Based on observations, record review, and interviews during the recertification survey conducted 2/11/2025 - 2/13/2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 resident (Resident #57) reviewed. Specifically, Resident #57 was observed wearing their thoracolumbar sacral orthosis brace (TLSO brace, a spinal brace worn to limit movement of the spine to help with healing of spinal fractures) incorrectly, the comprehensive person-centered care plan did not address interventions for the thoracolumbar sacral orthosis brace, and staff involved in Resident #57's care were not educated on the application of the thoracolumbar sacral orthosis brace. Findings include: The undated facility policy, Durable Medical Equipment, documented the facility would ensure residents received medically necessary durable medical equipment as part of their comprehensive care plan and included: - A physician, nurse practitioner or therapist would assess the residents' medical needs and document in the care plan. - A physician order as needed based on the type of durable medical equipment. - Staff would be trained on the proper and safe use of the equipment based on the type of durable medical equipment. Resident #57 had diagnoses including osteoporosis with current pathological (a fracture caused by weakened bones) fracture of vertebrae (bones in the spine). The 12/21/2024 quarterly Minimum Data Set assessment documented the resident had severely impaired cognition, used a walker and wheelchair, had no impairment to upper and lower extremities, received occupational therapy and physical therapy, and had no splint or brace assistance. The 11/20/2024 hospital discharge summary documented a thoracolumbar sacral orthosis brace was prescribed, was to be worn when out of bed and when ambulating, could be donned/doffed (put on/taken off) at bedside, and was not required when in bed or sleeping. Obtain a thoracolumbar spine upright standing x-rays (attempted 11/16/2024 but patient could not stand). If the resident had any weakness in their lower extremity that was new, obtain magnetic resonance imaging (MRI) of the thoracic lumbar spine urgently, and once obtained, the resident would require a referral to neurosurgery. The 11/20/2024 hospital pre-admission intake/referral documented the resident used a thoracolumbar sacral orthosis brace and it was to be worn when out of bed. Physician orders did not include the use of a thoracolumbar sacral orthosis brace or instructions for use. A 11/20/2024 at 2:53 PM progress note by Registered Nurse #20 documented the resident wore a thoracolumbar sacral orthosis brace while out of bed due to compression fractures. The Comprehensive Care Plan, initiated 11/20/2024 and revised 12/9/2024, documented the resident had a self-care performance deficit related to activity intolerance, confusion, impaired balance, and limited mobility. Interventions included a thoracolumbar sacral brace on for all out of bed activities; the registered nurse was responsible for the intervention. There were no further interventions documenting the care of or monitoring of the thoracolumbar sacral orthosis brace. The certified nurse aide care instructions as of 11/20/2024 documented under transfers the resident used a thoracolumbar sacral orthosis brace to be on for all out-of-bed activities. A 11/20/2024 physical therapy treatment encounter note electronically signed 11/21/2024 at 12:43 AM (no staff identified) documented staff and the resident's family member were educated and trained on justification and management of the thoracolumbar sacral orthosis brace as well as proper donning/doffing of the brace with good staff/family response. (At the time of the encounter note the resident was residing on Unit 1, the rehabilitation unit.) A Minimum Data Set progress note on 11/24/24 at 3:07 AM by Licensed Practical Nurse #21 documented the resident wore a thoracolumbar sacral orthosis brace while out of bed due to compression fractures. The 11/25/2024 admission history and physical by Physician #14 documented the resident was recently hospitalized with weakness and found to have a lumbar-1 compression fracture treated with bracing. The plan was to continue with bracing as directed, and to get an upright film (x-ray) when possible, when the resident was able to bear weight. The updated 11/26/2024 care conference summary documented: - recurring restorative occupational therapy, physical therapy, and speech language pathology to address deficits in transfers, ambulation, self-care and cognition in order to return to private residence with family member. - had potential for acute/chronic pain due to arthritis and burst lumbar-1 vertebrae. - family would need to learn how to place brace on which could be done by one individual. A 12/2/2024 at 2:58 PM Certified Occupational Therapy Assistant #6 treatment encounter documented skilled instruction was provided to resident and caregiver for training for donning (putting on) of the thoracolumbar sacral orthosis brace. Nursing progress notes documented: - on 12/7/2024 at 8:26 AM by the Director of Nursing, the resident was discovered sitting on the floor in their room leaning on their wheelchair and their back brace was not in place. The resident had no injuries and stated they were trying to go to bed. - on 12/8/2024 at 1:28 PM by Licensed Practical Nurse #2, the resident continued to be confused and took their thoracolumbar sacral orthosis brace off. - on 12/24/2024 at 9:47 AM by the Minimum Data Set Coordinator, the resident removed their back brace many times that morning. - on 12/25/2024 at 7:57 AM the Minimum Data Set Coordinator, the resident removed their back brace prior to sliding out of their wheelchair. Physician orders revised 1/20/2025 documented physical therapy 5 times/week for 4 weeks for therapeutic exercises, therapeutic activities, neuromuscular re-education, group therapeutic activities, manual therapy, wheelchair management, hot/cold pack and gait therapy. There was no documentation for a thoracolumbar