were no nursing notes documenting an order for a urinalysis and culture, or if the resident had a urine sample collected. There were no documented laboratory results for a urinalysis or culture. During an interview on 9/13/2024 at 12:10 PM, Registered Nurse #52 stated if a verbal order was given for a lab, the order should be placed in the computer. The lab sheet was printed and placed with the specimen. The lab order was also placed on the 24-hour report. Lab results were faxed to the unit and the Supervisor was called with abnormal results. During an interview on 9/16/2024 at 12:17 PM, the Assistant Director of Nursing stated urinalysis orders could be entered into the computer by any nurse and placed on report in the electronic medical record software. They did not see that Resident #120's urine was collected for a urinalysis. It was important to follow physician orders. They stated Physician #54 ordered the urinalysis to be collected and it was not completed timely. During an interview on 9/16/2024 at 3:56 PM, the Director of Nursing stated urinalysis orders were faxed to the lab and the urine specimen was collected and sent to be processed. If a urinalysis could not be completed, the licensed practical nurse should have documented the reason why it was not obtained and medical should have been notified. It was important to obtain a urinalysis to follow up on the results; the urinalysis was missed and should have been completed. During an interview on 9/13/2024 at 1:27 PM, Physician #54 stated they had filled in at the facility for three days and wrote Resident #120's order for a urinalysis. When they wrote orders, they also placed them on a calendar for Physician #19 to follow up on. Physician #54 stated they assigned the follow-up back to Physician #19 due to not seeing the results. It was important for a urinalysis to be obtained timely so treatment could be started if there was a urinary tract infection. Nursing should document if a urinalysis could not be obtained and notify medical so new orders could be placed. 10NYCRR 415.12 .

Based on observation, record review, and interviews during the recertification survey conducted 9/9/2024-9/16/2024, 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 1 of 2 residents (Resident #137) reviewed. Specifically, appropriate hand hygiene was not performed by Licensed Practical Nurse #31 during a wound care treatment for Resident #137. Findings include: The facility policy, Dressing-Clean Technique, revised 12/2007, documented a clean dressing technique was used to provide an appropriate and safe environment conducive to wound healing and should be used during all dressing changes unless otherwise specified by the physician, and gloves should be changed, and hands washed after the removal of a soiled dressing. Resident #137 had diagnoses including Parkinson's disease (a progressive neurological disorder) and a local infection of the skin and subcutaneous tissue. The 7/29/2024 Minimum Data Set documented the resident had intact cognition, an unstageable pressure injury, and was taking an antibiotic daily. The Comprehensive Care Pan last reviewed 8/9/2024, documented the resident had a skin integrity problem related to a sacral ulcer wound, left heel and right heel deep tissue injury (a maroon/purple area of intact skin due to underlying damage). Interventions included administer treatment as ordered. The resident was at risk for infection related to a wound infection on 7/31/2024. Interventions included treatment per physician order and observe for signs and symptoms of infection. The 7/30/2024 physician order documented sacral wound to be cleansed with half strength Dakin's solution (use to prevent and treat skin and tissue infections), apply skin prep (a skin protectant) around perimeter of wound, apply fluffed Dakin's (antiseptic) soaked gauze to wound base, do not pack, cover with foam 6 x 6 dressing daily and as needed if soiled or dislodged. The 9/2/2024 physician order documented Tetracycline HCl Oral Capsule (an antibiotic) four times a day for 10 Days for wound infection. During a wound care observation on 9/12/2024 at 2:24 PM, Licensed Practical Nurse #31 removed a soiled dressing from the resident's sacral wound, moistened clean gauze with Dakin's solution, cleansed the wound, moistened more gauze with Dakin's, and applied gauze to the wound bed. Licensed Practical Nurse #31 did not change gloves or perform hand hygiene after removing the soiled dressing and before applying a clean dressing. Licensed Practical Nurse #31's personnel file documented they completed Hand Hygiene Competency Test on 8/18/2023 and on 8/31/2024 participated in the Infection Control Clinic. During an interview on 9/12/24 at 2:46 PM, Licensed Practical Nurse #31 stated hand hygiene should be done before and after entering a room and in between glove changes. During a dressing change, gloves should be changed after removing the old dressing and after cleansing the wound. Their gloves were potentially soiled if they touched a dirty dressing and if they touched clean dressing supplies with those same gloves. The dirty gloves could contaminate the clean dressing supplies. If the clean supplies touched the wound, it could contaminate the wound and cause an infection which could cause the wound to get worse. The resident had a history of wound infection and was currently being treated for an infection. During an interview on 9/16/2024 at 1:24 PM, Licensed Practical Nurse Unit Manager #1 stated hands should be washed and clean gloves applied before and after removing an old dressing, after cleansing the wound, and after applying a new dressing. If clean gloves touched something dirty, they should discard those gloves, wash their hands, and apply new gloves. If gloves were dirty and the nurse touched clean supplies those supplies would be contaminated and they would have to start the wound care all over again. This caused a risk for infection. Resident #137 currently had an infection to the sacral wound and had a history of wound infections. During an interview on 9/16/2024 at 5:03 PM, the Director of Nursing stated during wound care hand hygiene should be performed and clean gloves applied before starting wound care. After removal of soiled dressing gloves should be removed, hand hygiene performed, and new gloves applied before cleansing the wound and applying a new dressing. At completion of wound care, hand hygiene should be performed after removing gloves. Resident #137 currently had a Stage 4 (full thickness tissue loss with exposed muscle, tendon, or bone) pressure ulcer on their sacrum and was currently on Tetracycline (antibiotic) for infection of that pressure ulcer. 10NYCRR 415.19(b)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 9/9/2024-9/16/2024, the facility did not ensure they were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized work area for 1 of 1 resident (Resident #90) reviewed. Specifically, Resident #90's call bell did not function as designed and they did not have the means of directly contacting caregivers. Findings include: The facility policy Call Lights, revised 10/24/2022, documented all residents would be provided with a method to communicate requests and needs, directly to staff or a centralized work area from the bedside, bathing, and bathroom areas through audible signals, visible signals, or electric/wireless systems. The facility would have a process to routinely ensure the call system for residents was operational. If a call light was defective, staff would report immediately to maintenance and the charge nurse. Staff would provide the resident with an alternate means of calling for assistance. Resident #90 had diagnoses including dementia and cerebral infarction (stroke). The 7/12/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, was dependent with bed mobility and transfers, required partial/moderate assistance with personal hygiene, and had no functional limitation in their range of motion in their upper or lower body. The Comprehensive Care Plan revised 5/3/2024 documented the resident was at risk for falls related to cognition, elimination, and mobility. Interventions included keeping items on the nightstand or within reach. There was no documentation to keep the call bell within reach. During an observation and interview on 9/9/2024 at 12:05 PM, Resident #90 was lying in bed with their call bell draped over their lap. The resident attempted to use their call bell and stated they wanted their legs moved but their call bell did not work. The call bell did not activate when pushed. The resident stated they would just yell out until staff heard them when they needed something. During an observation on 9/9/2024 at 12:28 PM, Resident #90 was calling out for a nurse. Certified Nurse Aide #25 entered the resident's room. At 12:30 PM Certified Nurse Aide #25 exited Resident #90's room and told Licensed Practical Nurse #26 the resident's call bell was not working and Licensed Practical Nurse #26 stated they would contact maintenance. During an observation and interview on 9/10/2024 at 9:25 AM, Resident #90 was lying in bed with their call bell clipped to the right side of the bed. They stated their call bell was still broken and staff was too busy to fix it. The call bell did not activate the alarm or light when pushed. During an interview on 9/13/2024 at 9:26 AM, Certified Nurse Aide #25 stated they cared for Resident #90 on 9/10/2024 during the day shift and they were not aware their call bell was not working. They stated they would have notified the nurse and the maintenance department. They were not familiar with work orders, and they did not know how to complete them. They stated it was important for the resident to have a working call bell for safety reasons. During an interview on 9/13/2024 at 9:45 AM, Licensed Practical Nurse #26 stated Resident #90 was on their assignment on 9/9/2024 and 9/10/2024. They could not recall if they were made aware Resident #90's call bell was not working. If they were made aware, they would have contacted maintenance. They did not know how to use the work order system so they would call maintenance when they needed them. They stated it was important for the resident to have a working call bell so they could notify staff when they needed assistance. During an interview on 9/13/2024 at 10:35 AM, Registered Nurse Supervisor #27 stated they were covering unit 3 all week and they were not aware Resident #90's call bell was not working. They stated they should have been made aware because they had extra call bells they could have tried, or they would have provided the resident with a tap bell until it was fixed. They stated it was important for the resident to always have a working call bell so they could communicate with staff and for their safety. During an interview on 9/13/2024 at 1:02 PM, Certified Nurse Aide #28 stated they were aware Resident #90's call bell was not working on the morning of 9/9/2024. They notified Licensed Practical Nurse #26 and they attempted to call maintenance multiple times, but they could not get in contact with maintenance. They stated they notified the Director of Nursing the call bell was not working at the end of their day shift. They had never completed a work order were unsure how to do it. They stated it was important for the resident and all residents to have a working call bell for their safety. During an interview on 9/13/2024 at 1:20 PM, Plant Operation Director #29 stated they were notified of a broken call bell in room [ROOM NUMBER] earlier that week. They received a work order on 9/9/2024 at 2:00 PM but they were not able to get to it until the morning of 9/10/2024. They stated they preferred work orders instead of staff members calling them so they could keep track of the issues and when they were addressed. 10 NYCRR 415.29

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00314894 and NY99331169) conducted 09/9/2024-9/16/2024, the facility did not provide a safe, clean, comfortable, and homelike environment for 4 of 4 resident areas (Main Lobby, Second floor resident room [ROOM NUMBER]A, Third floor nursing station, and Third floor day room area) reviewed; and for 2 of 2 oxygen storage rooms (Third and Fourth floor oxygen storage rooms) reviewed. Specifically, there were multiple walls with peeling wallpaper and unclean floors with dust and food debris. Additionally, Resident #36's right wheelchair brake was broken and not repaired timely. Findings include: The facility policy, Daily Cleaning, dated 6/1/2000, documented the facility was cleaned daily and would be always kept clean; VCT (vinyl composition tile) flooring was dust mopped and then wet mopped with the specified cleaner; walls and doors were spot washed with a disinfectant cleaner when soiled; and all repair work must be logged in the maintenance logbook. The facility policy, Maintenance Electronic Work Order System, revised 12/2008, documented the facility would use an electronic work order system to better facilitate maintenance repairs/requests and to further communicate the needs of the residents with the maintenance staff. Designated facility staff would enter requests into the electronic system and maintenance would view them; maintenance would only sign off on requests when they had been addressed. The facility policy, Medical Equipment Management Plan, revised 7/2017 documented the goal of the facilities medical equipment management plan was to minimize the clinical and physical risks of equipment through inspection, testing, and regular maintenance and to provide education to personnel and the procedures to follow when reporting equipment problems, failures, and user errors; and the skills and/or information to perform maintenance activities. UNCLEAN, UNHOMELIKE ENVIRONMENT The following observations were made on 9/9/2024: - at 9:15 AM, the Main Lobby/receptionist area had peeling wallpaper. - at 10:36 AM, the housekeeping closet across from resident room [ROOM NUMBER] had an 8-inch x 3-inch hole in the wall. - at 11:03AM, the Fourth floor oxygen storage room had a thick layer of dust and dried debris on the floor. - at 11:25 AM, the Third floor day room had peeling and curling wallpaper that was falling off the walls. - at 11:27 AM, the floors in resident room [ROOM NUMBER]A were unclean. There were yogurt containers, chocolate candy rolls, and food crumbs under the bed. - at 11:29 AM, the Third floor oxygen storage room had significant dust on the floor. - at 11:46 AM the Second floor nursing station floors were unclean and stained. - at 11:54 AM, the Second floor storage room next to resident room [ROOM NUMBER] had unclean and stained floors. During an interview on 9/12/2024 at 11:37 AM, Certified Nurse Aide #25 stated they thought housekeeping was responsible for cleaning the floors around the nursing station and resident rooms. During an interview on 9/12/2024 at 11:42 AM, Housekeeping Aide #39 stated they were responsible for cleaning half of the unit which included the solarium and the nursing station. Their duties included emptying trash and mopping floors. They stated maintenance was responsible for cleaning the oxygen storage closets and if floors were heavily stained Housekeeping Supervisor #47 would take care of them. During an interview on 9/12/2024 at 11:50 PM, Unit Secretary #50 stated the floors under the Second floor nursing station were not clean but had been mopped. They were unsure how long the floor had been unclean. During an interview on 9/13/2024 at 1:23 PM, Certified Nurse Aide #34 stated when areas or objects on the unit were damaged or broken, they asked Unit Secretary #50 to place a work order. They did not put work orders in themselves. They stated the resident rooms should be clean and home-like. During an interview on 9/13/2024 at 1:25 PM, Certified Nurse Aide #46 stated the wallpaper in the Third floor dayroom had been peeling for a while. It was not a clean and home-like environment, and they would not want their house to be in the same condition. During an interview on 9/16/2024 at 2:23 PM, Housekeeping Supervisor #47 stated floors were cleaned twice daily. They had problems with removing the black stains from the nursing station floors and agreed they were unclean. They had been stripping and waxing floors but fell behind in schedule. If an area or object needed repairs, staff would notify them, and they would put a work order in. They were unsure who was responsible for cleaning the oxygen storage room closets due to limited staff having keys. They had a key, but housekeeping staff did not. UNSAFE BROKEN RESIDENT EQUIPMENT Resident #36 had diagnoses including Alzheimer's disease. The 8/9/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, had upper extremity impairment on one side, used a wheelchair, and required supervision/touching assistance with transfers. During an observation and interview on 9/9/2024 at 2:15 PM and 9/11/24 at 11:43 AM, Resident #36 was in their room with their wheelchair on the right side of their bed. They attempted to lock the right wheel on their wheelchair, but it would not lock. They stated their right wheelchair brake had been broken for a few weeks. They had notified staff multiple times and were still waiting for maintenance to fix it. During an interview on 9/13/2024 at 9:30 AM, Certified Nurse Aide #25 stated Resident #36's right wheelchair brake was broken. They thought it had not worked for a few weeks. They did not notify the nurse or maintenance because they thought they were already aware it did not work. During an interview on 9/13/2024 at 9:50 AM, Licensed Practical Nurse #26 stated Resident #36 was alert and oriented, able to make their needs known and they used their wheelchair to get around the unit. They stated they were not aware their wheelchair did not lock, or they would have notified maintenance. During an interview on 9/13/2024 at 10:39 AM, Registered Nurse Supervisor #27 stated they were not aware of Resident #36's right wheelchair brake not locking. They expected staff to notify them so they could have provided the resident with another wheelchair until it was fixed. During interviews on 9/13/2024 at 1:20 PM and at 3:26 PM, Plant Operations Manager #29 stated housekeeping and certified nurse aides were responsible for cleaning the utility rooms. They thought housekeeping cleaned the oxygen storage room, Housekeeping Supervisor #47 had a key, but the housekeepers did not. They were not aware of Resident #36's broken wheelchair brake until they received a work order on 9/11/2024 at 2:47 PM. 10 NYCRR 415.29(j)(1)

