**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 5/2/25, the facility did not ensure that residents who were unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene for one (1) (Resident #6) of two (2) residents reviewed. Specifically, Resident #6 had a moderate amount of unwanted facial hair on their upper lip, chin, and neck. The finding is: The policy titled A.M. Care, dated 4/10/2018, documented AM (morning)care will be provided for all residents in preparation for breakfast and the daily routine. Part of AM care included assisting with grooming needs: shave or clip facial hair. The policy titled Shaving a Female Resident, dated 5/8/2018, documented a nursing assistant will shave the face of a female resident, as needed, to remove extraneous facial hair. The nursing assistant is to report to immediate supervisor that the procedure was completed, any pertinent observations, and document appropriately. The policy documented to report if resident refused to be shaved. Resident #6 had diagnoses including anxiety, cognitive communication deficit (difficulty communicating their thoughts), and the need for assistance with personal care. The Minimum Data Set (a resident assessment tool) dated 2/21/25, documented they were severely cognitively impaired, sometimes understood and sometimes understands. They had no rejections of care, required partial/moderate assistance with personal hygiene, and substantial/maximum assistance for bathing/showering. The comprehensive care plan, dated 12/3/24, documented Resident #6 required one-person physical assistance for showers and received their shower on Thursdays in the afternoon. They were on anticoagulant therapy, and staff were to utilize an electric razor for shaving safety. The [NAME] (a guide used by staff to provide care) dated 5/1/25, documented Resident #6 was a partial/moderate assist (one-person physical assist) for showers, weekly on Thursdays. The Certified Nurse Aide task documentation from 4/1/25-5/1/25 documented Resident #6 was assisted with personal hygiene at least once daily, with no refusals. Showers were documented weekly. The Treatment Administration Record from 4/1/25-4/30/25 documented weekly skin assessments from the nurse. Review of the nursing progress notes dated 4/1/25-5/1/25 revealed there was no documented evidence that Resident #6 was offered or refused shaving. During an observation on 4/29/25 at 8:53 AM, Resident #6 was in their wheelchair in the main dining room, at a table with two other residents. They had visible facial hair, approximately one centimeter long on their upper lip, chin and neck. During an interview on 4/29/25 at 10:07 AM, Resident #6's family member stated they had noticed the facial hair in the past. They stated Resident #6 did not like it and they would want it shaved. Resident #6's family member stated the resident was unable to take care of it themselves. During observations on 4/30/25 at 11:07 AM in the dining room, and 5/1/25 at 7:40 AM in the common area on West, Resident #6 was in their wheelchair. They had visible facial hair, approximately one centimeter long on their upper lip, chin and neck. During an interview on 5/1/25 at 9:45 AM, Registered Nurse #1, Unit Manager stated Certified Nurse Aides should shave residents on their shower days, but they should offer to shave them whenever they notice visible facial hair. If a resident refused to be shaved it should be documented. They had not been told that Resident #6 refused to be shaved. During an interview on 5/1/25 at 9:55 AM, Registered Nurse #2 stated Certified Nurse Aides should shave the residents on their shower day, or whenever they notice there is unwanted facial hair. They had not been informed Resident #6 refused to be shaved. They did not know when Resident #6 was last shaved. During an interview on 5/1/25 at 10:02 AM, Certified Nurse Aide #1 stated Resident #6 got up before 7:00 AM on 5/1/25. They stated they provided AM care, including washing face and hands, under arms, brushing hair, and incontinent care. Certified Nurse Aide #1 stated they did not notice Resident #6 had visible facial hair. They stated residents were usually offered shaving on their shower day, but they should offer to shave them if they notice visible hair. They stated it was important to shave unwanted facial hair for dignity. Certified Nurse Aide #1 stated they did not know when the last time Resident #6 was offered to be shaved because they didn't work on their unit very often. During an interview on 5/2/25 at 8:53 AM, Certified Nurse Aide #2 stated there was no set schedule for shaving residents' facial hair. Staff should offer to shave them at least on their shower day, or whenever they notice it. They did not know when the last time Resident #6 was shaved. During an interview on 5/2/25 at 9:43 AM, the Director of Nursing stated Certified Nurse Aides were responsible for shaving the residents' facial hair. They stated the residents should be offered to be shaved on their shower days, and any time staff notice they have visible facial hair. The Director of Nursing stated it was very important for unwanted facial hair to be removed for the resident's dignity and self-esteem. 10NYCRR 415.12 (a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review conducted during a Standard survey completed on 5/2/25, the facility did not ensure that they established and maintained 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 one (1) (Resident #54) of four (4) residents observed for infection prevention and control during care. Specifically, staff did not wear personal protective equipment including gowns while providing incontinent care for Resident #54 who had ESBLs (extended spectrum beta-lactamase-an infection caused by antibiotic resistant bacterial enzymes) in their urine. The finding is: The policy titled Transmission Based Precaution Levels (Type of Infection Condition, Techniques, and Documentation) Skilled Nursing Facility dated 6/6/2024 documented that enhanced barrier precautions involved gown and glove use during high contact resident care activities (including changing incontinence briefs) for residents known to be colonized or infected with a multi drug resistant organism as well as those at an increased risk of multi drug resistant organism acquisition. Resident #54 was admitted to the facility with diagnoses of type 2 diabetes, chronic kidney failure, and muscle weakness. Review of the Minimum Data Set (a resident assessment tool) dated 3/14/2025 documented that Resident #54 was severely cognitively impaired and was dependent on staff for toileting. The enhanced barrier precautions list, provided by the Assistant Director of Nursing/Infection Preventionist, dated April 2025 documented that Resident #54 was on enhanced barrier precautions for having ESBLs in their urine. The comprehensive care plan dated 4/11/2025 documented that Resident #54 was totally dependent on two staff members for toileting. The [NAME] (used by staff to guide care) dated 5/1/2025 documented that Resident #54 was always incontinent of urine and to check their brief after meals. Laboratory reports for Resident #54 from 2/16/2025 to 4/21/2025 documented the following: 2/16/2025 - colony count greater than 100,000 CFU (colony forming unit)/ml (milliliter) of Escherichia coli (ESBL) bacteria in their urine. 4/21/2025 -colony count greater than 100,000 CFU/ml of Escherichia coli (ESBL) bacteria in their urine. During an observation of Resident #54's room on 4/30/2025 at 11:00 AM, revealed a blue diamond on the name plate outside the resident's door. Observation in Resident #54's room revealed a poster with enhanced barrier precautions and what personal protective equipment staff were to wear during care for residents. There was a container attached to the wall next to the door that contained yellow gowns to wear when care was performed. During an observation of incontinent care on 4/30/2025 at 11:00 AM, Certified Nurse Assistant #3 and Certified Nurse Assistant #4 donned gloves to change Resident #54's wet incontinence brief. They did not wear gowns while Resident #54's brief was changed. During an interview on 4/30/2025 at 11:17 AM, Certified Nurse Assistant #4 observed the blue diamond on the resident's name plate and stated that meant the resident was on enhanced barrier precautions. Certified Nurse Assistant #4 stated that they should have worn a gown when they performed incontinent care for Resident #54. During an interview on 4/30/2025 at 11:18 AM with Certified Nurse Assistant #3, they stated that Resident #54 was on enhanced barrier precautions, and they should have worn a gown when