sacral orthosis brace. The certified nurse aide care instructions as of 2/13/2025 documented under transfers the resident used a thoracolumbar sacral orthosis brace, to be on for all out-of-bed activities. There was no documentation for application of the thoracolumbar sacral orthosis brace in the February 2025 Treatment Administration Record or in the February 2025 Certified Nurse Aide tasks documentation. The following of observations of Resident # 57 were made: - on 2/11/2025 at 10:52 AM seated in the common area near the elevator on unit 2 wearing a black, synthetic fabric brace with upper and lower attachments that were both resting above the resident's breasts, with bilateral black straps that were several inches above their shoulders (not resting on their shoulders). The resident stated it kept them from falling forward. - on 2/12/2025 at 10:39 AM returning from therapy with Physical Therapy Assistant #7; the brace was positioned on their breasts. Physical therapy assistant #7 stated the device the resident was wearing was a back brace for a compression fracture, which they had when they were admitted to the nursing home, and therapy at the facility had nothing to do with recommending it. - on 2/13/2025 at 9:25 AM being taken to physical therapy by Physical Therapy Assistant #7; the brace was positioned on their breasts. - on 2/13/25 at 10:11 AM returning from therapy with Physical Therapy Assistant #7; the front part of the brace was positioned on their breasts. Upon closer inspection, the back of the brace was firm with straps to the head support part of the brace. Physical Therapy Assistant #7 stated the front-facing part of the brace should be positioned with the smaller plate on their chest and the lower part of the fabric brace with Velcro around their abdomen. Due to the resident's body shape and not sitting up straight in their wheelchair the brace usually rested on their breasts. During an interview on 2/12/25 at 11:31 AM Certified Nurse Aide #10 stated the certified nurse aides put the thoracolumbar sacral orthosis brace on the resident when they got them out of bed and removed it at bedtime. They stated they thought the instructions for use were on the certified nurse aide instructions, but they were not sure, they just knew to do it. They stated to check with therapy because they remembered hearing staff had been signed off on how to apply and remove the thoracolumbar sacral orthosis brace. During an interview on 2/12/25 at 2:15 PM the Director of Therapy stated they were familiar with Resident #57 and knew they had a thoracolumbar sacral orthosis brace. They did not know what staff were supposed to apply the brace to the resident or who was educated on applying it. During a follow-up interview on 2/12/25 at 3:15 PM the Director of Therapy provided a hard copy of the current certified nurse aide care instructions that highlighted under the topic transferring: thoracolumbar sacral orthosis brace on for all out-of-bed activities. They also provided a hard copy of the occupational therapy and physical therapy treatment notes (11/20/2024 and 12/2/2024) that documented staff and caregiver education on the thoracolumbar sacral orthosis brace. They stated the brace should fit on the resident's lower torso around their abdomen. They had not seen the resident in a while but knew that after the brace was applied and once the resident sat down, the brace usually rode up on them to their chest. They did not know if they had a staff sign-in sheet for the education of applying the thoracolumbar sacral orthosis brace, as it would have been done when the resident was first admitted on Unit 1. During an interview on 2/13/25 at 9:40 AM Certified Nurse Aide #11 stated they were not educated on how to apply the thoracolumbar sacral orthosis brace even though the aides were the ones who put it on the resident in the morning. The resident was admitted in November 2024 and resided on Unit 1. The back part of the brace should fit just above the buttocks on their back and the lower front piece should fit on their abdomen with the smaller plate on their chest/sternum. The brace usually rode up from the resident's abdomen to their chest. During a follow-up interview on 2/13/25 at 9:44 AM Certified Nurse Aide #10 stated Unit 1 staff was educated on applying the thoracolumbar sacral orthosis brace to Resident #57, but they never were. During an interview on 2/13/25 at 9:55 AM Certified Nurse Aide #12 stated they put the thoracolumbar sacral orthosis brace on Resident #57 many times, but they did not know what it was for. They never received education on how to apply the thoracolumbar sacral orthosis brace. During an interview on 2/13/25 at 10:06 AM Licensed Practical Nurse #13 stated the thoracolumbar sacral orthosis brace Resident #57 wore was for a back fracture. They were admitted to Unit 1 and came with the brace. They had not been educated on how to apply the brace. The larger, firm, rectangular-shaped flat plate of the brace was supposed to be on the resident's lower back sitting above their buttocks, but it moved around to their front, and the front of the brace also rode up to the resident's chest. The resident sometimes removed the brace. They had asked and questioned nurses about the fit of the thoracolumbar sacral orthosis brace (they could not name who) but nothing had ever been done. During a follow-up interview on 2/13/25 at 11:28 AM the Director of Therapy stated they did not have a sign-in sheet for Unit 1 staff who had the training last fall (November 2024) for the thoracolumbar sacral orthosis brace, and they likely did a verbal education for those staff. During an interview on 2/13/25 at 11:32 AM Licensed Practical Nurse Unit Manager #3 stated they did recall Unit 1 staff being educated on the resident's thoracolumbar sacral orthosis brace last fall (November 2024) but could not recall if it was a read-and-sign or verbal training. They stated Resident #57's brace was recently discussed in morning report because it moved