Based on record review and interview during the recertification and abbreviated (NY00350839 and NY00331169) surveys conducted 9/9/2024-9/16/2024, the facility did not ensure maintenance of acceptable parameters of nutritional status for 3 of 4 residents (Residents #2, #88, and #195) reviewed. Specifically, Residents #2, #88, and #195 developed pressure ulcers and their nutritional needs were not reassessed timely to accommodate increased requirements for wound healing. Findings include: The facility policy, Nutritional Screen/Assessment, revised 5/2017, documented the dietetic technician and registered dietitian were responsible for nutritional screening, assessment, setting of measurable goals and implementing the nutritional plan of care to obtain the resident's optimal nutritional status. The screening included but was not limited to skin intervention as indicated. The resident would be continually assessed, and findings were documented in the dietary progress notes and nutritional care plan. Estimated needs were documented as 30 - 35 calories/ kilograms of body weight for pressure sore healing, 1.2 grams - 1.5 grams of protein for pressure ulcers and 25 milliliters to 30 milliliters of fluid for the elderly. 1) Resident #195 had diagnoses including a hip fracture and chronic kidney disease. The 4/27/2022 admission Minimum Data Set assessment documented the resident had moderately impaired cognition, required supervision with set up help for eating, was at risk of developing pressure ulcers, weighed 168 pounds, had no unhealed pressure ulcers, and had moisture associated skin damage (skin impairment caused by excessive moisture). The 4/22/2022 physician order documented a regular diet, mechanical soft (easy to chew) texture, and regular liquid consistency. The 4/26/2022 Registered Dietitian #4 Dietary/Nutritional Screen documented the resident required 1300 calories and 52 grams of protein (0.8 grams of protein per kilogram of body weight) per day. The resident had intact skin with a surgical incision, received a regular consistency diet, and had variable intakes consuming 50-75% of meals, with some 25-75%. The plan was to encourage intake and follow up as needed. The 5/6/2022 at 1:39 PM Licensed Practical Nurse #1 progress note documented the resident had an open area to their buttock and the Assistant Director of Nursing was made aware. The 5/12/2022 at 1:22 AM Registered Nurse Supervisor #3 progress note documented the resident had right buttocks wounds that measured 3.8 centimeters x 1.5 centimeters, and 1.9 centimeters x 1.7 centimeters; and a left buttock wound that measured 1.8 centimeters x 1.5 centimeters (no depth recorded for any of the areas). The areas had bloody drainage, they were cleansed, and a protective dressing was applied. Nursing was to update the primary care provider in the morning. There was no documented evidence the resident's provider was notified of the skin impairments. The 5/16/2022 at 1:25 PM Registered Dietitian #4 progress note documented they were made aware of a wound on the resident's buttocks. The resident was consuming 75-100% meals and intakes were adequate to improve wound status and maintain weight. The plan was to trial Ensure Clear (dietary supplement) at breakfast. There was no documented evidence the resident's nutritional status was reassessed timely when the resident developed multiple wounds 10 days prior, or that the resident's protein and calorie needs were reassessed to accommodate increased needs for wound healing. The Comprehensive Care Plan initiated 4/21/2022 documented the resident was at risk for alterations in nutrition related to impaired skin integrity. Interventions included a regular diet, mechanical soft consistency. On 5/16/2022 supplements on meal trays; Ensure Clear at breakfast was added as an intervention. The 6/7/2022 at 4:27 PM Registered Dietitian #4 progress note documented the resident had no reported skin breakdown and Ensure Clear would be discontinued. There was no documentation in the resident's medical record their skin impairment was healed. The 6/16/2022 at 4:44 PM Registered Nurse Unit Manager #6 progress note documented the resident had an unstageable (type of pressure ulcer where wound bed was obscured by non-viable tissue) pressure ulcer on their coccyx (tailbone) that was 6 centimeters x 3 centimeters x 1.5 centimeters with 0.3 centimeters of undermining (wound edges separate from surrounding healthy tissue creating a pocket). Slough (tan/grey non-viable tissue) was noted with moderate serosanguinous (combination of blood and serum, the clear part of blood) and odor (possible indication of infection). A wound care consult was ordered. The 6/16/2022 Nurse Practitioner #7 progress note documented nursing staff had concerns of a sacral wound which was not present during the last routine examination. The resident reported pain at the wound site requiring oral narcotics. The wound was assessed as a large unstageable sacral ulcer with odor and sloughing eschar (brown/black non-viable tissue). Wound care orders were in place and an immediate referral to outpatient wound care was recommended. The 6/23/2022 outside Wound Care Nurse Practitioner #9 progress note documented the resident had a Stage 4 pressure ulcer with moderate serosanguinous drainage measuring 8 centimeters x 8 centimeters x 1.8 centimeters with undermining between 8 to10 o'clock that was 0.9 centimeters. The wound was mostly covered in eschar and slough which was debrided (removal of dead tissue using a scalpel). The 6/24/2022 at 11:23 AM Registered Dietitian #4 progress note documented they were made aware the resident had impaired skin and their intakes were fair at 25-75%. Promod (high protein supplement) was recommended twice daily to promote wound healing. There was no documented evidence the resident's protein and calorie needs were reassessed to accommodate increased needs for wound healing and to ensure the resident's provided food and fluids met their nutritional needs. The 7/1/2022 outside Wound Care Nurse Practitioner #9 progress note documented the resident's Stage 4 pressure ulcer was 8 centimeters x 7.8 centimeters x 1.8 centimeters and the wound continued to make minimal progress. The 7/6/2024 at 10:24 PM Registered Dietitian #4 progress note documented the Interdisciplinary Team met to discuss the resident. The resident received a regular consistency diet, consumed 50% of meals, and received a protein supplement. There was no documented evidence the resident's protein and calorie needs were reassessed to accommodate increased needs for wound healing. The 7/7/2022 at 5:26 PM Registered Nurse #10 note documented the resident was sent to the hospital from their wound care appointment. The 7/13/22 hospital discharge summary documented the resident was treated by an outside wound consultant and at their 7/7/2022 wound appointment, the resident's wound was noted with odor and drainage and sent to the hospital. At the hospital, the resident was found with a large infected sacral ulcer with foul odor, exposed bone and surrounding necrotic (dead) tissue. Debridement was done by surgery and a wound vacuum assisted closure device was applied. During an interview on 8/23/2024 at 10:22 AM and on 9/6/2024 at 10:09 AM, Registered Dietitian #4 stated they were notified of resident skin issues during morning report however, they could not recall if this was the process when Resident #1 was admitted . When a resident's wound healed, they were also notified in morning report. They stated they should assess nutritional needs within 5 days after a skin impairment was found. A resident's nutritional needs changed when they had a wound and protein needs needed to be increased because protein helped with wound healing. When the resident initially developed a skin impairment, their nutritional needs would have changed from their initial assessment on 4/26/2022. On 6/7/2022, they did not recall how they became aware the resident's wound had healed when they discontinued Ensure and was not aware the wound treatment continued. When the resident developed a Stage 4 pressure ulcer, their needs would have changed again, and they would have increased nutritional needs. The resident should have been reassessed when the wound worsened. The resident was consuming 25-100% of meal and that could be inadequate calories and protein to promote wound healing. During an interview on 9/4/2024 at 8:20 AM, the Director of Nursing stated pressure ulcers, skin with moisture issues, and skin tears were tracked weekly because they could see changes to skin from week to week and keep dietary and therapy involved with changes. The registered dietitian should be involved with wounds and either the Nurse Manager or Wound Nurse was responsible for notifying them. They expected the registered dietitian to be notified within 24 hours during the week. If the registered dietitian made a recommendation, the physician determined if it would be implemented, and it required an order. Once the order was obtained, it should be implemented as soon as nursing confirmed the order. During a telephone interview on 9/9/2024 at 8:28 AM, the facility's current Medical Director stated it was important for the registered dietitian to be involved with wounds and residents were typically put on some sort of liquid protein to assist with wound healing. They expected the registered dietitian to reassess resident nutritional needs when a wound was found or worsened. If a resident did not receive adequate nutritional intake, it could potentially contribute to wounds worsening. 2) Resident #88 had diagnoses including Alzheimer's disease, depression, and age-related physical debility. The 7/24/2024 Minimum Data Set assessment (a health screen tool) documented the resident had severely impaired cognition, weighed 120 pound, had no significant weight changes, received a mechanically altered diet, and had 1 Stage 3 pressure ulcer (full thickness tissue loss) that was not present on admission. The Comprehensive Care Plan initiated 12/9/2022 documented the resident was at risk for skin injury related to advanced age, frail skin. The revised 5/10/2024 care plan documented a pressure ulcer on left plantar 9bottom) foot. Interventions included administer treatments as ordered. The Comprehensive Care Plan initiated 12/9/2022 documented the resident was at risk for alteration in nutrition related to depression, hypertension, and difficulty swallowing. Interventions included set up for meals with intermittent verbal cues. On 4/17/2024 interventions were updated to include Ensure Plus (a nutritional supplement) at all meals and fortified pudding at dinner. The 7/22/24 Quarterly Nutrition Review completed by Registered Dietitian #3 documented the resident received a ground consistency house diet, received Ensure Plus three times daily, an extra sandwich at lunch, and fortified pudding once daily at dinner. The resident weighed 119.3 pounds (54 kilograms), their body mass index was 23.3 (healthy), and had not had significant weight changes in the past six months. The resident had a Stage 3 pressure ulcer on their left foot. Their estimated daily nutritional needs were 1200 calories (22 calories/ kilogram of body weight), 69 grams protein (1.3 grams of protein per kilogram of body weight), and 1330 milliliters (25 milliliters per kilogram of body weight). The 8/13/2024 Wound Care Nurse Practitioner #42 progress note documented the resident was seen for follow up for their Stage 3 left foot pressure ulcer. The resident had poor oral intakes. The wound was worsening, it measured 1 centimeter x 0.9 centimeters x 0.6 centimeters, had undermining (erosion under the wound edges) from 1 o'clock to 1 o'clock, and the wound had heavy amounts of serosanguineous (a mix of blood and serum) exudate (drainage). Recommendations included a nutritional consult for the presence of the wound, with moderate to high risk for complications and to re-evaluate current supplementations. There was no documented evidence a nutrition consult was completed for the resident. The 8/21/2024 physician order documented the resident was to receive 100 milligrams of Doxycycline (antibiotic) twice daily for day 10 days for a wound infection. The 8/27/2024 Registered Dietitian #3 progress note documented the resident continued with a Stage 3 pressure ulcer to their left foot. They had recently started on antibiotics and fluids were to be encouraged. The resident weighed 114 pounds, had no significant weight changes, and their oral intakes were variable. Their estimated fluids needs were 1785 milliliters of fluids (35 milliliters of fluid per kilogram). The resident continued to receive whole milk at all meals, an additional sandwich at lunch, fortified pudding, and Ensure Plus at all meals. A Magic Cup (nutrition supplement) would be added at lunch and fortified pudding would be provided at the dinner meal instead of the lunch meal. During an interview on 9/13/2024 at 8:17 AM, Wound Care Nurse Practitioner #42 stated wound rounds were done weekly with the Assistant Director of Nursing and the registered dietitian did not round with them. The facility let them know which residents needed to be seen. They communicated their recommendations to the Assistant Director of Nursing who passed the recommendations on to the Interdisciplinary Team. They stated nutrition played a role in wound healing. Resident #88 has a Stage 3 pressure ulcer on their left foot. They had recommended a nutritional consult as the resident's wound had worsened and they were at high risk. They expected the registered dietitian to make them aware of any nutritional recommendations to follow up on. They were unaware a nutrition consult was not done. During an interview on 9/16/2024 at 11:39 AM Registered Dietitian #3 stated they used to go on wound rounds but did not go anymore. The Assistant Director of Nursing sent out a weekly wound sheet that documented the residents who had wounds, the stage of the wounds, and any recommendations the wound care physician had. They had 2 weeks to follow up with recommendations. Nutrition played an important role in wound healing. Residents who had wounds had increased nutrient needs, which included calories and protein. They stated Resident #88 had a Stage 3 pressure ulcer on their left foot. They had last assessed the resident's nutritional needs on 7/22/2024 at the lower end of their needs for protein and calories. They were unsure if they were made aware of the recommendation for a nutrition consult on 8/13/2024. They reassessed the resident's fluid needs on 8/27/2024 and added a magic cup when they were receiving antibiotic for an infected wound. They stated they did not follow up timely. During an interview on 9/16/2024 at 12:17 PM, the Assistant Director of Nursing stated wound rounds were completed weekly at the facility. The Wound Care Nurse Practitioner and the Director of Therapy attended wound rounds and the registered dietitian sometimes did. They documented the wound care physician's recommendations and sent them out to the interdisciplinary team. The registered dietitian should be reviewing the wound notes and following up on recommendations as nutrition played a role in wound healing. They stated Resident #88 had a Stage 3 pressure ulcer on their left foot and received antibiotics due to the wound becoming infected. They were unsure what the nutrition protocols were for wound healing. 3) Resident #2 had diagnoses including diabetes, Alzheimer's disease, and obesity. The 6/12/2024 Minimum Data Set assessment (health screening tool) documented the resident had severely impaired cognition, did not reject care, weighed 179 pounds, had no significant weight loss, and was at risk for pressure ulcers. The comprehensive care plan initiated 3/1/2022 and revised 3/22/2024 documented the resident was at risk for alteration in nutritional status related to diabetes and weight loss. Interventions included a sugar free diet, 4-ounce Health Shake (oral nutrition supplement) at all meals, and Magic Cup (nutrition supplement) at lunch and dinner. The 6/10/2024 Quarterly Nutrition Review by Registered Dietitian #4 documented the resident received a sugar restricted diet, 4-ounce Health Shake at all meals, weighed 179 pounds, had no known significant weight changes, and their skin was intact. Their estimated daily nutritional needs were based on 146 pounds (66 kilograms). Estimated calories were 1730 calories (26 calories per kilograms of body weight), 68 grams of protein (1 gram of protein per kilograms of body weight), and 1700 milliliters of fluids (25 milliliters per kilograms of body weight). A 7/30/2024 Licensed Practical Nurse #37 progress note documented a certified nurse aide made them aware the resident had an open area on their right buttocks. They notified the Wound Nurse, and the resident was seen by the Wound Care physician. New orders were obtained for treatment and the family was notified. New orders included to cleanse areas with wound wash, apply Medihoney (medicinal honey used for wound treatment) to wound base and cover with boarder dressing, change daily and as needed. A 7/30/2024 Wound Care Nurse Practitioner #42 progress note documented the resident was seen for a new skin and wound consult. The resident had a Stage 3 (full thickness tissue loss) wound measuring 1.2 centimeters x 1.5 centimeters x 0.2 centimeters. The treatment plan included cleanse area with wound cleanser, apply medical grade honey to the base of the wound, secure with border foam and change daily, and increase protein intake. There was no documented evidence the resident's protein needs were reassessed prior to the wound resolving on 8/13/2024. During an interview on 9/13/2024 at 8:17 AM Wound Care Nurse Practitioner #42 stated wound rounds were done weekly with the Assistant Director of Nursing and the registered dietitian did not round with them. The facility let them know which residents needed to be seen. They communicated their recommendations to the Assistant Director of Nursing who passed the recommendations on to the Interdisciplinary Team. They stated nutrition played a role in wound healing and they expected the registered dietitian to be made aware of any nutritional recommendations and to follow up. During an interview on 9/16/2024 at 11:39 AM Registered Dietitian #3 stated they used to go on wound rounds but did not go anymore. The Assistant Director of Nursing sent out a wound sheet weekly that documented the residents who had wounds, the stage of the wounds, and any recommendations the wound care physician had. They had 2 weeks to follow up with recommendations. Nutrition played an important role in wound healing. Residents who had wounds had increased nutrient needs, which included calories and protein. They stated Resident #2 had a Stage 3 pressure ulcer on their sacrum that was identified on 7/30/2024. They did not reassess the resident's needs when the wound was identified and did not follow up on the wound care physician's recommendations as it was an oversight. They did not see the resident again until 8/19/2024. During an interview on 9/16/2024 at 12:17 PM the Assistant Director of Nursing stated wound rounds were completed weekly at the facility. The Wound Care Nurse Practitioner and the Director of Therapy attended wound rounds and the registered dietitian sometimes did. They documented the Wound Care physician's recommendations and sent them out to the Interdisciplinary Team. The registered dietitian should review the wound notes and following up on recommendations as nutrition played a role in wound healing. 10 NYCRR 415.12(c)(2)