they performed incontinent care. Certified Nurse Assistant #3 stated that there could be cross contamination between residents if a disposable gown was not worn. During an interview on 4/30/2025 at 11:20 AM with Registered Nurse Unit Manager #3, they stated they expected staff to wear the appropriate personal protective equipment when they performed incontinent care. Registered Nurse Unit Manager #3 they stated that Resident #54 had a history of ESBL in their urine and that was why Resident #54 was on enhanced barrier precautions. Registered Nurse Unit Manager #3 stated that gowns should have been worn by staff because they risked getting bacteria on their clothes and they could spread the bacteria to other residents. During an interview on 5/1/2025 at 12:55 PM with Assistant Director of Nursing/Infection Preventionist, they stated that any resident with open areas, catheters, or ESBLs in their urine, staff were required to wear gowns and gloves during care. They stated that the blue diamond on the resident's name plate indicated that the resident was on enhanced barrier precautions. They stated that they had posters on the back of the resident's room doors that let staff know what type of personal protective equipment to wear when care was performed. They stated that there was a bin on the wall that contained gowns for staff to wear when they performed care, and they expected staff to wear them. They stated that staff were to wear gowns and gloves so that they did not spread bacteria to other residents. During an interview on 5/1/2025 at 1:07 PM with the Director of Nursing, they stated that they expected staff to wear appropriate personal protection equipment when they performed care on a resident with a history of urinary tract infections. During an interview on 5/2/2025 at 9:00 AM, Physician #1 stated they expected staff to wear a gown and gloves when they performed incontinent care especially for a resident with ESBL in their urine. 10NYCRR 415.19(a)(2)

Based on observation, record review, and interviews conducted during a Standard survey completed on 6/6/23, the facility did not ensure each resident was treated with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #66) of two residents reviewed. Specifically, the facility did not ensure Resident #1 was treated with respect and dignity by a Certified Nurse Aide (CNA) while providing morning care. The finding is: The policy and procedure (P&P) titled Dignity dated 8/1/19, documented each resident has the right to be treated with dignity and respect. All activities and interactions with residents by any staff must focus on assisting the resident in maintaining his or her self-esteem and self-worth. 1. Resident #66 had diagnoses including chronic respiratory failure, diabetes, and depression. The Minimum Data Set (MDS-a resident assessment tool) dated 5/10/23 documented Resident #66 was cognitively intact and required extensive assist with bed mobility and toileting. Review of the comprehensive care plan revised 5/23/23 revealed Resident #66 had an ADL (activities of daily living) deficit and required total assistance for toileting hygiene and was frequently incontinent of bowel. During an observation of morning care on 6/2/23 at 10:00 AM, CNA #1 brought linens into Resident #66's room, went into the bathroom, and let the water run, donned (put on) gloves and the resident stated you'll need more washcloths than that. At 10:01 AM, CNA #1 removed their gloves and stated they'd get some wipes and then stated, I really want to go home, then left the room. Resident #1 stated this was CNA #1's typical attitude and they always acted this way. The resident stated they did not feel the statement was dignified. At 10:03 AM, CNA #1 returned to the room and got the resident's personal clothes out of the closet, put the resident's head of bed down, went to the bathroom and stated, no gloves and you see why I want to go home. During an interview on 6/2/23 at 10:24 AM, CNA #1 stated they normally didn't speak that way in front of a resident and they were having an off day. During an interview on 6/2/23 at 11:18 AM, the Registered Nurse (RN) Unit Manager (UM) #1 stated staff should not be saying that they want to go home in front of a resident because it was inappropriate, rude and could make the resident feel like they did something wrong. The RN UM #1 stated it was a dignity issue. During an interview on 6/6/23 at 11:05 AM, the Director of Nursing (DON) stated the statement made by CNA #1 sounded like they were being rude and that wasn't what they expected regarding customer service toward residents. 10 NYCRR 415.5(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Complaint investigation (NY00316113) during a Standard survey completed on 6/6/23, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for three (Residents #39, #74 and #101) of six residents reviewed for ADL's. Specifically, Residents #39 and #74 did not receive assistance with toileting needs as per their plans of care and Resident #101 did not receive assistance with their preferred number of showers per week as per their plan of care. The findings are: The policy and procedure (P&P) titled Perineal Incontinent Care documented perineal care will be provided with AM & HS (bedtime) care and when residents are incontinent or cannot provide such care for themselves. Nursing Assistants will provide incontinent care for residents. Perineal care will be given to cleanse the genital area, to prevent infections and to eliminate odors. The P&P titled ADL Assistance and Supervision dated 1/4/2018 documented, the Unit Manager/designee will ensure that a plan of care for receiving ADLS assistance and/or supervision is incorporated into the daily nursing care of each resident. The Team Leader provides a daily report to the Nursing Assistants regarding the ADL assistance/ supervision status of each assigned resident as needed. The Team Leader monitors the ADL assistance/ supervision provided for residents throughout the shift and gives appropriate guidance and assistance to Nursing Assistants. The P&P titled Bath, Tub/Shower dated 8/7/21 documented a tub bath or shower will be given to provide comfort and relaxation. A tub bath or shower will be given once a week and/or as deemed necessary to all residents or per resident preference. 1. Resident #39 had diagnoses that included dementia with agitation, peripheral vascular disease (PVD- poor circulation of lower extremities), and major depressive disorder. The Minimum Data Set (MDS - a resident assessment tool) dated 3/23/23 documented Resident # 39 had severe cognitive impairment and did not exhibit rejection of care. The resident required total assistance of two persons for toilet use (includes cleanses self after elimination, changes pad, adjusts clothes). Resident #39's undated comprehensive care plan (CCP) identified as current by the Director of Nursing (DON), documented Resident #39 had decreased ADL function and was always incontinent of bowel and bladder. Interventions included the use of incontinence products (brief), provide prompt incontinent care and check, and change every 2 to 4 hours and required total dependence of one person for incontinence care. Resident #39's undated [NAME] (a guide used by staff to provide care) identified as current by the DON, documented the resident was always incontinent of bowel and bladder. Instructions included to check and change every 2 to 4 hours, incontinent product (brief) and requires total dependence of one person. Review of Resident #39's Progress Notes dated 5/13/23 through 6/6/23 revealed there was no documented evidence the resident refused incontinence care. During a continuous observation on 6/2/23 at 8:57 AM through 1:38 PM, Resident #39 was seated in a Broda chair (specialized wheelchair) in the [NAME] Unit Lounge and was not checked for incontinence. At 1:38 PM Resident #39 was transported from the lounge to activity off the Unit. During an interview on 6/2/23 at 1:41 PM, Certified Nursing Assistant (CNA) #3 stated they were assisted CNA #10 on 6/2/23 with morning care and transferring Resident #39 out of bed before breakfast approximately 8:30 AM. CNA #3 stated they had not checked or provided incontinent care to Resident #39 after 8:30 AM and did not know if CNA #10 had checked and provided care to Resident #39 before leaving the facility at 1:00 PM. CNA #3 stated Resident #39 was unable to communicate if they were incontinent and should be checked and changed every 2 - 4 hours according to the plan of care for dignity and prevent skin breakdown. During an interview on 6/2/23 at 1:57 PM CNA #7 stated they had