around and fit incorrectly on the resident, but nothing was done about it as far as they knew. During an interview on 2/13/25 at 11:44 AM, the Director of Nursing stated they brought up the topic of Resident #57's thoracolumbar sacral orthosis brace last week during morning report. They discussed the necessity for the resident's brace, the incorrect fit once the resident was seated, and the resident removed it frequently. They questioned if the resident still needed the brace if it did not fit the resident properly. They did not know which staff had been educated on the brace. They thought by bringing it up in morning report, therapy would take it back to the Nurse Manager, who would then notify the medical provider. The comprehensive care plan should have a dedicated topic for the resident's Lumbar-1 compression fracture, so the interventions for the thoracolumbar sacral orthosis brace would have been more easily recognized. 10NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 2/11/2025-2/13/2025, the facility did not review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails for 1 of 2 residents (Resident #12) reviewed. Specifically, there was no documented evidence risks and benefits were reviewed and informed consent was obtained prior to the placement of bilateral bed rails on Resident #12's bed. Additionally, the comprehensive care plan did not include the use of bed rails. Findings include: The facility policy, Bedrail Determination, dated 2/1/2024 documented the use of side rails or bed rails on beds would be permitted to provide greater independence however had the potential for entrapment and harm. The process included: - The resident was screened upon admission, readmission, or change of condition determining level of independence with bed mobility and transfers. - The resident was evaluated to identify appropriate alternative interventions to address a medical symptom prior to installing assist rails. - The resident was evaluated for risk of entrapment from assist bars prior to installation. - The risks and benefits were discussed and consent for installation was obtained. - The facility would review ongoing need for the assist rails quarterly and as needed. - The residents care plan was updated to reflect use of the assist rails. - The physician documented an order for the need for the assist rails prior to installing. - Maintenance was contacted for installation of assist rails. The blank facility form Informed Consent for Use of Assist Rails, listed the risks and benefits of the assist rails, the employee's name who reviewed the risks and benefits with the resident, the name of individual giving consent with the signature and date as well as a check mark if the consent was obtained via telephone. Resident #12 had diagnoses including morbid obesity, heart failure (insufficient pumping), and respiratory failure. The 12/21/2024 Minimum Data Set assessment documented the resident had intact cognition, was independent with bed mobility and transfers, and did not use bed rails. The Comprehensive Care Plan initiated 6/4/2021, documented the resident was at risk for falls related to fatigue and shortness of breath. Interventions included call bell in reach, use of handrails on walls, and evaluation for adaptive equipment ensuring the least restrictive devices. The resident had an activities of daily living performance deficit related to limited mobility. Interventions included independence with bed mobility. There was no documented use of bed rails. The 5/23/2024 Physical Therapist #24 progress note documented Resident #12 was assessed on 5/7/2024 as well as this day for bilateral assist rails. The resident required bilateral assist rails to maintain independence with bed mobility tasks as well as avoiding excessive desaturation (low oxygen levels) as the resident required increased assistance when attempted without assist rails. The 6/21/2024 Assist Rail Determination form completed by Registered Nurse Minimum Data Set Coordinator #23 (former Director of Nursing) documented Resident #12 displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed and expressed a desire to have assist rails for safety and/or comfort. The 12/20/2024 Assist Rail Determination form completed by Registered Nurse Minimum Data Set Coordinator #23 documented the resident did not display poor bed mobility or difficulty moving to a sitting position on the side of the bed and assist rails were not indicated at this time. There was no documented evidence the informed consent for the use of assist rails was obtained or the risks and benefits were reviewed with the resident or resident representative prior to their placement. During an observation and interview on 2/11/2025 at 10:37 AM, Resident #12 had bilateral assist bed rails on their bed. They stated they used the assist rails every day to get out of bed and would not be able to get out of bed without the assist rails. They did not recall anyone reviewing the risks and/or benefits or signing a consent form. During an observation on 2/13/2025 at 8:52 AM, Resident #12 was in bed sleeping with bilateral assist bed rails on their bed. The undated resident [NAME] (care instructions) did not include the use of bed rails. During an interview on 2/13/2025 at 8:52 AM, Certified Nurse Aide #25 stated if a resident had assist rails it was documented in the care plan. Many residents had assist rails which were used to help with mobility, and they believed the assist rails required a consent. Maintenance placed the assist rails on the beds. They stated Resident #12 had assist rails which should be documented on the care plan. During an interview on 2/13/2025 at 8:59 AM, Licensed Practical Nurse #2 stated several residents had assist rails on their beds. They did not know if assist rails required a consent form or who put the assist rails on the beds. A resident could get entrapped between the bed and the assist rail and it was important for residents to know both the benefits and the risks of the assist