Based on observation, record review, and interview during the recertification survey conducted 9/9/2024-9/16/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and include the expiration date when applicable for 3 of 3 medication carts (Second floor short hall, Second floor long hall, and Third floor long hall) reviewed. Specifically, - the Second floor short hall medication cart contained 49 loose, unidentified pills; eye drops for Resident #446 without an opened or expired/discard date; inhalers for Residents #127, #118 and #47 without an opened or expired/discard date; and an inhaler without any resident identifiers. - the third-floor long hall medication cart had one loose pill; 2 opened medicated pain patches and a vial of nitroglycerin (treats chest pain) tablets without resident identifiers; an insulin (treats blood sugar) pen for Resident #14, eye drops for Resident #33, and inhalers for Residents #63, #18, and #16 that did not have opened or expired/discard dates. Findings include: The facility policy, Vials, effective 10/2004 documented multi-dose vials were dated and initialed when they were opened. The vials were discarded when they were empty or when the manufacturer's expiration date was reached, but not to exceed 28 days. All drugs were checked prior to use and ensured outdated drugs were not used. Multi-dose vials that were not dated when opened were disposed of 28 days after the date dispensed by the pharmacy. This was a quality control fail safe. The facility policy, Inhalers, revised 3/2011 documented inhalers were stored (labeled) in the medication cart and discarded when empty or expired. The expiration date was checked prior to administration. The facility policy, Medication/ Treatment Labeling and Storage, revised 7/2013 documented the facility maintained proper labels for medications and proper storing instructions. Medications without labels were returned to the pharmacy for destruction, all medications were stored in their original containers. Medication carts were kept clean, organized, restocked, and fully equipped. SECOND FLOOR SHORT HALL MEDICATION CART: During an observation of the Second floor short hall medication cart with Registered Nurse #36 on 9/10/2024 at 3:14 PM there were Lumigan (treats eye pressure) 0.01% eye drops without and opened or expiration/ discard date for Resident #446; a Budesonide-Formoterol 80-4.5 microgram/ actuation inhaler, an albuterol sulfate (treats difficulty breathing) 90 microgram/ actuation inhaler with a pharmacy dispensed date of 7/22/2024 without an opened or expired/ discard dates for Resident #127; an albuterol sulfate 90 microgram/ actuation inhaler with a pharmacy dispensed date of 7/29/2024 without an opened or expired/ discard dates for Resident #118; and an albuterol sulfate 90 microgram/ actuation inhaler with a pharmacy dispensed date of 7/22/2024 without an opened or expired/discard dates for Resident #47. There were 49 loose, unidentified pills scattered in the medication drawer, and a Dulera (treats asthma) inhaler that did not have a resident identifier. Registered Nurse #36 stated any multi-dose medication should be dated as opened. If there was a medication that was not dated it should be discarded because it may not be good. It was important to know if medications were expired. Expired medications may not be as effective or overly effective. If Resident #446 was receiving expired eye drops their glaucoma (eye disease causing eye pressure and blindness) could progress. They were not sure of the policy on dating inhalers as opened but thought inhalers should be labeled as opened for the same reasons as the eye drops. During an interview on 9/10/2024 at 4:14 PM Licensed Practical Nurse #37 stated if a medication was not dated, they would not use it. An opened date on medications was important to know if the medication was expired. There could be a reaction if expired medications were given. THIRD FLOOR LONG HALL MEDICATION CART: During an observation of the Third floor long hall medication cart on 9/10/2024 at 4:00 PM with Licensed Practical Nurse #31, there was an opened vial of nitroglycerin tablets, an opened box 1% lidocaine (treats pain) patches, an opened box of 5% menthol patches (treats pain) with no resident identifiers; an opened multi-dose Lantus (long-acting) insulin pen for Resident #14 with a pharmacy dispensed date of 7/4/2024 without an opened or expired/ discard date; refresh liquid eye gel and eye drops for Resident #33 without an opened or expired/discard date; one loose round white pill labeled with AZ 011 in the third drawer of the medication cart; an opened fluticasone-vilanterol (treats breathing problems) 100-25 microgram/ actuation inhaler dispensed from the hospital with a due date of 4/1/2024 for Resident #63; a budesonide-formoterol (treats breathing problems) 160-4.5 microgram/ actuation inhaler with no opened or expired/ discard date for Resident #18; and an opened Combivent (treats breathing problems) 20-100 microgram/ actuation inhaler with no opened or expired/ discard date for Resident #16. Licensed Practical Nurse #31 stated without an opened date they would not know if the medication was expired, and all medications should have resident identifiers to ensure they were administered to the correct resident. If the resident's received expired medications, they may not be as effective or there could be negative effects. The opened/ expired date should be checked on all medications prior to administration. If they had medications that were not dated as opened, they should discard them, and a replacement would be ordered. Insulin was good for 30 days and they were not sure about eye drops or inhalers but went by the 30-day rule for expiration of medications. During an interview on 9/11/2024 at 1:28 PM Licensed Practical Nurse #24 stated expired medications might not be as effective or work as intended. They had administered the medications yesterday without opened or expired/ discard dates. They should have looked for the expiration dates and should have thrown away the undated medications and ordered new ones. During an interview on 9/16/2024 at 1:37 PM, the Assistant Director of Nursing stated medications should be dated when opened. The opened date was used to determine the expiration date. Without an opened date, it would not be known if the medication was still good. Residents should not receive expired medications. Staff should check the opened and/or expired date prior to administering a medication. If a medication was expired, it should be thrown away and the pharmacy should be called for a replacement. The pharmacy delivered twice daily during the week and once daily on the weekends. 10NYCRR 415.18(d)

Based on observation and interview during the recertification and abbreviated (NY00336546) surveys conducted 9/9/2024-9/16/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 1 of 2 meals (the 9/10/2024 dinner meal) reviewed and for 4 of 4 residents (Residents #15, #93, and #112). Specifically, food was not served at palatable and appetizing temperatures during the dinner meal on 9/10/2024. Additionally, Residents #15, #93, and #112 stated the food was served cold, and Resident #36 stated the food was not palatable and was served cold. Findings include: The facility policy, Food Preparation, Service and Distribution, revised 10/2022, documented: - Holding foods in the tray line or alternate meal preparation and service areas may include steam tables, where hot foods were held and served, and chilled areas where cold foods were held and served, would not hold foods in the danger zone (temperatures above 41 degrees Fahrenheit and less than 135 degrees Fahrenheit). - Dining locations included any area where one or more residents ate their meals. These included dining rooms or mobile food carts that maintained food in proper temperature and out of the danger zone. - Hot foods should be served hot and cold foods should be cold in accordance with resident preference. During an interview on 9/9/2024 at 11:27 AM, Resident #93 stated they usually ate their meals in their room and by the time it was served, the food was usually cold. During an interview on 9/9/2024 at 1:58 PM, Resident #15 stated meals were served cold and there was no microwave to reheat the food on the unit. During an interview on 9/9/2024 at 2:14 PM, Resident #36 stated the food did not taste good, did not look appealing, and was served cold. During an interview on 9/10/2024 at 9:19 AM, Resident #112 stated meals were often late and served cold. During a dinner meal observation on 9/10/2024 at 6:17 PM, Resident #71 was served their dinner meal tray. A replacement tray was ordered, and Resident #71's original tray was tested. The hamburger was measured at 118.4 degrees Fahrenheit, the noodles were 116.8 degrees Fahrenheit, the peanut butter and jelly sandwich was 46.2 degrees Fahrenheit, the applesauce was 67.5 degrees Fahrenheit, the coffee was 133.9 degrees Fahrenheit, and the water was 52.2 degrees Fahrenheit. During an interview on 9/10/2024 at 6:19 PM, Certified Nurse Aide #30 stated if meals were not served at appropriate temperatures the food could grow bacteria and if ingested by the residents, they could get sick. They took a food safety course, and the hot food was supposed to be over 140 degrees Fahrenheit, and the cold food was supposed to be under 45 degrees Fahrenheit. They stated all the food/drink items on Resident #71's meal tray were not at appropriate temperatures. During an interview on 9/11/2024 at 1:05 PM, Food Service Director #40 stated they completed test trays two or three times a week along with the registered dietitian. They would send an extra tray to the unit, take the food temperatures, and taste the food to ensure quality. They stated they wanted hot food items over 135 degrees Fahrenheit, cold food items less than 55 degrees Fahrenheit, and milk less than 45 degrees Fahrenheit. Hot food items that measured between 116 degrees Fahrenheit and 118 degrees Fahrenheit was not appropriate, and applesauce should have been served cold and measured less than 67 degrees Fahrenheit. During an interview on 9/16/2024 at 11:16 AM, Registered Dietitian #4 stated they completed test trays once or twice a week throughout the facility. They tested the food temperature after it was cooked and would test it again when it was on the unit. They stated breakfast was hard because of the scrambled eggs and most of the residents' complaints were that breakfast was served cold. They would offer alternates if they received complaints. They stated it was important for food to be palatable and served at appropriate temperatures or the residents might not eat as much. They stated there was danger for food borne illness if temperatures were not in range, but they were unsure of specific temperatures. Their expectation was for all residents to have palatable foods. 10NYCRR 415.14(d)(1)(2)

Based on observation, record review, and interviews during the recertification survey conducted 9/9/2024- 9/16/2024, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service in the facility's main kitchen and Third floor kitchenette. Specifically, in the main kitchen, there was debris on the floors and counters, unclean areas, a drain back up, gloves were not used properly, and food was not cooled properly. The Third floor kitchenette was unclean. Findings included: The facility policy, Grease Traps, revised 12/2006, documented the facilities safety elements of the environment were maintained, tested, inspected, and included checking the grease traps monthly. Staff should maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. The facility policy, General Kitchen Cleaning, revised 6/1/2023, documented staff shall maintain sanitation of the kitchen through compliance with a written comprehensive cleaning schedule. The facility policy, Food Cooling Temperature Log, effective 7/2008, documented staff would ensure the proper temperatures for chilling of foods to eliminate food borne illness. All potentially hazardous foods were cooled from 135 degrees Fahrenheit to 41 degrees Fahrenheit within six hours or less. The following observations were made in the main kitchen on 9/9/2024: - at 9:42 AM, the dry storage area had debris on the floor and under the shelving. - at 9:46 AM, there was food debris under and around the cookline equipment. - at 9:48 AM, the 2 bay sink at the end of the cookline was leaking from the right-side faucet, there was grime build up on the plumbing, and a bus pan was full of moldy stagnant liquid beneath the sink plumbing. There were numerous ant bait stations, glue traps, and steel box traps for pests throughout the kitchen. - at 9:57 AM, the cooler was labeled out of order and handwritten next to the out of order sign was for two years and counting. The cooler had food spills and debris inside. - at 10:00 AM, the walk-in freezer had food debris on the floors and under the shelving, there was ice piling up beside the door. - at 10:01 AM, there was a yellow dried puddle under shelving of the walk-in cooler. - at 10:07 AM, there was a significant amount of food debris on the floor under the ice machine and around the floor drain. There was debris where water had backed up from the floor drain by the back door. The following observations were made in Third floor kitchenette on 9/9/24: - at 9:37 AM, there were sugar packets scattered on the floor. - at 9:39 AM, the right side of the warmer was not clean. - at 9:41 AM, a dirty black plastic bin under the sink was full of water with a white/grey film on the surface of the water. - at 9:45 AM, the faucet of the large sink basin was leaking behind the cold water handle. - at 9:49 AM, the stainless-steel shelving in the middle island had dried food debris on the bottom shelf. - at 9:56 AM, the walk-in freezer had food debris on the floor and ice buildup on the door. - at 10:00 AM, there was food debris behind the ice machine - at 10:02 AM, the eye wash station was unclean with food debris. - at 10:04 AM, the paper towel dispenser had a dried white/gray substance covering it. The following observations were made in the main kitchen on 9/10/24: - at 10:10 AM, there was debris and grease staining under and around the cook line equipment and tables. - at 10:10 AM, there was a dirty bus pan. - at 10:11 AM, there was debris and drain back up by the back door, ice machine, and around the mop sink area. Dish racks were stacked and stored on the floor by the ice machine. - at 10:27 AM, the out of order cooler had debris and food spills. - at 10:28 AM, the kitchen floors were unclean and had a tacky/sticky built up layer of grease and grime. - at 10:39 AM, the walk-in freezer had several cases of food stored directly on the floor. There was food debris and excessive icing on the floor. During an observation on 9/10/2024 at 10:09 AM and 10:19 AM, the third-floor kitchenette area ice machine was dirty, and the floors were sticky. During an observation in the main kitchen on 9/11/2024 at 12:11 PM, there was food debris under the refrigerator at the end of the cook line, and at 12:12 PM the floor around the ice machine and back door had a significant amount of food debris and drain backup strewn around the ice machine and leading to the back door. During an observation in the main kitchen on 9/11/24 at 1:18 PM, there was a six-inch square pan wrapped in plastic wrap labeled grilled cheese PR (pureed) 9/11 just inside the walk-in cooler door on a middle shelf. The pureed grilled cheese temperature was measured at 104 degrees Fahrenheit. At 1:43 PM, the pan and contents measured at 98 degrees Fahrenheit. At 1:47 PM, Food Service Director #40 placed the pureed grilled cheese in the walk-in freezer and uncovered the product. During an interview on 9/11/24 at 1:51 PM, [NAME] #55 stated when they made food items like pureed grilled cheese, they put it in the freezer. They had also made a cold three bean salad and put that in the walk-in cooler by accident. They stated the pureed grilled cheese was made about an hour or two prior to the observation. They normally documented only when they checked the temperatures for food items like turkey. They stated the cooling requirement when meat was put in the oven to be used the next day, it must be cooled down within 2 hours, or 4 hours after that. [NAME] #55 referred to the cooling log sheet for guidance and stated the temperature was required to be around 70 (degrees Fahrenheit) and below after two hours, and 40 (degrees Fahrenheit) and below after another 4 hours. The grilled cheese would not meet the cooling requirement if it was left in the walk-in cooler. They would have to discard the food and start over because it would not meet the cooling requirements. During an interview on 9/12/2024 at 11:42 AM, Housekeeping Aide #39 stated they took out the trash in the Third floor kitchenette, wiped down the tables, and mopped after lunch. They stated they were not trained to wipe down the refrigerator. During an interview on 9/13/2024 at 1:34 PM, the Food Service Director stated they were not sure who cleaned the kitchenettes. They stated the shelf was stained from spilled cranberry juice. The faucet in the main kitchen was leaking for one month. They stated over the weekend they noticed the grease in the bus pan, and they discarded it. The floors in the kitchen were cleaned daily and the floors in the walk-in coolers were cleaned weekly. There was a problem with the floor drain earlier in the week when it got clogged. They were not sure when the water backed up by the ice machine. Food and debris should not be on the floors, under equipment, or in the coolers. It was important to keep the kitchen and kitchenette clean and to cool foods properly for the safety of the residents. 10NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey conducted 7/25/22-8/2/22 the facility failed to determine the clinical appropriateness of self-administration of medications for 1 of 2 residents (Resident #55) reviewed. Specifically, Resident #55 had a bronchodilator inhaler (used to treat asthma) at their bedside, was not assessed to determine their ability to safely self-administer medications and did not have a physician order for self-medication. Findings include: The facility policy Self-Administration of Medications dated 11/23/21 documented: - Self-administration of medications was indicated by the team leader. - Continued approval of the self-administration of medications by the resident was dependent on the resident's compliance with physician orders and facility procedures. The facility policy Medication/Treatment Labeling and Storage revised 7/2013, documented: - Residents' medications/treatments were properly labeled by the pharmacy and when received in the nursing unit, were to be placed in the proper storage area; medication room, supplies in clean utility room, treatment cart or medication cart. Resident #55 had diagnoses including asthma. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition and required extensive assistance of 1 for personal hygiene. Physician orders dated 11/3/21 documented Symbicort Aerosol 160/4.5 mcg (micrograms) 2 puffs two times daily for wheezing. On 7/25/22 at 11:16 AM the resident was observed in their room with a Symbicort Aerosol inhaler on their overbed table. They stated they had never had a self-medication evaluation. The regular nurses let them keep the inhaler at their bedside some of the time because they knew the agency nurses did not always give it to them. They knew to administer the inhaler two times a day, between 8-9 AM and 4-5 PM. The 7/2022 medication administration record (MAR) documented Symbicort Aerosol 160/4.5 mcg, 2 puffs inhale orally two times a day for wheezing in AM and PM. The MAR documented the medication was administered by licensed practical nurse (LPN) #5 in the AM and by LPN #40 in the PM on 7/25/22. During an interview on 8/2/22 at 9:35 AM with LPN #41 they stated they were not aware of any residents on Unit 2 who were able to self-medicate. If residents could self-medicate, there would be a physician order. During an interview on 8/2/22 at 9:43 AM with registered nurse (RN) Unit Manager #6 they stated there were no residents on Unit 2 who could self-administer medications. Resident #55 did not have an order to self-medicate. They were not aware of any self-medication assessment tools in the facility. During a telephone interview on 8/2/22 at 10:54 AM with LPN #5, they stated they had picked up the inhaler from the resident's room on the morning of 7/25/22 after the morning medication pass, so it must have been left from the evening nurse on 7/24/22. The resident was able to use the inhaler themselves so they would open the cap on the inhaler and let the resident self-administer the 2 puffs. They always went back to retrieve the inhaler from the resident and would put it back in the medication cart. They were not aware of the resident being evaluated for a self-medication assessment. During an interview on 8/2/22 at 11:52 AM with the Director of Nursing (DON) they stated residents would need a physician order to self-medicate. They were not aware of any self-medication assessment tool that would be used to help determine if a resident could self-medicate. The facility did not often have residents who could self-medicate. Resident #55 did not currently have self-medication orders and could self-medicate if evaluated. During an interview on 8/2/22 at 12:36 PM with attending physician #13, they stated they only knew of a different resident on Unit 3 who could self-medicate. Residents would need to demonstrate they could take a medication safely in order to self-medicate, and that would require a physician's order. Resident #55 would be capable of self-medicating with an inhaler, but it should not be at the bedside without a physician's order. 10NYCRR 415.3(e)(1)(vi)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification and abbreviated (NY00277703) surveys conducted 7/25/22-8/2/22, the facility failed to ensure residents had the right to reside and receive services with reasonable accommodation of needs and preferences for 1 of 1 resident (Resident #53) who required a shower gurney (a mobile shower bed used to transport a person with limited body movement into a shower) for bathing. Specifically, Resident #53 was assessed as requiring a shower gurney for bathing safety, the plan of care did not reflect the need for a shower gurney, a shower gurney could not be located by staff, and the resident was not showered as requested and planned. Findings include: The facility policy Activities of Daily Living (ADLs) dated 11/2016 documented each resident would receive and the facility would provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. A resident would be given the appropriate treatment and services to maintain or improve their ability to carry out ADLs including hygiene (bathing) and mobility (transferring). The facility policy Interdisciplinary Care Planning dated 1/18/21 documented the care plan was developed based on information obtained from assessments/observations. Care Plan Focuses were addressed for every resident including bathing and transferring. The resident's care plan and care instructions were to always be current and accurately reflect the resident's status. Resident #53 had diagnoses including hemiplegia (paralysis on one side of the body) following cerebral infraction (stroke) affecting the left non-dominant side. The 5/24/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and required extensive assistance with transferring and personal hygiene, and physical help in part of bathing activity. A 1/31/22 registered nurse (RN) #26 progress note documented the resident had an incident related to poor positioning in a shower chair requiring staff intervention to safely lower the resident to the floor. The resident would benefit from skilled rehabilitation for safe positioning. There was no documentation the resident received an evaluation for safe positioning between 2/1-2/14/22. Occupational therapist #32 progress notes documented: - on 2/15/22 the resident demonstrated a decline from the last plan of care on 11/25/21. The resident had a fall out of their shower chair and required an assessment of a shower gurney for safety. The assessment noted the resident's prior level including substantial/maximal assistance with shower and bathing and current level was unable to be assessed related to safety concerns. The plan of care included to educate caregiver on appropriate durable medical equipment (DME) for increased safety during showers. The plan of care did not include the specific DME that was recommended. - on 2/22/22 caregivers demonstrated safe handling techniques during transfer with the mechanical Hoyer lift to the shower gurney. The resident demonstrated increased safety during the showering process. - on 2/25/22 the discharge summary documented caregivers were assessed for proper positioning and handling techniques during showers utilizing a shower gurney with good carryover of education and safety techniques. The 5/13/22 certified occupational therapy assistant (COTA) #30 screening documented they reviewed the care plan and care instructions for accuracy including bathing. The screening did not indicate if changes were needed. The resident [NAME] (care instructions), active on 7/25/22, documented the resident required extensive assistance of 1 staff with upper and lower body bathing. The resident was to be showered on Fridays during the 7 AM- 3PM shift. The care instructions did not include equipment to use with bathing. The comprehensive care plan (CCP), active on 7/25/22, documented the resident required extensive assistance of 1 staff with upper and lower body bathing. The care plan did not include equipment to use with bathing. The activities of daily living (ADL) documented N/A on 7/21/22 for bathing by certified nurse aides (CNA) #24 and 31. The resident was provided physical help with bathing on 7/23 and 7/25 by CNA #25. The resident was totally dependent on staff for bathing on 7/26/22 by CNA #17. 7/8/22 and 7/22/22 (Fridays) were both blank for bathing. During interviews with the resident: - On 7/25/22 at 3:48 PM, they stated staff had been providing them with bed baths and not showers, and they wanted a shower. They were told the facility did not have a shower gurney for them to use in the shower room. - On 7/26/22 at 9:59 AM and 4:47 PM, they had not received a shower. - On 7/27/22 at 9:02 AM, they had not yet received a shower. During an interview with CNA #25 on 7/27/22 at 2:33 PM, they stated they provided the resident with a bed bath most of the time because the resident slid out of the shower chair and wheelchair. They had checked all the units for a shower gurney and did not find one. They reported this to licensed practical nurse (LPN) #33. They had not reported it to the RN Unit Manager. They were supposed to tell a Unit Manager, or a Supervisor and they had not. They did not know how long the shower gurney had been missing. The care plan did not note to use a shower chair or shower gurney, they just knew from experience. They stated the therapy department did not tell them what equipment to use with showers. The CNA stated the only way to give the resident a shower was with a shower gurney. The CNA stated the last time they brought the resident in the shower room they had to call for help because the resident was slipping from the shower chair. The resident told the CNA they wished staff could find the shower gurney so they could take a shower. When observed on 7/27/22 between 3:07 PM- 3:23 PM, there were no shower gurneys in the facility shower rooms or on Units 2, 3 or 4. During an interview with CNA #34 on 7/27/22 at 3:11 PM on Unit 3, they stated there was not a shower gurney on the unit. During an interview with LPN #35 on 7/27/22 at 3:17 PM on Unit 4, they stated there was only one shower gurney in the building and they did not know where it was. During an interview with CNA #36 on 7/27/22 at 3:22 PM on Unit 2, they stated there was not a shower gurney on the unit. They stated the gurney was normally kept on Unit 4. During an interview with CNA #24 on 7/27/22 at 3:25 PM on Unit 3, they stated there was a shower gurney on Unit 4 as it did not fit in the shower room on Unit 3. They stated Resident #53 was the only resident that required the shower gurney. They were not scheduled on the days the resident was supposed to have showers, so they only provided bed baths to the resident on the off days. During an interview with RN Unit Manager #22 on 7/27/22 at 3:42 PM, they stated there was a shower gurney available on Unit 4. The Assistant Director of Nursing (ADON)/ RN Unit Manager accompanied 2 surveyors to the shower room on Unit 4 and there was no shower gurney observed. During an interview with the Director of Plant Operations on 7/28/22 at 11:00 AM, they stated the shower gurney was moved to the Unit 4 shower room the night of 7/27/22. It had been in the back service hallway on Unit 4 and had been there a long time. They would expect nursing staff to know where the gurney was located. During an interview with RN Unit Manager #9 on 7/28/22 at 1:35 PM, they stated equipment required during a shower should have been noted on the resident's care plan. It would have been added by therapy. If it was not listed staff should ask nursing staff what equipment to use and nursing would have therapy assess the resident. The shower gurney was kept on Unit 4. They had not seen staff use a shower gurney with the resident. During an interview with OT #32 on 8/2/22 at 9:06 AM, they stated the therapy department would be responsible for recommending shower equipment. If it was recommended an e-mail would be sent and therapy would update the care plan. They wrote a note on 2/15/22 that the resident needed to be assessed for a shower gurney for safety. The resident was then assessed and found to be appropriate to use a shower gurney. They stated an e-mail was sent to RN Unit Manager #26 on 2/16/22 communicating this plan. The OT stated it should have been added to the care plan. This would normally be added after the staff training was completed. The staff had all been aware the resident used a shower gurney. They had not been made aware that staff were not able to locate a shower gurney or that the resident was not receiving their showers. 10NYCRR 415.5(e)(1)

Based on record review and interview during the recertification survey conducted 7/25/22-8/2/22, the facility failed to ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 of 1 residents (Resident #82) reviewed. Specifically, Resident #82 sustained a dislocated left shoulder and the investigation was not thorough and complete as there was no documented evidence the facility investigated possible causes of the dislocated shoulder; no documented evidence the facility ruled out abuse/neglect, and no documented evidence the facility determined whether the resident's comprehensive care plan (CCP) was followed when care was provided. Findings include: The facility policy Accident/Incident Report Investigation and Prevention revised 4/2015 documented the facility would conduct an immediate and thorough investigation upon discovery of an incident during the shift that the incident occurred. Resident #82 had diagnoses including dementia, osteoarthritis of both hips, and weakness. The 3/13/22 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, was dependent on staff for activities of daily living (ADLs), and did not have any behaviors. The comprehensive care plan (CCP), dated 3/8/22, documented the resident had a self- performance deficit for bed mobility related to dementia, osteoarthritis, and limited range of motion. Interventions were the resident would be positioned safely with extensive assistance of 2 persons while in bed. The 3/28/22 nursing progress note at 1:14 PM by licensed practical nurse (LPN) #10 documented the resident was unable to lift their left arm and grimaced when touched. A call to physician #13 was placed and an x-ray was ordered. The 3/28/22 physician's order documented x-ray of left shoulder and elbow related to pain. The Incident Report, initiated by registered nurse (RN) #11 on 3/29/22 at 7:30 AM documented: - on 3/28/22 at 1:14 PM, the resident's spouse reported to the nurse the resident was unable to lift their left arm and complained of pain on palpation. - LPN #10 immediately notified physician #13 and an x-ray was ordered to rule out fracture or dislocation. The 3/30/22 x-ray report documented the resident had a dislocation of the left shoulder and an impacted fracture could not be excluded. The 3/30/22 nurse practitioner (NP) #12's progress note documented the resident was seen for left shoulder pain. The resident was diaphoretic (sweaty) with a heart rate of 104 beats per minute, and was tearful. NP #12 ordered the resident to be sent to the emergency room for evaluation. The 3/29/22 incident report was updated (date of update to report not documented) and noted the resident had a left shoulder dislocation. There was no documented evidence the facility investigated possible causes of the dislocation and no documentation a determination was made whether the resident's CCP was followed at the time of the injury. The 3/31/22 hospital discharge summary documented the resident had advanced dementia was noted to not be moving their left shoulder as they normally did. The physician took the resident to the operating room and put the shoulder back in place (closed reduction) under anesthesia. During an interview on 7/27/22 at 2:45 PM, with certified nurse aide (CNA) #17, who care for the resident on 3/28/22, stated the resident required total assistance of 2 persons with care, rolling in bed, bathing, dressing and transfers. They reported the resident would scratch and pinch during care. CNA #17 stated they remembered the resident having a shoulder injury but could not recall who was involved in their care. During an interview with CNA #16 on 7/28/22 at 11:05 AM, they stated the resident appeared fine on 3/27/22 during the day shift and then they had a day off on 3/28/22. On 3/29/22, they returned to work and the resident was injured. They stated the resident required extensive assistance of 2 persons with bathing, rolling in bed, boosting up in bed, and transferring into and out of bed. CNA #16 stated the resident was sometimes grabby during care but did not strike, hit, or pinch the caregivers. CNA #16 stated if the staff explained care to the resident, they were cooperative with care. During an interview with CNA #15 on 8/1/22 at 1:47 PM, they stated they helped provide care to the resident with CNA #17 on 3/28/22 during the day shift. They stated themselves and CNA #17 lifted the resident's arms to wash the resident and rolled the resident in bed to perform care. CNA #15 stated they did not notice any injury during care on 3/28/22. During a telephone interview with LPN #10 on 8/2/22 at 9:46 AM, they stated they worked on 3/28/22 and between 10:00 AM and 11:00 AM, they were alerted that the resident was not able to lift their left arm. Upon entering the room, LPN #10 observed the resident was unable to lift their arm, grasp items with their left hand, and grimaced when their arm was touched. LPN #10 stated they called NP #12 for an x-ray order. LPN #10 stated they had not received any information from the previous shift about an injury and became aware that morning when the resident's family member alerted them. During a telephone interview with NP #12 on 8/2/22 at 11:56 AM, they stated the resident had dementia and was dependent on staff for all ADL care. NP #12 did not know how the resident sustained a shoulder dislocation. During an interview with RN #11 on 8/3/22 at 10:23 AM (the Director of Nursing from 2/22/22 until 4/2022), they stated they filled out an Incident Report for the resident on 3/29/22 and saw the resident that morning on rounds. They had LPN #10 call the NP at that time. RN #11 did not document an assessment in the resident's medical record and did not interview any staff from previous shifts or days to attempt t determine a cause of the injury. RN #11 stated they thought statements were taken from the staff working at the time the resident's injury was identified. 