not assisted CNA #10 with Resident #39, had not provided any care, or checked the resident for incontinence on 6/2/23. CNA #10 stated they did not know if CNA #10 had checked and provided care to Resident #39 before leaving the facility at 1:00 PM. CNA #7 stated Resident #39 was unable to communicate if they were incontinent and should be checked and changed every 2 to 4 hours according to the plan of care for dignity, prevent urinary tract infections and skin breakdown. During an interview on 6/2/23 at 3:04 PM, CNA #8 stated they had removed Resident #39 from an activity at 2:30 PM to check the resident for incontinence. The resident was incontinent of both bladder and bowel, required incontinence care and did not know how long the resident was sitting in their urine and feces. CNA #8 stated if Resident #39 was last provided care prior to breakfast at approximately 8:30 AM then they should have been checked for incontinence no later than 12:30 PM because the resident was unable to communicate if they were incontinent. Resident #39 was care planned to be checked and changed every 2 to 4 hours for dignity and prevent skin breakdown. During an interview on 6/2/23 at 3:19 PM, Registered Nurse (RN) #3 stated Resident #39 was care planned to be checked and changed every 2 to 4 hours, was totally dependent on staff for incontinence care to maintain dignity, good hygiene, and skin integrity; and was unable to communicate if they were incontinent. RN # 3 stated if Resident #39 last received care at approximately 8:30 AM then CNA #10 should have ensured the resident was checked for incontinence by 12:30 PM. During an interview on 6/5/23 at 1:00 PM CNA #10 stated they were responsible for providing care to Resident #39 on 6/2/23 until 1 PM when they had left the facility. CNA #10 stated Resident #39 was provided incontinent care before breakfast at approximate 8:30 AM and should have been checked and changed every 2 to 4 hours according to their plan of care but was not because they didn't have time. CNA #10 stated the resident should have checked by 12:30 PM for incontinence and provided care as needed before they had left the facility. During an interview on 6/6/23 at 10:43 AM, RN Unit Manager (UM) #4 stated Resident #39 was totally dependent on staff to maintain hygiene including incontinence care and was to be checked and changed every 2 to 4 hours according to the plan of care. RN UM #4 stated they would have expected CNA #10 to communicate to the remaining CNA and nurses they were unable to check and change the resident per their plan of care prior to leaving the facility. RN UM #4 stated the CNAs should be following the plan of care and the staff nurses were responsible to ensure the plan of care was followed and incontinent care is provided timely. RN UM #4 stated they were ultimately responsible to ensure the staff were following the plan of care for all residents. 2. Resident #74 had diagnoses that included Alzheimer's Disease, dementia with severe agitation and anxiety, and cognitive communication deficit. The MDS dated [DATE] documented Resident #74 was rarely/never understood and understands. The resident required extensive assistance of two persons for toileting and was always incontinent. Resident #74's comprehensive care plan (CCP) last revised 10/6/22, documented Resident #74 was always incontinent of bowel and bladder. Interventions included to offer toileting after meals (initiated: 12/21/22); incontinent care every 2-4 hours and as needed (initiated: 6/6/23) and to provide prompt incontinent care (initiated 10/6/22). The CCP revised on 12/8/22 documented Resident #74 required total dependence for hygiene; two-person extensive physical assist for transfers and toileting. The Follow Up Question Report dated 5/31/2023 - 6/6/2023 did not document toilet use for Resident #74 during day shift hours 6:00 AM to 2:00 PM. Review of the [NAME] for Resident #74's with an as of date of 6/6/23 revealed it was reflective of the CCP regarding the resident's toileting needs. Review of Resident #74's Progress Notes dated 5/22/23 through 6/6/23 revealed there was no documented evidence the resident refused incontinence care. During intermittent observations on 6/2/23 at 8:43 AM through 11:48 AM, Resident #74 was seated in scoop wheelchair in the East Unit Lounge in front of a table. 8:43 AM- the resident was fidgety, moving, and repositioning legs frequently. 8:57 AM- the resident was still fidgety and making crying noises. 9:22 AM- the resident was placing their legs over the arm rest on scoop chair, mumbling and making crying noises 10:19 AM- the resident was sleeping with their head in downward position with their chin to their chest. During continuous observations on 6/2/23 at 11:48 AM through 2:00 PM, Resident #74 remained seated in scoop wheelchair in the East Unit Lounge in front of a table and was not checked for incontinence. During an observation on 6/02/23 at 1:06 PM, while on East Unit, CNA #11 was heard saying out loud while walking down hallway in front of lounge where residents were seated, there is no way we are going to be able to change all these residents and put them into bed. During an interview on 6/2/23 at 1:50 PM, Resident #74 responded yes when asked if they were wet and needed to be changed. During an interview on 6/2/23 at 2:04 PM, CNA #2 stated they were assigned to Resident #74 and that they had not toileted Resident #74 since getting them up around 6:30 AM. CNA #2 stated they had no idea about Resident #74's incontinent care frequency but should be checking them every 2 hours. CNA #2 stated they were unable to check Resident #74 because they had so many residents, and Resident #74 required two- assist. CNA #2 stated they did not report to anyone that they needed help and could not meet #74's care needs timely. During an interview on 6/2/23 at 2:11 PM, Licensed Practical Nurse Team Leader (LPN) #5 stated Resident #74 was unable to voice their needs and would get worked up if they needed something. LPN # 5 stated the unit dropped down to 2 CNAs before lunch and was not informed that Resident #74 hadn't been toileted and should have been. LPN #5 stated some residents were unable to tell staff when they need to be changed and this places them at risk for urinary tract infections (UTIs), skin issues, and safety risk-falls. During an interview on 6/2/23 at 3:28 PM, RN UM #1 stated their expectation was that residents were toileted every 2-4 hours to prevent skin breakdown, falls, UTI's and for comfort. RN #1 stated there wasn't enough time and hands with having only 3 aides on the unit. RN #1 stated there were 42 residents on the East Unit and when staffed with 3 aide's residents may not be toileted or provided incontinent care as often as they should be. The priority was to keep them safe, feed and attend to them as quickly and efficiently as possible. Additionally, RN UM #1 stated Resident #74 should have been checked and had they been informed, they could have helped. During an interview on 6/6/23 at 2:51 PM, the DON stated Resident #74 was incontinent, totally dependent on staff and had a care plan for providing incontinent care every 2 - 4 hours. The DON stated CNA #2 should have informed the team leader and/or the Unit Manager that they were unable to provide care as planned for Resident #74, so the care could be provided. 