rails. During an interview on 2/13/2025 at 9:07 AM, Licensed Practical Nurse Unit Manager #3 stated many residents had assist rails which required a provider order, an evaluation from Physical Therapy, a signed consent documenting risks and benefits, and a care plan. Maintenance put the bars on the beds. They stated Resident #12 had enabler bars, used them to get in and out of bed, and did not have an order or consent form. During an interview on 2/13/2025 at 10:06 AM, Rehabilitation Coordinator #9 stated all residents were evaluated on admission by a physical therapist for appropriateness of assist bars. If appropriate, the physical therapist documented the recommendation in the electronic record and notified nursing. Nursing was responsible for obtaining an order from the medical provider and obtaining the consent form. They stated Resident #12 was evaluated 5/23/2024 by Physical Therapist #24 who determined assist rails were appropriate and assist rails were on the resident's bed. They stated the assist rail determination form was completed by the Minimum Data Set Coordinator #23. It was important to have an order and signed consent form as entrapment was a risk for the assist rails. During an interview on 2/13/2025 at 10:20 AM, Minimum Data Set Coordinator #23 stated their only involvement in the assist bars was completion of the assist rail evaluation for the Minimum Data Set Assessment. When completing the assist rail evaluation, they reviewed the physical therapy notes for the assist rail assessment, looked for an order from the provider, looked at the bed in the resident's room, or asked the resident. They noticed many residents did not have a consent form signed which was important because it reviewed the risks and benefits. During an interview on 2/13/2025 at 11:26 AM, the Director of Nursing stated all residents were evaluated on admission by physical therapy for their ability to move in bed and for assistance needed with positioning. If physical therapy determined assist rails were appropriate, nursing was notified, nursing added them to the care plan, obtained an order from the physician, and reviewed the risks and benefits with the resident who would then sign a consent. The Minimum Data Set assessment was updated annually documenting appropriateness of assist rails for each resident. It was important to follow the process because there was a risk of entrapment and not every resident was appropriate for the assist rails. They were notified 2-3 weeks ago that the process was not being followed by the Minimum Data Set Coordinator #23. It was important to have an order and obtain a consent, for resident safety and so the resident knew the potential risks of using bed rails. 10NYCRR 415.12(h)(1)(2)

Based on observations, record review, and interviews during the recertification survey conducted 2/11/2025-2/13/2025, the facility did not ensure the safe and secure storage of medications in accordance with currently accepted professional principles and include the expiration date when applicable for 1 of 3 medication carts (Unit 1 medication cart) reviewed. Specifically, multiple eye drops in the Unit 1 medication cart were not appropriately labeled or dated. Findings include: The facility's policy, Equipment and Supplies for Administering Medications updated 4/2022 did not address pharmaceutical labeling or medication safety. During a medication storage observation on Unit 1 on 2/11/2025 at 11:13 AM with Licensed Practical Nurse # 2 the medication cart had the following medications with no pharmacy labels and the tops of the boxes ripped off: - Resident #8's latanoprost eye drops (used to treat glaucoma, high pressure in the eye) with an open date of 12/24 and the resident name written on the inside of the box in black magic marker - Resident #12's artificial tears with the resident name written on the inside of the box in black magic marker. - Resident # 20 had latanoprost eye drops with an open date of 1/21 with the resident's name written on the inside of the box in black magic marker. During an interview on 2/11/2025 at 11:14 AM Licensed Practical Nurse #2 stated all medications should have pharmaceutical labels including eye drops, ear drops, and nasal sprays. All medications should be labeled by the pharmacy. Licensed Practical Nurse #2 stated there was no way to know how to administer the eye drops if there was no label on them. If the eye drops fell out of the box without a label there would be no way to know who they belonged to. The medication would need to be reordered from the pharmacy. During an interview and observation of the Unit 1 medication cart on 2/13/2025 at 9:07 AM Licensed Practical Nurse # 2 stated the latanoprost eye drops did not have a pharmaceutical label however the resident's name was written on the inside of the box. Licensed Practical Nurse # 2 stated there were no visible instructions for administration and the pharmacy should have been notified. The unlabeled medications from 2/11/2025 remained in the medication cart. During an interview on 2/13/2025 at 10:41 AM Licensed Practical Nurse #3 Unit Manager stated nurses who were administering medications should verify that all medications were labeled by the pharmacy. If a medication was not labeled, they expected the nurse to address the situation with the pharmacy. Licensed Practical Nurse Unit Manager #3 stated lantaprost was a prescription eye drop and should have a proper label. Artificial tears were a stock item and was it not acceptable to not have a resident specific label. The residents name should be written on the bottle in black magic marker. During an interview on 2/13/2025 at 12:32 PM the Director of Nursing stated eye drops must be dated when opened. Eye drops should remain in the original box with the pharmacy label. It was not appropriate to have a resident name written on the inside of the box instead of a pharmacy label. If the eye drops were still in the cart without a label, they be thrown away and reordered. There was a risk to a resident of receiving the wrong eye drops if they were not labeled appropriately. 