10NYCRR 415.4(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey conducted 7/25/22-8/2/22, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's nursing needs for 1 of 1 resident (Resident #8) reviewed for bathing care plans. Specifically, Resident #8's care plan documented they required extensive assistance with bathing, and they showered themself without assistance. Findings include: The facility policy Activities of Daily Living (ADLs) dated 11/2016 documented each resident would receive and the facility would provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. A resident would be given the appropriate treatment and services to maintain or improve their ability to carry out ADLs including hygiene (bathing) and mobility (transferring). The facility policy Interdisciplinary Care Planning dated 1/18/21 documented the care plan was developed based on information obtained from assessments/observations. Care Plan Focuses were addressed for every resident including bathing and transferring. Resident #8 had diagnoses including anxiety and major depressive disorder. The 7/16/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required supervision with assistance of 1 for walking in their room, supervision with set-up for locomotion on the unit, supervision with set-up help only for personal hygiene, and physical help in part of bathing activity. The undated comprehensive care plan (CCP) documented the resident had a self-performance deficit for bathing related to activity intolerance. Interventions included extensive assistance of 1 and provide verbal cues/encouragement. There were no further specifics on the CCP to address the resident's preference for type of bathing or planned schedule for bathing. A 4/8/22 occupational therapy (OT) #48 plan of care note documented the resident was last seen in 10/2021 and required substantial/maximal assistance for bathing. The helper did more than half the effort and lifted or held the resident's trunk or limbs. The resident [NAME] (care instructions) active in 7/2022, documented the resident required extensive assistance of 1 for bathing, and limited assistance of 1 with wheelchair to follow for ambulation in the corridor. The care instructions did not include bathing-type preference, scheduled bathing day or shift, or cues/encouragement required. The 7/2022 Unit 3 shower list documented the resident was scheduled for showers on Mondays during the day shift. The activities of daily living (ADL) bathing record documented: - on Wednesday 7/20/22 by certified nurse aide (CNA) #44, independent-no help provided. - on Monday 7/25/22 by CNA #25, supervision with set-up help only. - on Tuesday 7/26/22 by CNA #8 independent with bathing. The ADL record did not include the type of bathing provided (bath, shower, sponge/bed bath). A 7/25/22 at 6:50 AM progress note by registered nurse supervisor (RNS) #45 documented they were made aware the resident was going into the shower room for a shower (the documentation did not include how the resident was attempting to enter the shower). Staff tried to redirect the resident as it was not the resident's shower day. The RN told staff they would have to stay with the resident until they finished their shower. During an interview with the resident on 7/25/22 at 10:38 AM, they stated they had not had a shower in 3 weeks as the water had to be fixed. The resident asked staff if they could take a shower yesterday and was told to take a shower in the early morning. The resident took a shower by themselves the morning of 7/25/22 without any staff assistance. During an interview with CNA #25 on 7/27/22 at 2:44 PM, they stated they went into the shower room with the resident on 7/25/22. The resident was able to do their own shower and the CNA brought them towels, shampoo, and checked on them. They did not have to stay with the resident the whole time and just checked periodically. The resident's regularly scheduled shower day was Monday. There had not been any issues with showers and the resident did not need assistance. The care instructions would note the level of assistance needed, but if a staff was familiar with the resident, they already knew the level of assistance without looking. Extensive assistance would mean a staff person had to stay with the resident. The CNAs were to follow the care plan. If a resident was extensive assistance on their care instructions and wanted to do it themselves, therapy would assess the resident. They stated they had not told anyone the resident did their own care, as everyone was already aware. The care plan should be followed for resident and staff safety and the nurse should have been told. During an interview with RN Unit Manager #9 on 8/1/22 at 11:48 AM, they stated staff would know how to care for a resident by looking at the care plan. The resident's current care plan documented the resident required extensive assistance of 1 for bathing. That meant the resident required physical help/verbal cuing with bathing. The resident was independent with actual washing but needed a staff member to be with them, per the care plan. They did not know the resident needed assistance for safety reasons and thought staff could leave the resident for short periods of time. They were not aware the resident took a shower by themselves and/or needed intermittent supervision. They would want to be notified if the care plan was not being followed. They had not been made aware of the 7/25/22 incident when the resident showered by themself and they should have been. During an interview with RNS #45 on 8/2/22 at 1:32 AM, they stated the day shift staff was responsible for showers. Night licensed practical nurse (LPN) #46 called the RN to let them know the resident was insisting on taking a shower. The staff called because another CNA was going in the shower room with a male resident and Resident #8 was attempting to go in at the same time. They told LPN #46 to redirect the resident and recommended staff provide the resident with a shower. The staff should have been following the care plan and looking at it before care for safety reasons. If the resident required extensive assistance, staff should have been in the shower room with the resident. During an interview with LPN #46 on 8/2/22 at 1:51 AM, they stated the resident insisted on taking a shower during the overnight shift on 7/25/22. CNA #24 was getting a male resident ready to shower and Resident #8 did not want to wait. The RN told the LPN to tell the CNA the resident should be monitored. The LPN stated they were told the resident was independent with showering. Extensive assistance meant staff needed to provide physical assistance with bathing and should be present in the room. Staff should have followed the care plans to ensure safety. They were not aware the resident had showered independently without staff present. During an interview with OT #32 on 8/2/22 at 9:06 AM, they stated the resident was discharged from services on 4/20/22. At that time the resident required extensive assistance with bathing. Extensive assistance meant the resident required moderate/minimum or maximum physical help in the shower and staff should remain in the shower. Staff should have followed the care plan because that was the assessed level of assistance the resident needed. They were not aware the resident was taking showers on their own. Therapy should have been made aware of any changes so they could reassess the resident for safety and required level of assistance. 10NYCRR 415.11(c)(2)(ii)

Based on record review and interview during the recertification and abbreviated surveys (NY00296799) conducted 7/25/22- 8/2/22, the facility failed to provide or obtain radiology or other diagnostic services to meet the needs of its residents; and be responsible for the quality and timeliness of the services for 1 of 2 residents (Resident #302) reviewed. Specifically, a STAT (emergent) X-ray of the right hip was ordered for Resident #302 on 5/29/2022 and it was not completed until 5/30/22 and the resident was diagnosed with a fractured right hip. Findings include: The facility policy Policy on Radiology and Other Diagnostic Services dated 1/1/2000 documented the facility should provide or obtain radiology and other diagnostic services to meet the needs of its residents pursuant to an order by an appropriate practitioner. The facility was responsible for the quality and timeliness of such services. Resident #302 had diagnoses including a fractured sacrum (triangular bone at the base of the vertebrae) and atrial fibrillation. The 5/16/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and required limited to extensive assistance with most activities of daily living (ADL), had falls with fractures prior to admission, and had no falls since admission. The 5/29/22 at 6:19 PM Fall Assessment documented RN #39 was called to the unit at 1:30 PM to assess the resident after a fall. The resident told staff they fell and got themselves up. The resident was alert, oriented, and answered questions appropriately. The resident stated their right hip did not hurt but it was swollen, with a large purple 11.4 centimeter (cm) x 9.8 cm area. The physician was updated, and an order was obtained for an x-ray of the hip. The resident reported they transferred themselves off the floor and did not tell anyone they fell. The on-call physician was notified, and the fall was documented on the 24-hour nursing report. The 5/29/22 at 6:38 PM physician order documented an X-ray of the right hip STAT (immediately) for bruising. There were no corresponding nursing progress notes regarding physician orders for STAT x-rays. The 5/30/22 x-ray report documented the reported date was 5/30/22 at 12:05 PM and the examination date was 5/30/22 at 2:25 PM. The results documented the resident had a non-displaced fracture of the right greater trochanter (hip joint), deformity of the right pubic rami (part of the pelvis) and right pubic tubercle (part of the pelvis). The 5/30/22 at 10:45 PM LPN #41 progress note documented the resident fell on 5/29/22 and x-ray results noted a fracture of the greater trochanter. The on-call provider was notified, and orders received to transfer the resident to the hospital. The resident was transferred at 3:55 PM to the hospital. During an interview on 7/29/22 at 1:07 PM, RN #39 stated they were called to the resident room to assess the resident on 5/29/22 during the evening. The resident denied pain or discomfort. The resident stated they were trying to pull up their pants when they fell. The on-call physician was notified and ordered an x-ray. RN #39 was unable to recall if the x-ray order was STAT. The x-ray should have been completed within 6 hours if ordered STAT. The resident did not complain of pain but had a large bruise. The RN was on duty until 7:00 PM that day and the x-ray was not completed prior to the RN leaving and the information was added to the 24-hour report. During an interview on 8/1/22 at 1:12 PM, physician #13 stated a STAT x-ray based on the radiology company standards should be completed within 2- 4 hours to get the resident the treatment they needed. If a resident was in severe pain, nursing staff should notify the physician and they would send the resident to the hospital instead of waiting for an X-ray. 483.50(b)(2)(1)(11)

Based on observation, interview, and record review during the recertification and abbreviated surveys (NY00282793, NY00275980, NY00296065, NY00274624, NY00283438, NY00298775, NY00296718, NY00277703, and NY00277484) conducted 7/25/22-8/2/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal and oral hygiene for 11 of 17 residents (Residents #1, 24, 53, 55, 62, 63, 78, 82, 104, 112, and 149) reviewed. Specifically; - Resident #1 was not assisted with their preferred frequency of bathing and hair washing. - Resident #24 was not assisted with daily dressing. - Resident #53 received bed baths in place of preferred showers because the facility did not have warm water or a shower gurney available for resident use. -Resident #55 stated they did not receive a shower on their scheduled shower day and documentation did not include bathing. - Resident #62 was not assisted with combing and brushing their hair daily as preferred. - Residents #63 and 82 were not assisted out of bed during the day because there were no available mechanical lift pads. - Resident #78 was not shaved daily as preferred. - Resident #104 had not received a shower for three weeks due to cold water and only received bed baths. - Resident #112 was not assisted with daily dressing. - Resident #149 did not receive nail care, and their nails were unclean. Findings include: The facility policy Activities of Daily Living dated 11/2016 documented each resident was to receive the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. That would include giving the resident appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living, including hygiene-bathing, dressing, grooming, and oral care. 1) Resident #1 had diagnoses including atrial fibrillation (A-fib, abnormal heartbeat), depression, and anxiety. The 4/7/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, they considered choice of tub bath/shower/bed bath/sponge bath very important, required extensive assistance of 1 with toileting and hygiene, and was totally dependent on 2 for bathing. The 3/31/22 physician order documented weekly skin monitoring every Thursday on day shift. The 4/1/22 comprehensive care plan (CCP) documented the resident had bathing and hygiene deficits. Interventions included extensive assistance for bathing, toileting, and upper body care; document weekly on shower day; and offer choices. The 5/17/22 at 9:12 PM nurse progress note documented the resident requested showers be given on either Wednesdays or Thursdays. The 7/12/22 updated CCP documented the resident required extensive assistance of 1 for bathing. When interviewed on 7/26/22 at 5:16 PM, the resident's family member stated the resident was admitted for short term rehabilitation. The resident had an outside consult and had not had a shower prior to that appointment. The family and the resident stated the resident had not had a shower in over 3 weeks due to no hot water in the building. The following observations of Resident #1 were made: - On 7/26/22 at 11:26 AM and 6:05 PM, the resident was observed sitting in a wheelchair in their room watching TV. The resident was dressed with greasy looking hair. - On 7/27/22 at 9:18 AM, the resident was observed sitting in a wheelchair in their room watching TV. The resident was dressed with greasy looking combed hair. At 11:22 AM, the resident stated they could not remember the last time they had a shower or had their hair washed. The resident stated there was no hot water, so they refused showers. If day shift staff were unable to give a shower on the resident's weekly scheduled shower day, the evening shift was supposed give them one. - On 7/28/22 at 10:18 AM, the resident was observed sitting dressed in a wheelchair with greasy looking hair. The 6/30-7/25/22 certified nurse aide (CNA) bathing records documented the resident received partial assistance with bathing on 6/30/22 at 2:59 PM and 10:59 PM, 7/1/22 at 2:59 PM, 7/5/22 at 2:53 PM, 7/7/22 at 2:29 PM and 8:53 PM, 7/9/22 at 8:35 AM, 7/12/22 at 2:46 PM and 10:59 PM, 7/13/22 at 12:57 PM, 7/14/22 at 1:31 PM, 7/19/22 at 10:49 AM, 7/20/22 at 10:17 AM, 7/21/22 at 1:27 PM, and 7/25/22 at 2:10 PM. The records documented the resident was bathed and required total dependence on 7/22/22 at 11:26 AM and 7/26/22 at 11:13 AM. When interviewed on 7/27/22 at 2:57 PM, certified nurse aid (CNA) #4 stated resident specific care was listed on each resident's care instructions. Each resident was scheduled to receive a shower once a week or twice if preferred. Showers were given in the shower rooms located on each wing of Unit 2. There was a shower binder at the nursing station where staff documented they had given showers. Showers were also documented in the bathing tab of the resident's electronic medical record. CNAs were unable to add notes in the ADL tabs. By documenting in the bathing tab, that meant a full bath, body bath, sponge bath, or transfers in and out of the shower were done. Documentation did not include hair washing. The CNA stated checking the bathing box did not mean the resident had a shower. The CNA stated the last time the resident had a shower was about a week ago and was provided by another CNA. The CNA stated the last time they gave the resident a shower was about a month ago. The resident refused showers at times due to the shower water feeling too cold for them. When interviewed on 7/27/22 at 3:10 PM, licensed practical nurse (LPN) #5 stated care instructions documented resident specific care. Each resident was to receive a shower at least weekly or more often, depending on their preferences. The unit had a shower book at the nursing station and the LPN ensured it was completed after they performed skin checks on the residents' shower day. The LPN stated they were not aware Resident #1 had not had a recent shower. If a resident refused care, the CNA was to reapproach the resident. If the resident still refused, the LPN would reapproach the resident, inform the registered nurse (RN) Manager of the continued refusal, and enter a progress note regarding the refusal. The LPN was unable to access the electronic CNA documentation as they did not know how to. When interviewed on 7/27/22 at 3:29 PM, registered nurse (RN) Unit Manager #6 stated resident specific care was documented on the resident care instructions. When care was provided it was documented in the electronic record. The RN Manager expected each CNA to document all completed resident care throughout the shift. Each resident was to receive a shower at least once a week unless they requested them more frequently. Showers were documented in the electronic record in the bathing tab. The RN Manager stated many residents had refused showers in the past due to cold water temperatures and the rate of refusals had increased lately. Resident refusals were documented in the bathing section of the electronic medical record. If care was not documented by staff, it was considered not to have occurred. The RN Manager did not think residents' hair was washed if a shower was not given. The RN Manager was unaware of Resident #1's shower refusals due to water temperatures. 