3. Resident #101 had diagnoses that included fracture of left lower leg, depression, and anxiety. The MDS dated [DATE] documented Resident #101 was understood, understands and was cognitively intact. The CCP initiated on 4/21/23 documented under Customary Routine Resident #101 preferred a shower two times a week, every Thursday and Sunday. The [NAME] documented Resident #101 was to receive a shower on the 7AM to 3PM shift every Thursday and Sunday. The undated North Unit Shower List documented Resident #101 was to receive a shower on the 7 AM to 3 PM shift every Thursday and Sunday. The Bathing Schedule Task Report date 5/11/23 through 6/2/23 documented Resident #101 only received a shower on 5/26/23. Review of the Progress Notes dated 5/11/23 through 6/5/23 revealed there was no documented evidence Resident #101 received a bath/ shower or refused showers. During an interview on 6/02/23 at 12:33 PM, Resident #101 stated they did not get shower yesterday (6/1, Thursday) and was suppose too. During an interview on 6/06/23 at 9:51 AM, Resident #101 stated they did not get a shower on Sunday (6/4) and has only had a couple showers since admission about a month ago. They did get a shower today when they asked the aide for one because they had a doctor's appointment today. Resident #101 also stated they don't feel they should have to ask for their showers if they are scheduled. During an interview on 06/06/23 at 10:10 AM, CNA #5 stated they worked on Sunday with another aide CNA #12 and did not provide care for the resident and was unsure if Resident #101 received a shower. During the survey attempts were made to contact CNA #12 without success. During an interview on 6/6/23 at 10:32 AM, LPN #3 stated the residents should get their shower or bath on assigned days, if the resident refuses the aide should tell the nurse and the nurse should encourage the resident. If the resident still refuses it should be document in in the electronic medical record (EMR). During an interview on 6/6/23 at 12:29 PM, LPN #4 stated they usually work full time on the North Unit and were familiar with Resident #101. Sometimes the resident will refuse their shower because they like to sleep in and I'll go talk to the resident and encourage them, but they do not document if the resident refuses in the EMR. LPN #4 was unsure if the resident was re-offered a shower on 6/1/23 and 6/4/23. During an interview on 6/6/23 at 1:40 PM, RN UM #2 stated they were responsible for assigning resident shower days. The aides should report to the nurses if the resident refuses and it should be documented and offered the next shift or the next day. Residents should get their showers on their assigned days. During an interview on 6/6/23 at 2:18 PM, the DON stated they would expect the resident to get showers per their preference and plan of care, if it's not done for whatever reason the CNA should tell the nurse and the nurse should document a reason in the EMR. 10 NYCRR 415.12 (A)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 6/6/23, the facility did not 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 infection for two (Residents #35 and 66) of four residents reviewed for infection control practices during personal care. Specifically, staff did not perform adequate hand hygiene while providing fecal incontinence care (Resident #66) and pressure sore treatment (Resident #35). Additionally, when emptying a urinary drainage collection bag, staff did not use a barrier on the floor or alcohol to wipe the collection bag drain tube (Resident #35). The findings are: The policy and procedure (P&P) titled Handwashing Technique dated 3/19/20, documented staff were instructed to use the proper handwashing techniques under the following circumstances: after contact with contaminated linen, object, or article; before handling any item that was to be maintained in a clean state such as linens, dishes, etc. The P&P titled Dressing, Clean, Wound, Incision dated 8/6/19 documented staff were to remove soiled dressing, discard gloves and perform hand hygiene, apply nonsterile gloves, and cleanse the wound as ordered, apply topical medication as ordered, and place appropriate dressings over the wound. The P&P titled Catheter: Emptying/Changing of Urinary Drainage Bag dated 9/18/20, documented residents with indwelling catheters will have regular catheter care including emptying of drainage bag for purposes of preventing urinary tract infections. Steps of the procedure included placing a barrier pad on the floor and placing the graduated cylinder (used to measure volume of liquid) on top of the pad and under the collection bag tubing, disconnect the catheter tubing from the collection bag, allow all urine to drain into the graduated cylinder, cleanse end of catheter tubing with an alcohol wipe and reconnect the tubing to the collection bag. 1. Resident #35 had diagnoses including stage 4 pressure ulcer (full thickness tissue loss with exposed bones, tendons, or muscles) of the sacrum (area above the tailbone on right and left buttocks) and left buttock, diabetes, and depression. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 4/8/23 documented Resident #35 was cognitively intact, had an indwelling urinary catheter, and had two stage 4 pressure ulcers. Review of the comprehensive care plan (CCP) dated 1/30/23 documented Resident #35 had an indwelling urinary catheter that was used for wound management, staff were to empty the urine and record the output every shift and had a urinary tract infection (UTI). The CCP documented the resident had stage 4 pressure ulcers on their sacrum and ischial tuberosity (the curved bone that makes up the bottom of the pelvis). Interventions included to assess for signs of infection (drainage, redness, odor). Review of the Order Summary Report dated 6/5/23, revealed an active order dated 1/30/23 for a urinary catheter 16 Fr (French- gauge system used to measure the size of the catheter).There were orders dated 4/7/23 to irrigate the sacral wound with Dakin's solution (used to kill germs and prevent germ growth in wounds), pack wound with calcium alginate (highly absorptive dressing), then cover with a dry clean dressing (DCD); and to irrigate the left ischial tuberosity with Dakin's solution daily, pack with iodoform (aseptic gauze packing strip, pat dry, and cover with a DCD. During an observation of wound care on 6/2/23 at 1:20 PM, Licensed Practical Nurse (LPN) #1 placed treatment items on the resident's overbed table, and applied gloves. Certified Nurse Aide (CNA) #11 performed catheter care, then LPN #1 and CNA #11 turned Resident #35 onto their left side. The resident was incontinent of stool. LPN #1 used washcloths to provide bowel incontinence care, dried the area and applied barrier cream to the resident's upper posterior thighs and lower buttocks. Without changing their gloves and performing hand hygiene, LPN #1 removed the dressing on the resident's sacrum, irrigated the sacrum and ischial pressure ulcers with Dakin's solution, packed each ulcer, and covered with a DCD. LPN #1 removed their gloves and donned (put on) new gloves without performing hand hygiene, obtained the graduated cylinder from the resident's bathroom and placed it directly on the floor under the urinary collection bag. LPN #1 removed the catheter drain tube, opened the clamp and emptied urine from the collection bag into the graduated cylinder. LPN #1 re-clamped and refastened the drain tube to the collection bag without cleaning the end of the tubing with an alcohol wipe. LPN #1 emptied the urine into the toilet and placed the graduate back onto the shelf. LPN #1 then removed their right glove, picked up soiled linen that had been on the floor and exited the room without performing hand hygiene. During an interview on 6/2/23 at 1:55 PM, LPN #1 stated they didn't change their gloves after providing bowel incontinence care, and before they completed the resident's pressure ulcer treatments. LPN #1 stated they didn't expect Resident #35 to have had a bowel movement and didn't have another pair of gloves. The LPN #1 stated they should have changed their gloves so they wouldn't cross contaminate the ulcers. LPN #1 stated they emptied the urinary collection bag without using a barrier on the floor and an alcohol pad to clean the tubing. The LPN #1 stated they had never used an alcohol pad when emptying an indwelling catheter and didn't know if it was the facility policy. LPN #1 stated Resident #35 had a UTI about a month ago and seemed to get them a lot. During an interview on 6/6/23 at 11:37 AM, Registered Nurse (RN) Unit Manager (UM) #1 stated they expected that LPN #1 changed their gloves and performed hand hygiene after providing incontinent care and again after removing the old dressings to the resident's pressure sores. The RN UM #1 stated this was for infection control purposes, they could have cross contaminated the wounds and that this Resident #35 had one wound infection since January. RN UM #1 stated the proper procedure for emptying the urinary collection bag was to put a barrier on the floor, place the graduated cylinder on it and the collection bag tubing should have been cleaned with alcohol wipes before and after emptying the urine from the bag. The RN UM #1 stated this was for infection prevention and Resident #35 had a history of UTIs and had one recently in May. During an interview on 6/6/23 at 2:13 PM, the Director of Nursing/Infection Preventionist (DON/IP) stated they would have expected the LPN #1 to remove their gloves and wash their hands after providing bowel incontinence care and before they performed the clean portion of the treatment to prevent contamination and exposure to infectious organisms. The DON/IP stated the UM and themselves were supposed to ensure nurses were providing care correctly. The DON/IP stated the LPN #1 should have put a barrier on the floor and used an alcohol pad before reconnecting the drainage tube to the collection bag to prevent infection. 