10NYCRR 415.18(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 2/11/2025-2/13/2025, 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 23 resident rooms (room [ROOM NUMBER] on Unit 1) reviewed. Specifically, resident call bell systems did not function as designed and residents did not have a means to contact direct caregivers while in the bathroom. Findings include: The facility policy, Call Bell, last reviewed 2025, documented all staff were responsible for responding promptly to resident call bells. Failure to do so would result in disciplinary action. Staff must verbally acknowledge the resident upon entering the room. If the call bell was an emergent situation and required an immediate response, staff should call for back up and not leave the resident unattended. During a Resident Meeting on 2/11/2025 at 1:42 PM, 2 of 11 anonymous residents stated when the bathroom call bell was pulled it would flash outside of their door. If their room call bell was pushed at the same time to signal help from the room, it would cancel out the bathroom call light. 1 of 2 anonymous residents stated they were left in the bathroom for up to an hour before staff recognized they required assistance. Staff told them the room call light canceled out the bathroom call light. The following observations of room [ROOM NUMBER]'s call bell system were made: - on 2/12/2025 at 9:40 AM, the bathroom call bell was pulled. The light above the door frame was blue and flashed rapidly. A rapid beeping sound was heard in the hallway and at the nursing station. The call bell for the bed by the door was pushed and the flashing light outside of the door turned to a solid blue color and the rapid beeping sound disappeared. A slow, faint chirping sound was heard in the hall. The room was on nursing station call bell console displayed as a strobe-like flashing white light. - on 2/12/2025 at 10:02 AM, the light above the room door remained a solid blue. No staff answered the call light. - on 2/13/2025 at 9:27 AM, the bathroom call bell was pulled. The light above the door was blue and flashed rapidly. A rapid beeping sound was heard in the hall. At 9:29 AM, Licensed Practical Nurse #2 appeared at the doorway of room [ROOM NUMBER], looked in and walked away. They did not respond to the call bell. At 9:43 AM, the bathroom call bell was still activated and the light above the door remained a solid blue color with no sound. There were no staff observed in the vicinity. At 9:47 AM, Licensed Practical Nurse #2 responded to the call bell. Licensed Practical Nurse #2 activated the bathroom call bell and then activated the room call bell. The bathroom call light flashed blue rapidly above the door and when the room call light was pushed, the light above the door turned a solid blue color. During an interview on 2/13/2025 at 9:48 AM, Licensed Practical Nurse #2 stated the light above room [ROOM NUMBER]'s door flashed a rapid blue color and made a beeping sound to alert staff a resident was in the bathroom and needed assistance. They stated when they pushed the room call light, it cancelled out the bathroom call bell and the light stopped flashing. They were unsure why that occurred. They stated they were not sure how staff would know a resident was in the bathroom and needed assistance when the call light cancellation occurred. During an interview on 2/13/2025 at 10:38 AM Certified Nurse Aide #5 stated a flashing blue light above a room door signified that a resident needed assistance getting off the toilet. A regular room call bell would light up over the door as a solid blue color. They stated both indicated a resident required assistance, but a flashing blue light would be more emergent. The resident would need assistance in the bathroom as opposed to a room light where a resident might just need something else. During an interview on 2/13/2025 at 10:41 AM Licensed Practical Nurse Unit Manager #3 stated call bells should be answered in a timely manner. Maintenance should be alerted if a call bell did not work. They would verbally tell them or put a work order in. They were not aware of any call bell issues on the unit but acknowledged that some call bells cancelled each other out. They stated they were recently made aware that room [ROOM NUMBER]'s room call bell cancelled out the bathroom bell and had heard complaints from a resident council meeting. Staff would not know a resident needed assistance in the bathroom when this occurred and would put the resident at a higher risk for falls. They stated they thought maintenance was talking to their supervisor about the issue. There was no documented evidence a work order for room [ROOM NUMBER]'s call bell was submitted. During an interview on 2/13/2025 at 11:10 AM the Director of Environmental Services/Maintenance stated work orders were placed on a green slip by staff if there was an item that needed repair. They were not aware of any recent call bell work orders. There was a panel situated in between 2 resident beds in the rooms that could be opened to reset the call bell system if resident call bells did not work. They stated a resident's room call bell was on a cord. When the button was pushed, it would light in the room, above the outside of the room door and at the nursing station. A resident's bathroom call light would flash outside of the resident's room door and ring and flash at the nursing station. They knew room [ROOM NUMBER]'s room call bell cancelled out the bathroom call bell for approximately 6 months and no corrections had been attempted. They stated the manufacturer told them it was an old system and there was no fix. The call bell system overhaul was on the next budget meeting agenda. They stated if the light was lit up over the door, staff should still answer the call light. During an interview on 2/13/2025 at 12:32 PM the Director of Nursing stated they expected all staff to respond to a resident's call bell within 3 minutes. It was an unreasonable request at times for nursing, but any staff could respond to a call light and alert nursing if the request required a nursing task. They stated a bathroom bell would flash blue above a resident's room and was more emergent. They stated they were unaware of any call bell failures or cancellations. They stated if call bells were cancelled, a resident could be at a higher risk for falls and staff would not know they were in the bathroom. 10NYCRR 415.29