2) Resident #62 had diagnoses including Alzheimer's disease and depression. The 5/28/22 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, considered it somewhat important to choose between a tub, shower, bed bath, and sponge bath, required extensive assistance of 1 with dressing and personal hygiene, and physical help in part of bathing activity. The 6/3/22 CCP documented the resident required set up and supervision for bathing their upper body and staff bathed their lower body. Their hair was to be washed by the certified nursing assistant (CNA) and their shower day was Monday on the day shift (7 AM - 3 PM). The following observations were made of Resident #62: - On 7/25/22 at 3:29 PM, the resident was in their room lying in bed. Their hair was disheveled. Some hair was up in a claw clip on the right side of their head and the remaining hair was out of the claw clip and hanging loosely. The resident reported their hair was tangled and they had not received a shower. - On 7/26/22 at 10:46 AM, the resident was in their room lying in bed. Their hair appeared disheveled, some hair was up in a claw clip on the right side of their head and the remaining hair was out of the claw clip and hanging loosely. - On 7/26/22 at 10:54 AM, CNA #19 was brushing the resident's hair, the resident was wincing while their hair was being brushed. The resident's hair had a large, knotted tangle on the top right side of their head. The resident stated it was painful, but it needed to be done. The resident stated they had not been asked if they wanted their hair brushed and they did not want to take a cold shower due to the lack of warm water at the facility, and they had not had a shower in 3 weeks. During an interview with CNA #19 on 7/26/22 at 10:57 AM, they stated for the resident's hair to be that knotted and tangled it had been a long time since it was brushed. During an interview on 7/27/22 at 9:21 AM, the resident stated they wanted their hair washed, but the water was cold. During an interview on 7/27/22 at 9:25 AM, CNA #7 stated they were assigned to care for Resident #62 on 7/25/22 on the day shift. The resident refused to be showered because they did not want to take a cold shower. They did not wash the resident's hair, but they did brush the resident's hair. The resident's hair did have some knots on 7/25/22, but they were not able to get all the knots out of their hair. They were unsure of the last time the resident's hair had been washed. If the resident missed or refused their shower they would have to wait until the next time they were scheduled to receive a shower. The water at the facility had been cold recently so some residents had refused showers. During an interview on 7/28/22 at 1:05 PM, social worker #52 stated some residents had refused showers due to the cold water. They stated if residents were not groomed to their liking it could affect their mood and behaviors. During an interview on 7/28/22 at 1:35 PM, the registered nurse (RN) #9 Unit Manager stated residents had told them the water was cold and they missed taking showers. Staff washed the residents up at bedside if they did not want to take a shower. They expected hair brushing to be completed daily and as needed. During an interview on 7/28/22 at 1:55 PM, the facility's RN Nurse Educator #37 stated they had provided informal education to the Unit Managers on showering alternatives if a resident refused to be showered. The facility had shampoo caps and could provide bed baths. During a follow up interview on 7/28/22 at 2:03 PM, CNA #19 stated they were not aware the facility had shampoo caps. 3) Resident #24 had diagnoses including dementia without behavioral disturbance. The 7/16/22 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and required extensive of assistance of 1 staff member for dressing. The 3/8/22 comprehensive care plan (CCP) documented the resident required extensive assistance of 1 with both upper and lower body dressing and required both verbal cues and encouragement with dressing. On 7/25/22 at 1:06 PM, 3:47 PM, and 4:04 PM the resident was observed in their room from the hallway, wearing a hospital gown. On 7/26/22 at 4:46 PM, the resident was observed in bed, wearing a hospital gown, and could be seen from the hallway. The resident's closet contained 1 light blue button down shirt with a safety pin attached. There were 2 sets of pajama tops and bottoms in the dresser that still included the cardboard inserts. During a telephone interview with the resident's representative on 7/27/22 at 11:12 AM, they stated the resident had clothing, but when they visited the resident, they were always in a hospital gown. They stated the resident was given 2 pajama sets in December 2021 and no one from the facility had notified them the resident needed any additional clothing. During an interview on 7/27/22 at 9:45 AM, CNA #7 stated Resident #24 was wearing a hospital gown because they did not have any clothes. The resident was able to answer yes or no questions and sometimes the resident was resistive to dressing. They did not ask the resident if they wanted to wear a gown on 7/25/22 and just put one on them. They knew the facility had a donation clothing bin that staff could obtain clothes from, but they never went there. They did not let other staff know the resident did not have any clothes. They stated it was not dignified to put a hospital gown on the resident without asking them. On 7/27/22 at 3:05 PM, 7/29/22 at 1:17 PM, and 8/1/22 at 10:55 AM, the resident was observed from the hallway lying in bed wearing a hospital gown. During an interview with the Laundry and Housekeeping Supervisor on 8/1/22 at 11:05 AM, they stated the facility had a donation bin for clothing. Nursing staff could come and get clothes out of the bin, or they could let laundry staff know a resident needed clothing. During an interview on 8/1/22 at 11:10 AM, SW #49 stated if a resident needed clothing they would reach out to the family or representative and ask them to bring in clothes. They had not heard that Resident #24 did not have clothes and if the resident preferred to wear a hospital gown it should be care planned for. 10NYCRR 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification and abbreviated surveys (NY00277703, NY00296718, NY00283438, NY00282793, NY00277484, NY00275980 and NY00274624) conducted 7/25/22-8/2/22, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 3 resident units (Units 3 and 4) and 2 resident rooms observed. Specifically, there were unclean floors on Units 3 and 4, unclean walls on Unit 4, unclean privacy curtains on Unit 3, room [ROOM NUMBER] had a strong urine odor, and room [ROOM NUMBER] had an unclean commode. Findings include: The facility policy Room Cleaning Procedures dated 5/2021, documented the facility would provide an environment that fostered a positive self-image for the resident and preserves human dignity. Sinks and toilets were cleaned with disinfectant cleaner inside and out, and flooring was dust mopped and then wet mopped with the specified floor cleaner. The following observations were made on 7/25/22: - At 10:04 AM and 3:47 PM, the Unit 4 hallway baseboards outside of room [ROOM NUMBER] and across the hall outside of room [ROOM NUMBER] were unclean with black and brown debris. rooms [ROOM NUMBERS] had chipped and peeling flooring at the edge of the room door. room [ROOM NUMBER] bed A had an unclean tray table with coffee spills, and the wall above the garbage can to the right of the door was unclean with red and brown splash marks. The floor mat near bed A had sticky red/brown spots. There was debris and food crumbs on the floor next to 418 B bed. The floors at the end of the Unit 4 hall near rooms 418, 420, 421 and 422 had black, dried debris. - At 10:45 AM, Unit 4 room [ROOM NUMBER] had peeled flooring at the edge of the door. - At 11:55 AM, 3:37 PM, and 4:24 PM room [ROOM NUMBER] had a strong urine odor that was detected when standing outside of the room. - At 1:07 PM, room [ROOM NUMBER] floor and walls were unclean. The following observations were made on 7/26/22: - At 9:44 AM, 1:41 PM, and 4:29 PM room [ROOM NUMBER] bed A had a wet spot under the bed and a strong urine odor coming from the room - At 9:49 AM, and 10:30 AM the Unit 4 floor at the end of the hall near rooms 418-422 remained visibly unclean with black debris. - At 9:50 AM and 10:45 AM, the Unit 4 room [ROOM NUMBER] wall remained unclean with brown, sticky splash substances inside the door above the trash can. - At 11:05 AM, a sign on the door of room [ROOM NUMBER] stated the toilet was out of order. - At 11:16 AM, the privacy curtain in resident room [ROOM NUMBER] was unclean with a brown stained area. - At 11:20 AM, the privacy curtain in resident room [ROOM NUMBER] was unclean with three large brown stains. - At 11:26 AM and 6:05 PM, Unit 2 resident room [ROOM NUMBER] bed A there were dried brown smears on the top of the commode seat behind a closed curtain area next to the resident. The smear on the front top of the seat was approximately 1 inch round and the smear on the top back of the seat was approximately 0.5 inches round. - At 12:33 PM, the end of the hall of Unit 4 near room [ROOM NUMBER] remained dirty. The baseboard near the Unit 4 nursing station television appeared brown and discolored with a dried, spilled liquid. The following observations were made on 7/27/22: - At 8:56 AM and 2:58 PM, room [ROOM NUMBER] bed A had a wet spot under the bed and the room smelled of urine. - At 9:18 AM, room [ROOM NUMBER] bed A, the commode seat for resident use had dried brown smears on the top of the commode seat. - At 11:46 AM, there was white powder and flaking on the floor at the entry to resident room [ROOM NUMBER]. On the wall adjacent to the garbage bin there were brown, speckled stains on the wall. - At 11:54 AM there were unclean floors with food debris and a smashed, 3-inch round brown item next to the door-side bed in resident room [ROOM NUMBER]. - At 2:58 PM the privacy curtain in resident room [ROOM NUMBER] was unclean and stained with an elongated brown stain measuring 8-inches by 1-inch. On 7/28/22 at 10:18 AM, room [ROOM NUMBER] bed A the commode for resident use placed to the left of the resident behind a closed curtain had dried brown smears on the top of the seat. When interviewed on 7/26/22 at 10:50 AM, the Housekeeping Supervisor stated they worked the floors and have had a lot of staff turnover and staffing issues. Their duties included cleaning floors, wiping down the rooms and cleaning bathrooms. Certified nurse aides (CNAs) stripped and changed beds and took out the garbage. Housekeepers removed the garbage from the garbage room. Housekeepers did daily wipe-downs and weekly high dusting. There was a contracted housekeeping service that was at the facility for 2 years, and they did not do a satisfactory job. The cleaning of privacy curtains needed to be addressed. The prior housekeeping contractor did not wash the privacy curtains. They could only fit three privacy curtains in the facility washing machine at one time. They stated Resident #110's toilet worked. The sign was meant to deter the resident from using the toilet as they wanted the resident to use a commode. Nursing was responsible for changing and cleaning the commodes. The dirty floor was a known issue, and the cleaning was kept up the best they could. During an interview on 7/27/22 at 9:01 AM, housekeeping staff #23 stated their work duties included emptying garbage and dirty linen bins two times a day. They were assigned to Unit 4 one week ago. When they arrived at the unit, they cleaned the common areas and restrooms. At 9:15 AM, they emptied the trash and returned to the unit to clean the residents' rooms. Resident room cleaning included sinks, tray tables, paper towel dispensers, toilets, commodes, and floors. When a room was scheduled for a deep clean, they wiped down bed frames, and walls. They were supposed to deep clean 6 rooms per month. They were responsible for cleaning the floors in the hallways, wipe handrails, dust, sweep and mop. Floors were supposed to be stripped and waxed. The debris at the end of the hall may had been under the wax. The facility did not currently have a floor technician. The housekeeping department was short-staffed. The rooms should not be unclean for the residents. During an interview on 7/27/22 at 9:08 AM, housekeeping staff #54 stated they cleaned all the rooms on Unit 3 on 7/26/22. They stated their cleaning duties include sweeping and mopping the floor, wiping down the tables, mopping under resident beds, cleaning toilets, and emptying the garbage. They stated they sprayed bleach to reduce the urine smell when mopping because it was important to keep all the rooms clean. During an interview on 7/27/22 at 9:15 AM, Housekeeping Supervisor #49 stated when they arrived on Unit 3 there was urine under the bed. They expected nursing staff to clean it, so it was not a puddle. Housekeeping staff was not supposed to clean up urine. They should notify nursing of the urine on the floor. Nursing staff should spray the commodes after they were emptied. During an interview on 7/27/22 at 9:54 AM, registered nurse (RN) Unit Manager/ Assistant Director of Nursing (ADON) stated Unit 4 had some housekeeping issues a few months ago, but the unit was starting to be cleaned better. During an interview on 7/29/22 at 12:52 PM, licensed practical nurse (LPN) #53 stated the resident in room [ROOM NUMBER]-A would urinate on the floor. Nursing staff should check on the room once or twice a shift, dump the commode and clean it with soap. They stated they occasionally noticed odors. They expected nursing staff to clean up the wet spots on the floor and it was not appropriate to have wet urine spots on the resident's floor. During an interview on 7/29/22 at 1:15 PM, CNA #15 stated commodes should be dumped a couple times a shift and rinsed out. If there were wet spots, they should clean up the wet spots and have the housekeeper clean up after. They stated room [ROOM NUMBER] had a strong odor and strong odors were not dignified. During an interview on 7/29/22 at 3:04 PM, LPN #41 stated CNAs should be emptying commodes frequently, and ensuring they were clean by using a Sani wipe. During an interview on 8/1/22 at 11:48 AM, RN Unit Manager #9 stated they were aware of the odors coming from room [ROOM NUMBER]-A. The CNAs were supposed to empty commodes. They stated last week there were strong odors coming from room [ROOM NUMBER]. The resident in room [ROOM NUMBER]-A would sometimes urinate on the floor and they had reminded staff to clean up urine from the floor and had housekeeping do a deep clean because it was not dignified to sit in a room that smelled like urine. They tried to keep rounding daily on the unit. 10NYCRR 415.29