2. Resident #66 had diagnoses including chronic respiratory failure, diabetes, and depression. The MDS dated [DATE] documented Resident #66 was cognitively intact and required extensive assist by staff with bed mobility and toileting. Review of the comprehensive care plan revised 5/23/23 revealed the resident had an ADL (activities of daily living) deficit and required total assistance for toileting hygiene by staff and was frequently incontinent of bowel. During an observation of morning care on 6/2/23 at 10:08 AM, CNA #1 donned gloves and washed the resident's underarms, applied deodorant, and put the resident's dress on. The CNA #1 then unfastened the incontinence brief and cleaned the resident's genitals and bilateral groins. Resident #66 then turned onto their right side and the incontinence brief was soiled with a large amount of stool. CNA #1 removed the soiled brief and used multiple wet wipes to clean stool from the resident's buttocks and sacrum. The CNA #1 touched the resident's buttocks with both hands to ensure the resident's rectal area was clean, then applied barrier cream to the buttocks and sacrum. CNA #1 applied a clean brief, had resident turn onto left side to smooth out the brief and fastened it. CNA #1 then pulled the resident's dress down, put a pillow under the resident's right leg, covered the resident with a sheet, retrieved a hair clip from the resident's bedside stand and handed it to the resident, closed the privacy curtain without changing their gloves and washing their hands. During an interview on 6/2/23 at 10:24 AM, CNA #1 stated for sanitary purposes they should have changed their gloves and washed their hands after cleaning stool from the resident. During an interview on 6/2/23 at 11:18 AM, the RN UM #1 stated CNA #1 should have changed their gloves and washed their hands after providing bowel incontinence care and applying barrier cream so that they did not spread bacteria throughout the room and back onto the resident who was now clean. During an interview on 6/6/23 at 11:05 AM, the DON/IP stated staff should change their gloves when soiled and would have expected CNA #1 to remove their dirty gloves, wash their hands and apply clean gloves to finish the tasks for Resident #66. 10 NYCRR 415.19(a)(1)(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during Complaint investigations (#NY00309961, #NY00316113) during the Standard survey completed on 6/6/23, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for three (East, West, North Units) of three resident care units. Specifically, the facility did not have adequate nursing staff based on the facility's established minimum number of staff for each unit and each shift. There was lack of answering resident call lights timely and providing toileting/incontinence care as planned. Resident's beds were not made, and residents didn't receive their medication on the East Unit the evening of 6/4/23. Additionally, the Facility Assessment did not include the minimal staffing numbers needed in order to care for their resident population. Resident #'s 3, 4, 8, 9, 12, 15, 16, 17, 20, 22, 32, 35, 37, 42, 44, 45, 46, 55, 56, 57, 58, 66, 74, 79, 81, 86, 89, 93 and 101 were involved. Resident Room #'s 24C, 25B, 26A, 27A and 28B were involved. The findings are: Refer to F677-Activities of Daily Living, scope and severity (S/S) =D 1a. Review of the Facility Assessment dated 2/28/23 documented the facility's average daily census was 105 residents. The facility assessment documented staffing needs were based on total resident population, resident acuity, and facility layout. Refer to the attached master staffing plan. There was no master staffing plan attached to the facility assessment. Review of the Master Staffing Plan 2023 provided by the Administrator on 6/1/23 at 11:24 AM, revealed on the LTC (long term care) units (East/West Unit) day shift had two Registered Nurse (RN)/Licensed Practical Nurse (LPN) team leaders and 4/5 nurse assistants 7 days per week. Evening shift had two RN/LPN team leaders and 3/4 nurse assistants 7 days per week. The Administrator stated this was the master plan that should have been attached to the Facility Assessment. Review of the Facility Assessment Direct Care Nursing Staffing Plan dated 6/5/23, provided by the Director of Nursing (DON) on 6/5/23 at 4:20 PM, revealed minimum nursing staff numbers, for an anticipated average census of 103, as follows: day shift nurses 4.5, Certified Nurse Aides (CNAs) 8. Evening shift nurses 4.5, CNAs 8. Night shift nurses 3, CNAs 3. Review of the Daily Staffing Sheets from 5/20/23 to 6/4/23 documented the facility did not meet their minimum number of CNAs on: 5/20/23 evening shift - 6.5 (down 1.5) 5/21/23 day shift - 6 (down 2) 5/21/23 evening shift - 6.75 (down 1.25) 5/22/23 evening shift - 6.75 (down 1.25) 5/25/23 evening shift - 7.5 (down .5) 5/27/23 day shift -7 (down 1) 5/28/23 day shift - 7 (down 1) 5/28/23 evening shift - 6.5 (down 1.5) 5/29/23 evening shift -6 (down 2) 5/31/23 evening shift- 6.5 (down 1.5) 6/4/23 day shift - 7 (down 1) 6/4/23 evening shift - 6 (down 2) 6/5/23 day shift - 5 (3 Unit Managers were listed as help CNA) During an interview on 6/5/23 at 8:39 AM, the Staffing and Labor Operations Specialist stated they used the adequate staffing grid provided by the Administrator for their staffing numbers, and it was based on the facility census. At 3:34 PM, the Staffing Specialist stated they used the adequate staffing column as their minimum staffing numbers. During an interview on 6/5/23 at 3:38 PM, the Regional Nurse Consultant stated the adequate staffing grid was not what was used for their minimum staffing numbers, and they would provide it. During an interview on 6/5/23 at 3:42 PM, the Staffing and Labor Operations Specialist stated they had many vacant positions in the facility that included for day shift 2 full time and 7 part time CNAs, evening shift 6 full time and 8 part time CNAs. They stated the facility used agency staff and they had one full time contract CNA which gets a fixed schedule and works every other weekend. The rest was made up of agency per diem CNAs who worked as their schedules allowed. The Staffing and Labor Operations Specialist stated it was hit or miss whether staff would be enticed by offered weekend bonuses. The Staffing and Labor Operations Specialist stated they worked with the DON and stated the Daily Staffing Sheets were the most accurate documentation of their facility staffing. During an interview on 6/5/23 at 4:20 PM, with the Regional Nurse Consultant present, the DON stated when the facility falls below the minimum staffing levels, they (the DON) go into the facility to assist. The DON stated they were at the facility Saturday (6/3) and Sunday (6/4) evenings to help pass dinner trays, answer call lights, and speak with family members to help. The Assistant Director of Nursing (ADON) also worked. The DON stated they were at the facility until after dinner but couldn't give a specific time. The DON stated today (6/5) they had many call ins (3 CNAs, 2 nurses, and 1 unit clerk), so the unit managers worked as CNAs. Sometimes the managers do have to take an assignment, however this morning would have been hard because of doctor rounds. During an interview on 6/6/23 at 10:25 AM, the DON stated the minimal staffing numbers (Facility Assessment Direct Care Nursing Staffing Plan) was dated 6/5/23 but had been in place since Spring of 2022. The DON stated according to the Daily Staffing Sheets dated 5/20/23, 5/21/23, 5/22/23, 5/25/23, 5/29/23, 5/31/23, and 6/4/23 the facility did not meet their minimum number of 8 CNAs and was aware they didn't meet the minimums. The DON stated on 6/5/23 they had 5 actual CNAs working, the 3 RN Unit Managers worked as CNAs. The DON stated the RN Unit Manager on the North Unit helped with the morning medication pass, then worked as a CNA. The DON stated they themselves, the Regional Nurse Consultant, and activity staff were on the units helping. 1b. Review of Resident Council Minutes revealed the following: - 3/23/23 meeting notes documented the residents voiced concerns that there are not enough staff on the units on the weekends. - 4/20/23 meeting notes documented, Old Business- Residents reported that there aren't enough staff in the building on the weekend. It was also documented in the minutes the issue was not resolved to their satisfaction, and the minutes were reviewed and signed by the Administrator. - 5/18/23 meeting notes documented, Old Business- revealed the minutes did not address the resident's previously voiced concern of their dissatisfaction regarding their staffing concerns. During a Resident Council meeting held on 6/1/23 at 10:07 AM with 11 residents participating, they stated at times their call lights were not answered for up to an hour while waiting for their needs to be met such as toileting; returning to bed and receiving their meals. The Residents stated there was poor staffing during the week on days and evening shift, and especially short staffing on the weekends during the day and evening shifts. 