Based on observations and interviews during the recertification survey conducted 2/11/2025-2/13/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for 2 of 2 meals reviewed (the 2/11/2025 1st floor dining room lunch meal and the 2/12/2025 1st floor dining room breakfast meal). Specifically, food was not flavorful and was not served at palatable and appetizing temperatures during the lunch meal on 2/11/2025 and breakfast meal on 2/12/2025. Additionally, 11 anonymous residents during a resident council meeting and four residents (Residents #8, #12, #51 and #54) interviewed stated the food did not taste good, it was often served cold, and the vegetables were overcooked. Findings include: The facility policy, Nutrition and Food Service Department, revised 2/2019, documented the food service department provided high quality, nutritious, palatable, and attractive meals in a safe sanitary manner. The facility policy, Sanitary Conditions, dated 12/2024, documented food must be kept in hot-holding equipment at a product temperature of 140 degrees Fahrenheit or above. During an interview on 2/11/2025 at 10:32 AM, Resident #12 stated the consistency of the food was more ground than regular, the vegetables were mushy, and the food was often cold. During an interview on 2/11/2025 at 11:14 AM, Resident #8 stated the food was cold and the vegetables were overcooked and mushy. They stated they had a meeting with someone from the kitchen, was unable to recall who, and was told the menu was changing and they were hoping for improvements. During a resident group meeting on 2/11/2025 at 1:42 PM, 11 anonymous residents stated the food was cold, and mushy. The regular vegetables were overcooked, and often were pureed in consistency. When they notified staff their vegetables were pureed, staff told them they had to accommodate all resident's dietary consistencies. During a lunch meal observation on 2/11/2025 at 12:16 PM, on the 1st Floor, Resident #12 was served their lunch tray. A replacement tray was ordered, and Resident #12's original meal tray was tested. At 12:17 PM, Dietary Aide #16 verified the measured food temperatures. The hamburger was measured at 125.2 degrees Fahrenheit, the cold dessert peach cobbler was 60.5 degrees Fahrenheit, and the cranberry juice was 51.4 degrees Fahrenheit. The hamburger was not hot, the bun was soggy, and the wax beans were overly soft. During a breakfast meal observation on 2/12/2025 at 8:23 AM, on the 1st Floor, Resident #51 was served their breakfast meal tray. A replacement tray was ordered, and Resident #51's original meal tray was tested. Resident #51 stated the food was always cold and the oatmeal was too thick and dry. Dietary Aide #17 verified the measured food temperatures. The scrambled eggs were 121.6 degrees Fahrenheit, and the milk was 49.5 degrees Fahrenheit. The eggs were not hot, the toast was cold and soggy, and the oatmeal was thick, pasty, dry, and chunky. During an interview on 2/12/2025 at 12:50 PM, Resident #54 stated the chicken alfredo noodles were cold, and broccoli was overcooked. They asked Dietary Aide #16 to heat it in the microwave. When it was returned to the resident, they stated the top of the dish was hot, but the middle was cold. The resident was not able to eat the meal and stated, this is a pile of mush. The broccoli was overcooked and mushy. During an interview on 2/12/2025 at 12:57 PM, Dietary Aide #16 stated residents complained the food was cold, they did not like the menu choices, and sandwiches were offered too frequently. They stated residents complained to Kitchen Supervisor #19 and a new menu was starting next week. They stated Resident #54 said their food was cold at lunch, so they heated it in the kitchen microwave. They did not test the temperature of the plate they heated, however stated it should be between 160-180 degrees Fahrenheit. The hamburger at 125.2 degrees Fahrenheit was not hot enough. They looked at the broccoli on several different resident plates and stated it looked mushy and overcooked because the broccoli had too much water in it. They stated food was supposed to look and taste good. During an interview on 2/12/2025 at 1:07 PM, Certified Nurse Aide #18 stated residents complained about the food a lot. Complaints included the food did not look good, was not hot, and did not taste good. Residents often refused to eat the food and were offered alternatives. During an interview on 2/13/2025 at 8:59 AM, Licensed Practical Nurse #2 stated residents often complained about the entree and were offered an alternative. If a resident did not eat and was not offered an alternative, they could get malnourished. They stated they notified the Unit Manager when residents did not eat. During an interview on 2/13/2025 at 9:07 AM, Licensed Practical Nurse Unit Manager #3 stated residents often complained about the food saying it was not home cooked, it was cold, the vegetables were overcooked, and did not look appetizing. If a resident complained about their meal, they offered an alternative and notified the Kitchen Supervisor. If residents did not eat, they could lose weight and have other medical issues. During an interview on 2/13/2025 at 9:36 AM, General Kitchen Manager #19 stated they were responsible for updating resident menus, training staff, completing test trays, and overseeing the kitchen. They had complaints about the food. Most of the complaints were about the consistency of the oatmeal and sometimes food was not hot. They stated when food was not hot it was brought to the cook to test the temperature of the item before and after reheating it. Dietary aides were not allowed to heat up plates. Residents also complained vegetables were overcooked and mushy, however, the facility did not have a steamer and had to boil all the vegetables which caused them to retain water. Food should be served to residents at 140 degrees Fahrenheit. The hamburger served at 125.2 and the eggs served at 121.6 degrees Fahrenheit were not served at palatable temperatures. The thick and pasty oatmeal, the cold and soggy toast, and the overcooked broccoli were not palatable. Residents should be served food that was palatable. 10NYCRR 415.14(d)(1)(2)