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the extended and abbreviated surveys (NY00298775) conducted 7/25/22-8/2/22, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 144 out of 144 residents including Residents #3, 12, 42, 53, 62, 78, 104 and 502 and for 1 additional resident area (beauty salon). Specifically, adequate hot water was not provided to resident rooms and shower rooms on all resident units (Units 2, 3, 4) and the beauty salon on floor 1. Review of the May 2022 Resident Council minutes included that the facility was getting a new boiler due to lack of hot water. The facility had several complaints regarding lack of hot water dating back to 2021. According to plant operation records, 1 of 3 hot water heaters supplying hot water to the facility became inoperable on June 7, 2022. The facility delayed addressing the lack of hot water and the Administrator stated they did not view a lack of hot water as an emergency. The facility had not provided alternative hot water sources for resident bathing and care while repairs were conducted. Hot water temperatures recorded throughout the facility between July 26-July 28, 2022, were observed to be between 78 and 88 degrees Fahrenheit (F). The facility had not provided alternative sources of hot water or educated staff on interim measures during the hot water outage that was expected to last an additional 4 weeks. Subsequently, due to the lack of adequate hot water residents had refused to take showers or bed baths. Additional residents stated they have had cold water experiences and had put up with the cold water to be bathed. Hot water temperatures were not maintained within the acceptable range of 90 degrees to 120 degrees F for resident use. This resulted in substandard quality of care with no actual harm with potential for more than minimal harm that was not immediate jeopardy for all 144 residents including Residents #3, 12, 42, 53, 62, 78, 104 and 502. Findings include: The facility policy Hot Water Supply dated 5/2021, documented a thermostat located directly at the hot water tanks in the Boiler Room regulated the facility's hot water supply. The domestic hot water temperature was regulated at a temperature range of 90 Fahrenheit (F) to 115 F; the temperature would not exceed 120 F. Temperatures were checked and recorded weekly in the tub rooms, in the solariums, and at one room per unit chosen at random. Results were logged and filed in the Environmental Service Managers office. Adjustments to the water temperatures were made if necessary. If the temperatures varied from a given range and could not be corrected in-house, the plumbing firm that the facility has an agreement with would be contacted to correct the problem. The facility policy Activities of Daily Living (ADL) dated 11/2016, documented the facility would provide the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish, and that the resident was given the appropriate treatment and services to maintain or improve their ability to carry out the ADLs to include bathing. The June Hot Water Heater Problem timeline of events for the hot water issue provided by the Plant Operations Director documented: - on 6/7/2022, maintenance discovered the number-2 hot water heater was in an alarm condition, was reset and the unit continued running. The plumbing contractor was contacted and notified of the problem. Additional rounds were initiated to monitor the building water temperatures. - On 7/12/2022, quotes were received for both the replacement and revamp of the hot water heating system. - On 7/14/2022 a signed work quote was returned to the plumbing contractor for the plate heat exchanger to be installed in an existing boiler. A plumbing vendor work order dated 6/8/22 documented the vendor was onsite, the tankless hot water heater was not functional, and a plan was made to replace the system. Hot water temperatures were measured (with internal probe thermocouple) with the following results: - 7/25/22 at 10:40 AM, 86 F at the sink in resident room [ROOM NUMBER]. - 7/25/22 at 10:50 AM, 83 F at the sink in resident room [ROOM NUMBER]. - 7/25/22 at 11:00 AM, 80 F in the shower in the 4th floor common bath. - 7/25/22 at 11:06 AM, 82 F at the sink in resident room [ROOM NUMBER]. - 7/25/22 at 11:14 AM, 83 F at the sink in resident room [ROOM NUMBER]. - 7/25/22 at 11:18 AM, 88 F at the sink in resident room [ROOM NUMBER]. - 7/25/22 at 11:20 AM, 84 F at the sink in resident room [ROOM NUMBER]. - 7/25/22 at 11:21 AM, 83 F in the shower in the 3rd floor common bath adjacent to the elevators. - 7/25/22 at 11:37 AM, 83 F at the sink in resident room [ROOM NUMBER]. - 7/25/22 at 11:43 AM, 80 F at the sink in resident room [ROOM NUMBER]. - 7/25/22 at 11:47 AM, 80 F in the shower in the 2nd floor common bath adjacent to the elevators. - 7/25/22 at 11:53 AM, 86 F in the shower in the 2nd floor common bath adjacent to room [ROOM NUMBER]. - 7/26/22 at 11:00 AM, 87 F at the sink in resident room [ROOM NUMBER]. - 7/26/22 at 2:36 PM, 85 F at the sink in resident room [ROOM NUMBER]. - 7/27/22 at 11:46 AM, 86 F at the sink in resident room [ROOM NUMBER]. - 7/27/22 at 11:49 AM, 86 F at the sink in resident room [ROOM NUMBER]. - 7/27/22 at 11:50 AM, 86 F at the sink in resident room [ROOM NUMBER]. - 7/27/22 at 11:54 AM, 83 F at the sink in resident room [ROOM NUMBER]. - 7/27/22 at 12:23 PM, 81 F at the sink in resident room [ROOM NUMBER]. - 7/27/22 at 12:46 PM, 81 F at the sink in the beauty salon. - 7/27/22 at 2:46 PM, 82 F at the sink in resident room [ROOM NUMBER]. - 7/27/22 at 3:46 PM, 79 F in the shower in the 2nd floor common bath adjacent to the elevators. - 7/27/22 at 3:49 PM, 78 F in the shower in the 2nd floor common bath adjacent to the nursing station. When interviewed on 7/25/22 at 10:40 AM, the Plant Operations Director stated about a month ago, 1 of the 3 on-demand hot water heaters went down. There was a plan in place to have the system replaced and to use a heat plate with one of the larger boilers. They were not sure the current system could handle the demand, so it was decided to replace them. There were no other systems in place for resident bathing other than trying to adjust bathing times to later or earlier when temperatures tended to be warmer. Water temperatures were not usually checked in resident rooms unless there were complaints. When measuring hot water temperatures, a digital probe thermometer was used. Temperatures were usually taken between 9:00 AM and 9:45 AM when most of the resident care was being performed. There were no specific trainings on taking water temperatures. Manufacturer's instructions were followed on how to take water temperatures. When interviewed on 7/25/22 at 11:37 AM, Resident #58 stated the hot water temperature could be measured if you could find hot water. They stated it would be nice to have warm water. When interviewed on 7/25/22 at 11:43 AM, Resident #33 stated the water was cold. It had been cold for a few months now. When maintenance was notified, they would say they were working on it. They were not fond of taking showers when the water was so cold, and washing their hands was also not comfortable. When interviewed on 7/25/22 at 4:35 PM, the Administrator stated the parts for the hot water equipment with an exchanger had been ordered last week. The parts would take about 4 weeks to come in and it would be a quick installation when the parts were received. The water temperatures seemed to be better at different times of the day. They stated the temperatures that were measured recently during rounds with Plant Operations were too low. On 7/26/22 at 10:10 AM, the Administrator stated the one, on-demand hot water heater went down a month ago. The water heater installation and replacement were all vendor recommended. Parts were ordered a week ago and it would take 4 weeks before the parts arrived. They expected the old units to be removed and the new system to be installed within the same week. The one on-demand unit that went down was beyond repair and a direct replacement would have taken 3 1/2 weeks, so they decided it made more sense to go with a brand new, better working system. The current on-demand units had on-and-off issues for years. The normal acceptable regulatory ranges for hot water temps should be 90-120 F. There were baths-in-a bag and hair wash caps that required no water, and these could be used to bathe residents. They were not sure what else could be done without hot water. There were no other interventions currently in place other than trying to adjust bathing times. When interviewed on 7/27/22 at 12:23 PM, Resident #12 stated their shower day was Tuesday. They had an outside appointment recently and they were supposed to take a shower before going out. They were told the hot water temperatures were good, but 5 minutes later when they got down to the shower it was too cold, and they did not want to take their shower. It was also hard to get shaving cream off their face with cold water. They did not feel clean without hot water. It had been like that since March 2022. When interviewed on 7/27/22 at 1:44 PM, beautician #42 stated their beauty salon hours were Tuesday through Friday from 8:00 AM-3:00 PM. The water problem had been going on for over a month and they tried to see residents around their showering schedule, so they did not have to wash residents' hair in the salon sink because the water was not warm enough. Residents would cancel their appointments because the water was too cold. Not having hot water did not affect them doing their job or using their salon equipment but it was not good that residents had their hair washed with cold water. When interviewed on 7/28/22 at 1:07 PM, the Administrator stated they did not think the facility had a policy for the loss of hot water as they did not think the loss of hot water would necessarily constitute an emergency. RESIDENT EXAMPLES: 1) Resident #78 had diagnoses including dementia and chronic kidney disease. The 6/10/22 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required limited assistance for personal hygiene and was totally dependent on one person for bathing. The 6/15/22 comprehensive care plan (CCP) documented a bathing self-care deficit related to dementia. Goals included the resident would have their bathing needs met through the next review. Interventions included extensive assistance of one for lower and upper body. The resident was to have a shower on Wednesdays during the day shift. During an interview on 7/25/22 at 11:21 AM, Resident #78 stated they preferred to be showered but the water was cold, and it did not feel good. During an interview on 7/27/22 at 9:24 AM, certified nurse aide (CNA) #20 stated they were assigned to care for Resident #78 today (7/27/22). Morning care included washing the resident. CNA #20 stated this was the resident's assigned shower day and they told Resident #78 the water was still cold that morning and the resident refused their shower. CNA #20 stated they did not want to give the resident a cold shower, so they provided the resident a bed bath with lukewarm water. The CNA stated the facility had not had warm water for morning bathing since June 2022 and sometimes evenings were better for shower temperatures. During an interview on 7/27/22 at 9:30 AM, Resident #78 stated they did not take a shower today. The water was too cold, so the aide had given them a quick wash-up with lukewarm water in a basin. During an interview on 7/27/22 at 3:05 PM, CNA #21 stated they had cared for Resident #78. The resident required assistance with washing up. They gave the resident the water basin and wash cloth. The water had not been hot. All the residents complained of the water being too cold. Many of the residents had not had baths in a while because the water had been so cold. The residents would say it was too cold for them and that they would prefer to shower another day. These residents should not be washed with cold water. Sometimes the water was just cold, not even lukewarm, and they would not want to bathe in cold water. During an interview on 7/27/22 at 9:40 AM, the Unit 4 registered nurse (RN) Unit Manager/Assistant Director of Nursing (ADON) stated they were not aware how long the water had been cold and was not sure when it would be fixed. They thought the temperatures were within normal limits and were not aware that some of the residents' room water temperatures measured 84 degrees. 2) Resident #104 had diagnoses of Parkinson's disease (a progressive neurological disorder) and depression. The 6/21/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and was totally dependent for bathing. The 3/8/22 comprehensive care plan (CCP) documented the resident required extensive assistance of 1 staff member for upper and lower body care. The activities of daily living (ADL) record documented the following bathing activity on Wednesdays on the 3 PM-11 PM shift in July 2022: - On 7/6/22, not applicable; - On 7/13/22, there was no documentation recorded; - On 7/20/22, there was no documentation recorded; and - On 7/27/22, not applicable. The undated care instructions documented the resident required extensive assistance of 1 staff member for upper and lower body care. The resident had showers scheduled for Wednesday on the evening shift. On 7/25/22 at 11:32 AM, Resident #104 was observed sitting in a recliner chair in their room watching television and they had a dark substance under their fingernails. They stated they had not had a shower in 3 weeks due to the lack of hot water at the facility and they did not want to shower with cold water. They stated staff would wash them up with water from the sink in their room, but it was also cold. On 7/25/22 at 11:35 AM, the temperature of the water from the resident's room sink was taken with a probe thermometer and it measured 84.5 degrees F. During an interview on 7/27/22 at 9:21 AM, Resident #104 stated their shower was scheduled for that afternoon. The water was cold when certified nursing assistant (CNA) #25 had washed them that morning with water from their sink. During an interview with CNA #24 on 7/27/22 at 3:25 PM, they stated Resident #104 was scheduled to receive a shower that evening on the 3 PM-11 PM shift. They stated other residents were refusing to shower due to the lack of hot water. They planned to offer Resident #104 their shower after checking to see if the water was warm. If the resident refused their shower, they would reapproach the resident later. During an interview with RN Unit Manager #9 on 7/28/22 at 1:35 PM, they stated staff had been reporting the hot water was cold for a couple of months. They had felt the hot water in the sinks, it was cold, and they would not want to take a shower with the water at that temperature. Residents had reported the water was cold and they missed taking showers. Staff had been giving residents bed baths due to the lack of hot water. They never mentioned the lack of hot water to the facility's administration because they were aware of the lack of hot water in the facility. During an interview on 7/28/22 at 1:55 PM, the RN Nurse Educator #37 stated they had been aware of the lack of hot water at the facility for several weeks to a month. They provided the Unit Managers with informal education on alternative methods for bathing the residents including shampoo caps, baths in a bag, and bed baths. The Unit Managers were aware and should ensure direct care staff were aware shampoo caps and baths in a bag were available for use. On 7/29/22 at 1:11 PM, CNA #25 stated Resident #104 received their shower on Wednesday evenings. They would wash the resident at bedside using water from the room sink and sometimes it felt cold. The resident tolerated the cold water because they wanted to be washed. There were a couple of times the resident did complain the water was cold and they wanted to skip being washed. They would let the nurse know when the resident refused to be washed. 3) Resident #502 had diagnoses including Parkinson's disease. The 5/21/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and required extensive assistance with bathing. The 5/2022 care instructions documented the resident required total care with upper and lower body bathing. The resident had showers scheduled for Wednesdays on the day shift. The resident's bathroom water temperature was measured on 7/25/22 at 11:18 AM at 88 degrees F. The resident was observed on 7/26/22 at 9:28 AM, lying in bed, with a urine odor coming from the bed. At 9:34 AM, CNA #8 came to the resident's room with a basin, filled the basin with water, and provided the resident with a full body bed bath. While the CNA was filling the basin with water, the water coming from the faucet was observed to be lukewarm. During an interview with Resident #502 on 7/26/22 at 9:16 AM, they stated they had not showered in a month, and had not had their hair washed in a week. They had asked for a shower last week but had given up on asking. The water for the showers had been cold and they did not like to take cold showers. During an interview with CNA #7 on 7/27/22 at 10:46 AM, they stated a lot of residents did not want to take a shower as the water was so cold. They tried to wash faces, hands, arm pits and peri areas. They stated water had been cold for a long time. When it was warm, it would get cold really quick. During an interview with CNA #8 on 7/27/22 at 2:40 PM, they stated the resident received day shift showers and they believed it was scheduled for Wednesdays. The resident refused care because of the water temperature being cold. The water had been cold for over a month now. A lot of the residents had been declining showers because of the cold water. During an interview with registered nurse (RN) Unit Manager #9 on 7/27/22 at 11:04 AM, they stated the CNAs were responsible for completing resident showers. The RN Unit Manager was aware the water did not stay hot and affected every department, including the quality of resident care. The water had not been hot since 6/2022. During an interview with physician #13 on 7/29/22 at 10:44 AM, they stated they were not made aware of any hot water issues. During an interview with the Medical Director on 7/29/22 at 10:56 AM, they stated they were aware that there were water issues and Administration was working on getting the hot water fixed. They were not sure how long there was a hot water issue. They stated that getting cleaned and groomed and personal appearance were important for residents' quality of life. If a resident was afraid of a cold water shower, that was not good for their daily quality of life. 10 NYCRR 415.29 f (6)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the recertification survey, the facility did not ensure each resident was treated with respect and dignity for 1 of 2 residents (Resident #22) reviewed for dignity. Specifically, two staff members referred to Resident #22 in a disrespectful and undignified manner during a dining service. Findings include: The 4/2019 facility Dignity Policy documents: - Residents are to be respected by speaking respectfully, addressing the resident by the name of his/her choice, and avoid using labels for residents such as feeders. Resident #22 was admitted to the facility on [DATE] and had diagnoses including dementia, legal blindness, and major depressive disorder. The 8/8/19 Minimum Data Set (MDS) assessment documented the resident had adequate hearing, understood others, had severe cognitive impairment, and required extensive assistance of one person for eating. The undated [NAME] (certified nurse aide, CNA, care instructions) documented the resident was to eat all meals in the solarium (unit dining room), required extensive assistance of one person, and was legally blind. A 10/31/19 nursing progress note documented the resident was very sad and weepy after her husband left and she continued to cry as she sat next to the medication cart. The resident was provided emotional support, redirection, and her spirits seemed to brighten with conversation between staff and peers. A 11/4/19 nursing progress note documented the resident's diet order was ground solids, regular liquids, and her eating status was total physical assistance. On 11/4/19 at 12:52 PM the following was observed in the solarium: - Resident #22 was seated at a table with 4 other residents and one visitor. - The dining room was full of multiple residents at other tables, another visitor, and several staff members. - CNA #4 stood near the resident, and without addressing her, pointed her finger over the resident's head and said loudly is she a feeder? and immediately said again is this one in my group a feeder? - Licensed practical nurse (LPN) #3 was on the other side of the table and replied Yes, she's a feeder. During an interview with LPN #3 on 11/07/19 at 9:15 AM, she stated she recalled CNA #4 asking if the resident needed assistance during the 11/4/19 lunch meal. She stated CNA #4 asked if the resident was a feeder. LPN #3 stated it was all right to ask if the resident was a feeder during the dining service if CNA #4 did not know. LPN #3 then stated using the term feeder was probably inappropriate and CNA #4 probably should have said it differently. She stated she also used the word feeder when replying to CNA #4 and she should not have used it as it was a dignity issue and she had not thought about that before. When interviewed on 11/7/19 at 10:45 AM, CNA #5 stated care instructions were on the [NAME], including level of feeding assistance needed. Most staff referred to residents who required assistance with eating as feeders, the term was commonly used at the facility and she had not been told otherwise. She stated she thought it could be wrong to use the term because it was disrespectful, and everyone did it. During an interview with registered nurse (RN) Unit Manager #6 on 11/7/19 at 12:45 PM, she stated it was not acceptable to use the term feeder for residents who required assistance with eating, as it was disrespectful and undignified. 