1c. Interviews with Residents and Family Members: During an interview on 5/31/23 at 11:01 AM, Resident #66 stated the facility was hideously understaffed. It was difficult for them because they would call for a bed pan, the staff wouldn't come, so they don't get the bedpan. Wait times vary for call light response, but sometimes they've waited up to an hour. During an interview on 5/31/23 at 12:39 PM, an anonymous family member stated nothing was on time; medications, meals, and answering of call lights. During an interview on 5/31/23 at 12:54 PM, Resident #101 stated the facility was always short staffed and most of the time there was one aide on the evening shift. The resident stated that weekends were the worst, they had to wait a long time to go to bed, sometimes until 11:30 PM at night. During an interview on 5/31/23 at 1:12 PM, Resident #35 stated there was not enough staff in the building and they could wait 30 to 45 minutes for staff to respond to their call bell when they wanted their pain medication. During an interview on 5/31/23 at 3:39 PM, Resident #4 stated there was not enough staff in the building. They would have to wait 15 minutes and sometimes up to an hour for their call light to be answered. If they can't hold it they end up urinating in their brief and then they feel terrible. During an interview on 6/1/23 at 3:06 PM, CNA #4 (East Unit) stated they usually only work with 2 CNAs on the evening shift, and it has been that way for the past year. They can't get everything done, showers, stocking rooms with gloves/soap. CNA #4 stated the residents get upset with them, sometimes they can't put everyone to bed by the end of their shift. During an interview on 6/2/23 at 11:14 AM, LPN #5 (East Unit) stated staffing in the facility was very poor and unfair to the residents, and staff can't get to the residents in a timely manner. LPN #5 stated the East Unit usually only had 2 to 3 aides on the day shift, and they were frequently asked to stay/work over 2-3 times a week. LPN #5 stated the staffing was even worse on the weekends, usually only 1-2 aides on a unit and short nurses. During an interview on 6/2/23 at 1:58 PM, CNA #5 stated the North Unit was often short staffed. Most of the time they have two aides on the unit, it's hard to get all the work done, and they usually don't take a break. There have been times, they were the only aide on the unit. CNA #5 stated sometimes management comes in to help when they were very short staffed. During an interview on 6/5/23 at 11:42 AM, an anonymous family member stated they had spoken to the DON concerning the staff shortage, call lights being on for 40 minutes, and weekends noted with only one CNA and one nurse on the unit. 2a. During an observation and interviews on 6/2/23 at 9:53 AM of the East Unit, Resident #66's call light was on, the resident looked upset and stated they were soiled. They stated the had the call light on for a half hour to ask for a bedpan, but nobody came, so they had a bowel movement in their brief. Observation at 9:54 AM of the nurse call system located at the nurse's station, showed the resident's call light had been on for 18 minutes. At 9:55 AM, LPN #5 stated CNAs and nurses were supposed to answer the call lights within 5 minutes. During an interview on 6/2/23 at 10:24 AM, CNA #1 stated they only had 3 CNAs on the unit that day and it was hard to get everything done for the residents. During an interview on 6/2/23 at 11:09 AM, the Registered Nurse (RN) Unit Manager (UM) #1 stated on the East unit, they currently had 42 residents. The RN UM #1 stated call lights should be answered in 10 minutes but would like them checked sooner. RN UM #1 stated 18 minutes was not acceptable but unfortunately it was happening, the staff and themselves can only be in one place at one time. They had 15 residents who needed physical assistance with meals and 15-16 residents who transferred with a mechanical lift. 2b. Observations and interviews on the East Unit on 6/2/23 revealed the following: -At 2:02 PM, beds were unmade with disposable incontinent pads and linens present on beds in rooms 24C, 25B, 26A, 27A and 28B. -At 2:04 PM, CNA #2 stated they can't finish their assignment and feel it was impossible due to having too many residents. CNA #2 stated the CNAs were responsible for cleaning and making the residents beds if there was no support staff available. -At 2:11 PM, LPN #5 stated the residents' beds should have been made by the day shift staff because it makes their rooms feel more like home -At 3:25 PM, Resident #18 stated it bothered them that their bed wasn't made. Don't like it messed up all day long and then have to go to bed in it. Resident #18 stated beds were quite often not made, and it doesn't feel homelike. Additionally, Resident #18 stated they think they were short staffed. -At 3:28 PM, the RN #1 UM stated their expectation stated the CNAs were supposed to tidy up and make residents beds to keep a clean, neat environment, and for quality of life. The priority is to keep residents safe, feed and attend to them as quickly and efficiently as possible. -At 3:42 PM, Resident #22 stated they liked their bed made because it made their room look nice. 2c. Observations and interviews on the East Unit on 6/5/23 revealed the following: -At 8:46 AM, the nurse call system at the nurse's station showed Resident #20's call light was on for 81 minutes, Resident #89 call light was on for 29 minutes, and Resident #8 call light was on for 24 minutes. There were many residents still in bed that have breakfast trays in front of them. Reviews of the 2 aide assignment sheet dated 6/5/23, located at the nurse's station, documented CNA #2 and CNA #3 had 21 residents each on their assignments. -At 8:50 AM, RN UM #1 stated they were working as a CNA that day and pushed a mechanical lift down the hallway. -At 8:55 AM, activity staff were on the unit and answered Resident room [ROOM NUMBER] call light and Resident Rooms #'s 18 and 15 were still on. -At 8:58 AM, CNA #2 stated they had two aides working that morning, that's why Resident #20 call light had been going off for so long, and the time on the call light system at the desk was correct. CNA #2 stated they were still trying to get people up for breakfast, and that Resident #20 wasn't on their assignment then went to the linen cart. -At 9:04 AM, Resident #55 was in bed and eating breakfast. The resident stated they preferred to be up for breakfast, they didn't know why they were still in bed, and to ask the person in charge. -At 9:06 AM, the DON was in with Resident #20, repositioning the resident in their bed. -At 9:11 AM, Resident #20 was lying in their bed and stated they wanted to go to the bathroom, and it had been hours and hours and they still haven't gone. The resident stated it was terrible today, they haven't gotten their breakfast yet and they are usually up for breakfast. At 9:13 AM, RN #5 (med nurse) went in to assist the resident. -At 9:43 AM, Resident #20 was brought to the dining room and their breakfast tray was provided to them. During an interview on 6/5/23 at 1:31 PM, CNA #3 stated they didn't have enough staff to get everything done for the residents. CNA #3 stated they didn't know Resident #20 call light was on for 81 minutes, and they had answered that resident's call light one time, told them they were trying to get everyone up and had to wait a few minutes. CNA #3 stated they tried to do the best they could. During an interview on 6/5/23 at 4:20 PM, with the Regional Nurse Consultant present, the DON stated there was no set time call lights should be answered but would like to say 10 minutes or less for the initial look in, and they ask that call lights stay on until the resident's needs are met to their satisfaction. During an interview on 6/6/23 at 1:50 PM, RN UM #1 stated Resident #55 usually gets up for breakfast, and they weren't up on 6/5/23 because they had 2 CNAs and themselves working. On days like that, they prioritize getting the residents up who need supervision or physical assistance with their meals. Then as time allows, they go back to get the rest of the residents out of bed who it was more of a preference for versus a safety issue. 