Based on observations, record review, and interviews during the recertification survey conducted 2/11/2025-2/13/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards in the main kitchen. Specifically, the main kitchen had multiple uncleanable surfaces, a leaking sink drain, stored pet beds, and unclean dishware. Findings include: The facility policy, Sanitary Conditions, dated 5/2024, documented food was stored, prepared, distributed, and served under sanitary conditions to prevent the spread of food borne illness and reduce practices which resulted in food contamination and compromised food safety. The following observations of the main kitchen were made on 2/11/2025: - at 10:10 AM there were rusty shelves in the walk-in cooler. - at 10:12 AM there were pet beds under the dry storage room racks. - at 10:15 AM clean dishware was stored in soiled pan on a rack by the hand sink. - at 10:15 AM the hand sink had bare wood holding it to the walls. - at 10:44 AM there was leaking plumbing into a bus pan under the 3-bay sink. - at 12:44 PM the bus pan under the 3-bay sink was catching drips and had food debris in with the collected drain line water. - at 12:46 PM the walk-in freezer had icing on the compressor lines. General Manager #19 stated the compressor lines were iced over for several months, and they were not sure if there was a work order to repair the icing on the compressor lines but there was a work order for the sink drain line. - at 12:52 PM [NAME] #22 was observed washing dishes, spraying them in the preparation sink beside the 3 bay sink. They stated it was the preparation sink, however they were using what was available to wash dishes - at 3:02 PM two cats were observed waiting to get into the dry storage room off the dining room. During a kitchen observation on 2/12/2025 at 2:56 PM clean dishes were stored in a soiled pan on a rack by the hand sink. During an interview on 2/11/2025 at 12:46 PM [NAME] #22 stated the sink had been leaking for the past year. During an interview on 2/12/2025 at 3:02 PM, General Manager #19 stated the rusty shelves and bare wood by the hand sink were not easily cleanable. They stated clean dishes should not be stored in the soiled pan by the hand sink. Pets were not allowed in the kitchen or storage rooms to prevent contamination. They were not sure why the 3-bay sink drain line had not been fixed. They stated the drain line issue could be the result of improper use of the prep sink. It was important to clean and store dishes properly to prevent contamination and bacterial growth. 10NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey conducted 6/13/23-6/16/23, the facility did not ensure each resident had the right to a dignified existence for 5 of 13 residents (Residents #9, 24, 28, 41, and 226) reviewed. Specifically, Residents #9, 24, 28, 41, and 226 waited for their meals to be served 24-28 minutes after their tablemates were served and eating their meals. Additionally, Resident #24 did not receive assistance with eating for 39 minutes after their meal was served and placed in front of them. Findings include: The facility policy Tray Delivery/In Room Dining revised 1/2019, documented food would be delivered within 20 minutes of plating. Trays would be set up and all food uncovered. For those residents who were identified to have supervision requirements or assistance, the trays would be left on the tray cart for a certified nurse aide (CNA) or nursing staff to deliver the tray and supervise/assist the resident during the meal. The facility policy Resident Meal Service revised 3/2019, documented the facility's goal was to provide a homelike experience, promote independence, and dignity with regard to the dining experience. Residents would be assigned to a dinner table that met their physical, mental, and psychosocial needs. Accommodations would be made to meet everyone's desires with regard to tablemates. Residents requiring assistance would be encouraged to eat in the solariums to ensure physical needs were met. Meals and beverages would be served from a portable food cart at a central location on each unit, serving one floor first and then moving to the next floor, the expectation was all staff would assist in ensuring the meal was served. Resident #28 was admitted to the facility with diagnosis including dementia, depression, and anxiety. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident had moderately impaired cognition and required supervision with setup at meals. Resident #9 was admitted to the facility with diagnoses including Alzheimer's disease. The MDS assessment dated [DATE] documented the resident had moderately impaired cognition and required extensive assistance with eating. Resident #24 was admitted to the facility with diagnoses including Alzheimer's disease. The MDS assessment dated [DATE], documented the resident had severely impaired cognition and required extensive staff assistance for most activities of daily living (ADLs) including eating. During an interview on 6/13/23 at 3:39 PM Resident #62 stated they did not like that food carts were delivered to the unit so far apart. Some of the residents received their meals way ahead of others. The following meal observations were made on Unit 2: - on 6/14/23 at 12:10 PM, the first cart of lunch trays was delivered to Unit 2. Resident #28 was seated next to 5 other residents