10 NYCRR 415.3(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and Interview during the recertification survey, the facility did not ensure residents participated in the development of their comprehensive care plans for 1 of 2 residents (Resident #94) reviewed for care plans. Specifically, Resident #94 was not invited to participate in her annual (comprehensive) care plan review meeting. Findings include: The facility's Care Planning Interdisciplinary Team policy, dated 2/21/19, documents: - Each resident and his/her family members and/or legal representative shall be permitted to participate in the development of the resident's comprehensive care plan (CCP). - The care plan is developed by a care planning/interdisciplinary teams which includes, to the extent possible, the resident, the resident's family or legal representative who should participate in the development of the care plan. Resident #94 was admitted to the facility on [DATE] and had diagnoses including hemiplegia (paralysis of one side of the body) due to stroke and contracture of muscle, multiple sites. The 9/28/19 Minimum Data Set (MDS) annual assessment documented the resident had intact cognition and had an active discharge plan. The social services progress note dated 9/27/19 at 11:30 AM documented the review type was annual, the resident was alert and oriented to person, place, time, and situation and was able to make her own decisions. Attendance at the annual review was documented and listed attendees. Attendees included social services, registered nurse (RN) Unit Manager, diet technician, and Director of Rehab. The team met and reviewed and updated care plans. There was no documented evidence the resident was invited to or attended the annual review. During an interview on 11/4/19 at 12:20 PM the resident stated she was not made aware of the annual care plan review meeting and she was not invited to attend. During an interview on 11/7/19 at 9:45 AM, social worker #16 stated an annual care plan review meeting was held on 9/27/19 for Resident #94. She could not recall if the resident attended and she did not believe she invited the resident. She stated the social worker was responsible for inviting residents in the facility and she would invite residents in person. She stated she did not document when she invited residents. She stated that she did not recall inviting Resident # 94 to her annual meeting. 10 NYCRR 415.11(c)(2)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey, the facility did not ensure each resident maintained acceptable parameters of nutritional status for 2 of 2 residents (Residents #4 and 105) reviewed for nutrition. Specifically, Resident #4 was not provided all her meal items per her meal plan and her consumption was not accurately documented. Resident #105 did not receive his nutritional supplement as ordered. Findings include: The facility's Clinical Nutrition/Dietary Policy revised 8/30/16 documents: - The purpose is to ensure that each resident is receiving menu items of their choice, within their current diet order. - To ensure all resident are provided with adequate nutrition based on their physician prescribed diet orders. 1) Resident #4 was admitted to the facility on [DATE] and had diagnoses including vascular dementia, osteoarthritis, and macular degeneration. The 10/26/19 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, required extensive assistance of one person for eating, had highly impaired vision and had not had weight loss/gain. The 10/24/19 dietary progress note documented the resident completed 58% of her meals, had decreased intake, and difficulty with self-feeding. The resident was on supplements including Ensure (nutritional drink) at breakfast and lunch, and fortified pudding at dinner. On 11/4/19 at 12:47 PM, the resident was observed in bed with her lunch meal. Her meal ticket on her tray, documented, 1/2 cup ground Caesar salad and 1 package salad dressing, 4 ounces (oz) mandarin oranges, 8 oz Ensure Plus, 4 oz cranberry juice, 8 oz water, 4 oz cottage cheese (x2), 1 chocolate ice cream, 2 oz ground baked pork chops, 2 oz au gratin potatoes and 4 oz diced beets. The resident's tray contained only the cottage cheese, mandarin oranges, cranberry juice, water, Ensure Plus, salad and salad dressing. The resident's tray did not contain any of her main lunch entrée. On 11/6/19 at 1:14 PM, the resident was observed in bed with her lunch meal. Her meal ticket on her tray, documented, 1/2 cup ground Caesar salad and 1 package salad dressing, 4 ounces (oz) mandarin oranges, 8 oz Ensure Plus, 4 oz cranberry juice, 8 oz water, 4 oz cottage cheese (x2), 1 chocolate ice cream, ½ ground Dijon chicken, 2 oz parsley boiled potatoes and 4 oz green beans. The resident's tray did not include the chicken, potatoes, or green beans. One container of cottage cheese, oranges and the resident's ice cream remained unopened on her tray. The resident consumed one container of cottage cheese and a muffin. The POC (point of care) Response History (certified nurse aide, CNA, intake documentation) included: - On 11/4/19, the resident consumed 75-100% of the cottage cheese, 100% of the Ensure, and 25-50% of her main lunch meal. The resident did not receive her main meal (meat and vegetables) on this day. - On 11/6/19, the resident consumed 51-75% of her cottage cheese, 100% of the Ensure, and 51-75% of her main lunch meal. The resident did not receive her main meal (chicken and vegetables) on this day. The undated comprehensive care plan (CCP) documented the resident was at risk for alteration in nutrition related to dementia, poor oral intake, macular degeneration, and arthritis. Interventions included supervision and set up for eating, small portion entrees, supplements on meal trays including 2 cottage cheese and Ensure at breakfast, and 2 cottage cheese and fortified pudding at lunch and dinner. When interviewed on 11/7/19 at 9:22 AM, CNA #14 stated the resident required staff to assist with her meal tray. She provided the resident with her silverware and opened all items on her meal tray as the resident had vision impairment and needed the help. The resident did not like most of the food that was sent up on her tray, so CNA #14 removed those items before she brought the tray into the room. The CNA then replaced the main meal with a muffin or a sandwich. The CNA reported the dietary department was aware the resident did not eat most of the items on her tray. When interviewed on 11/7/2019 at 10:00 AM the Registered Dietitian (RD) stated all items that were documented on the resident's meal tray ticket would be delivered to the resident on the meal tray. The meal was calculated to ensure the resident's estimated needs were being met. Staff were expected to deliver the meal tray with all the items on the ticket. If the resident then refused any food items a sandwich or replacement could be offered and documented on the meal ticket. She expected all items on the tray be opened and offered. She was not aware the resident was not receiving the meal items on her tray and did not know if the resident was meeting her estimated needs as the staff had been providing something different from what was on her ticket. During a follow up interview on 11/7/2019 at 10:30 AM, CNA #14 stated when she replaced the resident's main meal with a muffin, she calculated the percentage of what the resident consumed based on the food brought into her room and did not include the main entree and vegetables that were withheld. 2) Resident #105 was admitted to the facility on [DATE] and had diagnoses including dementia, dysphagia (difficulty swallowing) and weakness. the 10/11/19 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required limited assistance of one person for eating and was on a mechanically altered diet. The 10/7/19 dietary progress note documented the resident was not to be weighed per his advance directives, was frequently not accepting meals and snacks and meal completions were considerably decreased since the last quarterly assessment. The resident had supplements of Ensure (a nutritional drink) at each meal and Magic Cup (nutritional supplement) at lunch and dinner. The registered dietitian (RD) was to monitor intakes of the supplements. The undated comprehensive care plan (CCP) documented the resident was at risk for alteration of nutritional status related to history of skin breakdown, poor intakes, and dysphagia. Interventions included double portions at breakfast, supplements on trays, Ensure clear at breakfast, and for lunch and dinner Ensure plus and Magic Cup. All meals were to be served in the solarium. A 11/4/19 dietary progress note documented the resident was consuming 80% of Ensure at all meals and Magic Cup at lunch and dinner. Intakes at meals continued to be poor despite encouragement and alternates offered. On 11/4/19 at 1:20 PM the resident was observed in the unit dining room with his lunch meal. The resident's meal ticket documented, 8 ounces (oz) whole milk, 8 oz chocolate Ensure Plus, 4 oz Magic Cup, 8 oz cola, 1/2 cup ground Caesar salad and 1 package dressing, 1 slice yellow cake with whipped topping, 3 oz ground baked pork chop, 4 oz au gratin potatoes and 4 oz diced beets. The resident did not receive the salad, dressing, Ensure Plus, cola, or Magic Cup on his tray. On 11/5/19 from 5:21 PM to 5:47 PM, the resident was observed at the dining room table. His meal ticket documented, 4 oz mandarin oranges, 8 oz Ensure Plus, 8 oz whole milk, 8 oz ginger ale, 4 oz magic cup, 1 barbecue beef on bun, 6 oz split pea soup with 1 packet of crackers, and 4 oz corn O' [NAME]. The resident did not receive a Magic Cup with his meal. The POC (point of care) Response History (certified nurse aide, CNA, intake documentation) included: - On 11/4/19, CNA #5 recorded the resident refused Ensure and the Magic Cup at lunch and ate 0-25% of his meal; - On 11/5/19, the resident ate 0-25% of his dinner; and - There were no documented entries for the Magic Cup at dinner from 11/1-11/6/19. The [NAME] (CNA care instructions) dated 11/7/19 documented the resident eat all meal in the unit solarium (dining room), required limited assistance of one person for eating, and the supplements on meal trays were Ensure clear at breakfast, and for lunch and dinner Ensure plus and Magic Cup. During an interview on 11/7/19 at 9:15 AM, licensed practical nurse (LPN) #7 stated supplements such as Magic Cup were to arrive on the unit on the meal trays. Ensure was brought up from the kitchen on a drink cart and served in the dining room by staff per the resident's meal ticket. She stated the resident did not eat much and was more likely to drink his drinks. When interviewed on 11/7/19 at 10:00 AM, the registered dietitian (RD) stated the resident had supplements of Ensure at each meal and a Magic Cup at lunch and dinner for poor meal intake. The items should be included on his tray and if they were not, staff were to call the kitchen to obtain them. She stated she was unaware the Magic Cup with the dinner meal was not being recorded. When interviewed on 11/7/19 at 10:45 AM, CNA #5 stated Magic Cups and Ensure were provided from the unit freezer and drink cart. The items should be provided as noted on the meal ticket. She stated if Resident #105 refused food items, he did so by not eating/drinking the items rather than verbally refusing the items. She could not recall if the resident refused Ensure and the Magic Cup during the 11/4/19 lunch meal and did not recall if he was given the items at the table. 10NYCRR 415.12(i)(1)

Based on record review and interview during the recertification survey, the facility did not ensure certified nurse aide (CNA) performance reviews were completed at least once every 12 months for 2 of 2 CNAs (CNA #12 and 13) reviewed during the New York State Department of Health Nurse Aide Training Program review. Specifically, CNAs #12 and 13 did not have performance reviews documented at least once every 12 months. Findings include: The Certificate for Graduation from the CNA training program for CNA #12 was May 2018 and the Certificate for Graduation from the CNA training program for CNA #13 was August 2017. There was no documented evidence CNAs #12 and 13 had performance reviews completed at least once every 12 months. On 11/7/19 at 1:30 PM, the facility CNA Program Coordinator stated there was not an annual performance review available for CNAs #12 and 13. She was not responsible for the annual performance review of the CNAs. She said she had spoken to the Human Resources Director and they did not have a performance review for CNAs #12 and 13. 10NYCRR 415.26 (d) (7)

Based on observation and interview during the recertification survey, the facility did not provide a safe, functional environment for residents and staff for 1 isolated area (third floor short hall tub room). Specifically, the third-floor short hall tub room had a hole in the floor and the access panel door for the tub was opened and not secured. Findings include: During an observation on 11/5/19 at 10:35 AM, the floor within the third-floor short hall tub room had an approximate 4-inch circular hole in it, and the access panel door for the tub was opened and not secured. A drain line ran through this hole below the floor, and a tennis ball was found within this hole. Although the access panel door was opened, the lock was in the locked position. During an interview on 11/6/19 at 4:10 PM, the Plant Operations Director stated he was not aware that the tub in the third-floor short hall tub room had been pulled away from the wall and was not aware that there was a hole in the floor. No staff had told him about the hole in the floor or of the opened and unsecured access panel door to the tub. This was the only tub on the third floor. During an interview on 11/7/19 at 1:13 PM, certified nurse aide (CNA) #14 stated she had used the tub in the third-floor short hall tub room for two residents. She was aware of the hole in the floor and of the tennis ball in the hole. She never told the maintenance department about it. 10 NYCRR 415.29

Based on observation, record review, and interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, 3 cracked eggs were stored in an egg carton container that were leaking onto the carton of eggs below, a reach-in cooler had several pans of outdated food, the walk-in freezer had 2 inches of uneven ice buildup on the floor, and 3 boxes of food were encased within ice. Findings include: The facility's Receivable and Storage Policy, dated 1/2017, documents all foods are to be securely covered, dated, and labeled. The policy did not document how long food and beverages could be stored prior to being discarded. The work order dated 10/2/19, documented the walk- in freezer was leaking water and was serviced on 9/27/19 and rechecked on 9/30/19. The work order dated 11/4/19, documented the walk-in freezer had a buildup of condensation, water was leaking all over, and was serviced on 10/11/19. On 11/4/19 at 9:10 AM, the following was observed in a reach-in cooler in the main kitchen: - 1 pan of lettuce dated 10/25; - 1 pan of macaroni and cheese dated 10/26; - 1 pan of carrots dated 10/30; - 1 pan of French toast dated 10/31; and, - 1 plastic bag of pancakes dated 10/31. On 11/4/19 at 9:15 AM, the following was observed in the walk-in freezer in the main kitchen: - 2 inches of ice build-up on the floor in the rear of the freezer; - 1 metal scraper tool near the ice build-up; - In the front of the freezer, a 2-inch icicle hung from the ceiling vent; and, - Under the ceiling vent was a plastic container overfilled with ice placed on top of 2 boxes of pancakes and 1 box of French toast which were encased within ice. On 11/6/19 at 1:26 PM, the walk-in freezer had 3 inches of uneven ice build-up on the floor. The floor under the food storage racks was unclean with food debris. During an interview with the Food Service Director on 11/4/19 at 9:20 AM, he stated the cracked eggs should have been discarded to avoid cross contamination and food items should be discarded after 3 days to prevent food-borne illnesses. During a follow-up interview with the Food Service Director on 11/6/19 at 2:34 PM, he stated the walk-in freezer periodically had issues with ice build-up. During an interview with the Plant Operations Director on 11/6/19 at 4:20 PM, he stated the walk-in freezer started having issues a few months ago. 10 NYCRR 415.29 (j)(1)

Based on record review and interview during the recertification survey, the facility did not ensure a policy was developed regarding use and storage of foods brought to the residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not ensure the policy included a process for assisting residents in accessing and consuming the food if a resident was unable to do so on his or her own. Findings include: The facility policy titled Personal Food Storage, revised 2/2/2017, did not include documentation of a process for assisting residents in accessing and consuming the food if a resident was unable to do so on his or her own. During an interview on 11/6/19 at 2:30 PM, the Regional Food Service Director stated he was aware the policy needed to include a process for assisting residents in accessing and consuming the food if a resident was unable to do so on his or her own and the current policy did not include that process. 10 NYCRR 415.14(h)