2d. During a continuous observation on the East Unit on 6/5/23 from 9:22 AM to 10:21 AM revealed at 9:22 AM Resident #22 was sitting in the lounge and requested out loud their need to use the bathroom. The nurse (RN #5) was present in lounge assisting another resident with eating responded there were only 2 aides, and they couldn't leave to take them to the bathroom. At 9:45 AM, Resident #22 stated they'd like to go to the bathroom, but there wasn't any help and didn't know how long they had been waiting. At 10:14 AM, Resident #22 was observed and heard asking staff entering the lounge area if there were any aides to take them to the bathroom. At 10:17 AM, Resident #22 was heard calling out specific staff names and said, Can anybody help? At 10:19 AM, Resident #22 stated to the Activities Director (AD) Is there anybody yet? the AD responded, somebody is coming, and Resident #22 stated I hope so. At 10:21 AM, Resident #22 was heard saying Still haven't gone to the bathroom. This place is a disgrace. As a staff member removed Resident #22 from the lounge and wheeled them to their room. During an interview on 6/5/23 at 10:28 AM, the AD stated they will usually let a nurse or aide know if a resident requested to go to the bathroom. The AD stated this was important for dignity and would want their needs met. 2e. Review of the Medication Administration Records dated 6/1/23 to 6/30/23 for Resident #s 3, 4, 8, 9, 15, 16, 17, 20, 32, 35, 37, 42, 44, 45, 46, 56, 57, 58, 74, 79, 81, 86, 89, and 93 (East Unit) revealed medications scheduled to be given on 6/4/23 at 7:00 PM to 10:00 PM were not initialed as administered. During an interview on 6/5/23 at 9:00 AM, Resident #17 stated they did not receive their medications on Sunday (6/4), evening shift. Resident #17 stated they told the nurse, and the nurse never came back. During a telephone interview on 6/6/23 at 8:34 AM, LPN #2 stated they were the only nurse on the East unit after 6:00 PM on 6/4/23. LPN #2 stated that usually a supervisor would come to the unit and help them with a medication pass if they were alone, but on 6/4/23 no supervisor came to help. LPN #2 stated they found out later the supervisors were passing medications on other units. LPN #2 stated the medications they didn't click on they didn't give and that they signed for the medications they gave. LPN #2 stated the supervisors knew they needed help and were behind. LPN #2 stated they did what they could do and had never passed medications to the entire unit during the evening shift by themselves. Additionally, LPN #2 stated there were only two CNAs on unit as well, so they had to stop passing their medications to assist them. During a telephone interview on 6/6/23 at 9:20 AM, the Assistant Director of Nursing (ADON) stated the past weekend (on 6/4/23) they worked the evening shift as a CNA on the North Unit because there was no aide. The ADON stated if a nurse couldn't get their medications done, a supervisor should have been told, then a supervisor would go over to help them. The ADON stated but if a supervisor was already on a cart, they didn't know how that was supposed to get done. The ADON stated they were all multitasking on Sunday. Three attempts were made without sucess to contact LPN #8 Supervisor that worked 6/4/23 during the 7:00 PM-7:00 AM shift. During an interview on 6/6/23 at 2:25 PM (with the Regional Nurse Consultant present), the DON stated they strive to have two LPN medication nurses on each unit. On 6/4/23 the East Unit dropped down to one nurse at 7:00 PM. The Regional Nurse Consultant stated they identified 35 residents who had blanks on their MARs on 6/4/23. They stated there was a liberalized medication pass times and if LPN #2 would have notified a supervisor that they had trouble passing the medications, they would have adjusted to get done what wasn't done. The DON stated they thought there were enough nurses to get the work done and they met their minimum number of nurses. During a telephone interview on 6/6/23 at 3:38 PM, LPN #7 Supervisor stated they worked as the facility supervisor on Sunday 6/4/23 from 7:00 AM to 7:00 PM and passed medications on the [NAME] unit as well. LPN #7 stated it was difficult to complete their assignment but was able to get it done. LPN #7 stated they had to assist with aide work such as transfers, showers and anything that needed to be done. LPN #7 stated LPN #2 did not discuss their inability to complete their assignment with them on 6/4/23. LPN #7 stated they would expect a nurse to inform the supervisor if they needed assistance with their assignment. During an interview on 6/6/23 at 9:20 AM, the Assistant Director of Nursing (ADON) stated staffing had been terrible at the facility since they started working at the facility several months ago. The ADON stated they have worked the evening shift, passed medications, worked as a CNA, and supervised the building. They helped where they were needed. The ADON stated the past weekend (on 6/4/23) they worked the evening shift as a CNA on the North Unit because there was no aide. During an interview on 6/6/23 at 2:20 PM, the DON stated they didn't meet their minimum staffing numbers on those days (5/20/23, 5/21/23, 5/22/23, 5/25/23, 5/29/23, 5/31/23, and 6/4/23) and the Administrator was aware. The DON stated they do discuss staffing at resident council and if there are any individual concerns, they review it. The DON stated they try to accommodate resident's individual needs, but someone has to wait for staff to get in there and they apologize. During an interview on 6/6/23 at 2:49 PM, the Administrator stated staffing had been a challenge since they started at the facility two months ago and that they do their best to meet the facility assessment numbers (The Master Staffing Plan 2023). The Administrator stated they weren't aware of the separate minimum staffing numbers (Facility Assessment Direct Care Nursing Staffing Plan) the DON had provided. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, interview, and record review conducted during a Standard Survey completed on 7/30/21 the facility did not follow the prepared menus. One of one prepared lunch meal did not provide the residents receiving mechanically altered diets the same food item that was posted on the menus for that day. Specifically, on 7/28/21 puree and ground consistencies received ground pork with gravy instead of the Polish sausage which was listed on the posted menu. This affected the following residents (Resident #4, 5, 7, 21, 29, 40, 51, 60, 61, 69, 71, 86, 349, 352, and 353). The finding is: Review of the policy and procedure titled Diet Types and Menu Requirements date last modified 10/30/2018 revealed daily menus and menu cycles used at this facility will be planned to meet the nutritional and personal needs of residents. The approved menus in the preparation of meals with substitutions only made when food items are not available from vendors or there is a situation occurring requiring use of the emergency/ disaster menu. Review of the posted Fall/Winter Week1 Menu dated 7/25/21 revealed for Wednesday at lunch Polish sausage was listed as part of the main entree. Review of the Extension Sheets Week 1, Wednesday day 4 Fall/Winter dated 7/28/21 revealed at lunch Polish sausage was listed for both Mechanical Soft (ground consistency) and Puree diets. During an observation on 7/28/21 at 9:54 AM the cook placed pre-cooked ground pork and gravy in the Robo Coupe (equipment used to puree food) and pureed them together to a pudding like consistency to be used for residents on puree consistency. During an interview on 7/28/21 at 10:00 AM the cook stated, we use ground pork with gravy versus the Polish sausage for the puree and ground consistencies. I do not know why we do not use Polish sausage like the regular consistency, it has always been done that way. During an interview on 7/28/21 at 10:15 AM the Food Service Director stated, we do not use the Polish sausage for the puree or ground consistencies because it is too watery when we blend it and the skin leaves chunks. Ground pork and gravy was the closest to Polish sausage. During the lunch meal tray line observation on 7/28/21 between 11:30 AM and 12:15 PM Residents (#7, 29, 61, 71, and 86) were provided puree ground pork and Residents (#4, 5, 21, 40, 51, 60, 69, 349, 352, and 353) received ground pork on their meal plates. There was no Polish sausage provided. During a further interview on 7/28/21 at 1:16 PM the Food Service Director, stated the posted menu has Polish sausage listed on it for today (7/28/21) at lunch. We did give the puree and ground consistencies ground pork with gravy, not polish sausage. Maybe, I will have to look for a different Polish sausage product that will work. I understand that the mechanically altered diets should be receiving the same food items as what the regular consistencies receive, which is posted on the menu. During an interview on 7/30/21 at 11:59 AM the Registered Dietitian stated the posted menus should be followed. The puree and ground consistencies should have received Polish sausage. 415.14(c)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the Standard survey completed on 7/30/21, 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 two (Resident #s 43 and 60) of three residents reviewed for indwelling urinary catheters (Foley, tube inserted into the bladder used to drain urine). Specifically, proper infection control practices were not maintained. Residents #43 and #60's Foley catheter drainage bag (bag for collecting urine from the urinary drainage tube) and tubing were observed directly on the floor without a barrier. The findings are: The facility policy and procedure (P&P) titled, Catheter, Daily Care (Indwelling) dated 4/11/18, documented that staff were to ensure the drainage bag was attached to the bed frame or wheelchair and the drainage bag or tubing cannot touch the floor. 1. Resident #60 had diagnoses including chronic kidney disease, obstructive and reflex uropathy (urine backs up into the kidney), and urinary retention (inability to voluntarily empty the bladder). The Minimum Data Set (MDS - a resident assessment tool) dated 6/6/21 documented the resident usually understands, was usually understood, and was cognitively intact. Additionally, the MDS documented the resident had a Urinary Tract Infection (UTI) in the past 30 days and utilized an indwelling catheter. The Comprehensive Care Plan (CCP) dated 5/19/21 documented Resident #60 had an indwelling urinary catheter and the intervention to utilize a urinary leg bag (holds urine that drains from catheter and fits under clothing) when out of bed. Review of the Order Summary Report dated 7/29/21 revealed Resident #60 had a 16 F (French-size of catheter 5 mL (milliliter) balloon (used to anchor the catheter in the bladder) indwelling urinary catheter started on 5/19/21; and UTI protocol (an extra 240 mL of fluid offered each shift for residents with a UTI) was started on 7/26/21 for seven days. Intermitent observations of Resident #60 during survey from 7/26/21 through 7/29/21 revealed the following: - 7/26/21 at 9:29 AM, Resident #60 was sitting in their wheelchair in their bedroom with approximately four inches of the indwelling catheter tubing in direct contact with the floor. Additionally, the bottom of Resident #60's sneakers were in direct contact with the indwelling catheter tubing. - 7/28/21 at 8:16 AM, Resident #60 was sitting in their wheelchair in their bedroom with approximately eight inches of the indwelling catheter tubing in direct contact with the floor. Additionally, the bottom of Resident #60's sneakers were in direct contact with the indwelling catheter tubing. - 7/28/21 at 9:09 AM, Resident #60 was self-propelling their wheelchair back-and-forth in their bedroom with approximately eight inches of the indwelling catheter tubing in direct contact with the floor. Additionally, the bottom of Resident #60's sneakers were in direct contact with the indwelling catheter tubing. - 7/28/21 at 10:02 AM, Resident #60 was sitting in their wheelchair in the main dining room, participating in an activity program with approximately eight inches of the indwelling catheter tubing in direct contact with the dining room floor. Additionally, the bottom of Resident #60's sneakers were in direct contact with the indwelling catheter tubing, and sediment (stringy white flecks) was observed in the indwelling catheter tubing. - 7/28/21 at 11:51 AM, Resident #60 was self-propelling their wheelchair from the main dining room to a common area on the unit (approximately 120 feet), with approximately 3 inches of tubing dragging directly on the floor. - 7/29/21 at 7:40 AM, Resident #60 was self-propelling their wheelchair back-and-forth in their bedroom with approximately eight inches of the indwelling catheter tubing in direct contact with the floor. - 7/29/21 at 9:12 AM, Resident #60 self-propelling their wheelchair from their bedroom to the common area on the unit (approximately 75 feet) with approximately four inches of the indwelling catheter tubing dragging directly on the floor, and the urine in the indwelling catheter tubing appeared turbid (unclear, murky appearance). During an interview on 7/29/21 at 10:16 AM, Licensed Practical Nurse (LPN) #2 stated the floor was a contaminated surface, and if the urinary drainage bag directly touches the floor it would be considered an infection control issue. During an observation/interview on 7/29/21 at 10:38 AM, Registered Nurse (RN) Unit Manager (UM) #2 stated Resident #60's indwelling catheter tubing was quite long and directly touching the floor which has a lot of germs and could possibly increase the risk of infection. During an interview on 7/29/21 at 10:45 AM, the Director of Nursing (DON) stated that no tubing or bag should drag on the floor, the floor is dirty, and the tubing could collect germs from the floor which could be transferred to the bladder via the tubing, increasing the risk for infection. During an interview on 7/30/21 at 8:24 AM, Resident #60's Physician stated indwelling catheter bags and tubing should not come into direct contact with floor as that increases the risk for infection. 2. Resident #43 had diagnoses including congestive heart failure, dysphagia (difficulty swallowing), and anxiety. The MDS dated [DATE] documented the resident had an indwelling urinary catheter and was cognitively intact. Review of the Order Summary Report dated 7/30/21 revealed Resident #43 had a 16 F 10 mL balloon indwelling urinary catheter started on 5/28/21. During an observation on 7/26/21 at 11:16 AM, Resident #43's urine drainage bag was observed laying on floor without a barrier between the bag and the floor. The drainage bag was dated 7/8/21. Further observation on 7/29/21 at 8:16 AM revealed the resident was lying in bed, the urine drainage bag was on the floor next to the resident's bed, there was no barrier between the bag and the floor. The drainage bag was dated 7/8/21. During an interview on 7/29/21 at 12:16 PM, CNA #3 stated the urinary collection bag was not usually on the floor and it should be hooked on the bed. CNA #3 stated right now, they have a clean barrier under it because it's on the floor, but it should be on the bed. CNA #3 was observed to pick the drainage bag up off the floor and hook the drainage bag to the bedframe. During an interview on 7/30/21 at 8:46 AM, CNA #1 stated they usually hook the catheter bag on the bed, but if a bag was on the floor, they use a barrier between the floor and the bag because the floor was dirty, and they don't want to contaminate the bag. CNA #1 stated they remembered the drainage bag being on the floor the day before (7/29/21). During an interview on 7/29/21 at 2:30 PM, LPN #1 stated the expectation would be for the CNA to tell the nurse if a urine drainage bag was on the floor without a barrier so the nurse could replace the bag. During an interview on 7/30/21 at 9:20 AM, the RN UM #1 stated if a urine drainage bag was directly on the floor, the CNA should tell the nurse, so the nurse can clean the bag off if it was on a contaminated surface. The floor was considered contaminated. The RN UM #1 stated the drainage bag could either be attached to the bedframe with the hook or it could be on the floor with a barrier. During an interview on 7/30/21 at 10:02 AM with the Director of Nursing/Infection Preventionist (DON/IP) and the Regional RN Consultant present, the Regional RN Consultant stated usually urine drainage bags were hooked to the bedframe at the bottom of the bed. If it was a low bed, staff would put a barrier between the floor and the bag because it would touch if the bed was in a low position. The Regional RN Consultant stated staff could wipe the drainage bag down with a hydrogen peroxide wipe or some type of antibacterial wipe if it was found on the floor. The DON/IP stated an alcohol wipe would be acceptable, but it was not the preferred method to clean the drainage bag and that the floor was considered a contaminated surface. During an interview on 7/30/21 at 12:33 PM, the Administrator stated a resident with an indwelling urinary catheter should have their drainage bag affixed to the bed. 415.19(a)(1)