around the perimeter of the common area by the elevator. The residents were arranged facing each other in a group. Staff delivered lunch trays to the 5 residents seated near Resident #28. Resident #28 did not receive a lunch tray and asked when they were going to get to eat. At 12:20 PM several residents near Resident #28 were finished eating. Resident #28 stated I'm hungry. The Assistant Director of Nursing (ADON) told Resident #28 they were waiting for the trays to come. At 12:32 PM Resident #28 remained seated in the common area with an empty tray table in front of them and stated they were waiting for their lunch. At 12:36 PM the 2nd cart of lunch trays was delivered to the unit and at 12:38 PM resident #28 received their lunch (28 minutes after other residents). CNA #7 set up the resident's meal and stated they were not sure how the order of trays to the unit was determined. - on 6/14/23 at 12:12 PM the solarium on the 2nd floor was used as a dining room. Resident #9 was sitting at a table with two other residents who had their lunch trays and were eating. Resident #9 did not have a lunch tray. Resident #9 received their lunch at 12:36 PM (24 minutes after their tablemates) when the 2nd cart of trays was delivered to the unit. - on 6/15/23 at 12:31 PM, the first cart of lunch trays arrived. Resident #24 was seated at a table in the solarium which was being utilized as a dining room. Resident #24's lunch tray was placed on the table in front of them at 12:31 PM. Staff did not uncover the plate or assist the resident with the meal. Resident #69 was seated at the same table, had received their lunch at the same time and was being assisted by an occupational therapist (OT) with eating. At 12:49 PM the 2nd cart of lunch trays was delivered to the unit and staff distributed trays to residents. At 1:10 PM certified nurse aide (CNA)#7 sat down to assist Resident #24 with their lunch (39 minutes after the delivery of the resident's tray). CNA#7 stated that the resident should have been assisted with eating when the tray was delivered to ensure the resident's food was hot. During an interview on 6/16/23 at 9:54 AM licensed practical nurse (LPN) #10 stated the trays for Unit 2 came disorganized. They stated they should serve residents on one hall then the other. This would make it easier to distribute trays to residents. They stated residents who needed to be fed by staff should have their trays come on the cart together. This would allow them to be assisted after all the independent residents were served. LPN #10 stated there were no assigned seating arrangements for meals. The solarium was used as a dining room. LPN #10 stated residents at the same table should be served at the same time. During an interview on 6/16/23 at 10:47 AM the Assistant Director of Nursing (ADON) stated they helped oversee Unit 2. They stated there was no seating chart for meals. The ADON stated it was difficult to redirect many of the residents and they fed the residents where they were comfortable. They stated residents at the same table should be served at the same time. This could be difficult at times because the residents did not sit in the same place every day. They stated food service would arrange the trays on the carts per nursing requests. During an interview on 6/16/23 at 3:00 PM the Director of Clinical Nutrition stated nursing staff on the units requested that meal carts go to unit 2 first as there is more feeding assistance needed on that unit. They had also discussed having the delivery carts separate for each side of the unit. They stated nursing had requested the tray order inside the carts be changed to accommodate all residents at one table. 10NYCRR 415.5(a)

Based on observation, record review, and interview during the recertification survey conducted 6/13/23-6/16/23, the facility did not determine if a resident's right to self-administer medications was clinically appropriate for 1 of 1 resident (Resident #65) reviewed. Specifically, there was a medication cup filled with several pills on Resident #65's walker and there was no documented evidence the resident was assessed to determine their ability to safely self-administer medications, or a physician order for self-administration of medications. Findings include: The facility policy, Medication Administration-General Guidelines dated 3/17/22 documented residents were allowed to self-administer medications when specifically authorized by the medical provider and in accordance with the procedures of medication administrations. Resident #65 was admitted to the facility with diagnoses including diabetes, hypertensive chronic kidney disease, and coronary artery disease (CAD). The 3/21/23 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and was independent with their activities of daily living (ADLs). The 9/30/22 physician orders did not include an order for self-administration of medications for Resident #65. The comprehensive care plan (CCP) revised 10/14/22 documented Resident #65 had an altered cardiac status including coronary artery disease (CAD), diabetes mellitus (DM) type 2, peripheral vascular disease (PVD), hypertension (HTN) and hyperlipidemia (a high amount of fat in the bloodstream). Interventions were to monitor for chest pain, shortness of breath, administer medications per physician/nurse practitioner orders, and monitor/record/report to nurse any complaints of pain or requests for pain treatment. Resident #65 was observed on 6/13/23 at 11:33 AM ambulating with their walker in the hallway on Unit 1. The resident had a medicine cup filled with approximately 12 pills and a glass of water on the seat of their walker. At 12:58 PM the resident was ambulating in the hall with a medicine cup full of pills on the seat of their walker. The 6/2023 medication administration record (MAR) documented the following medications were administered at 9:00 AM on 6/13/23 by licensed practical nurse (LPN) # 5. The resident did not have medications scheduled for the day shift after 9:00 AM: - ascorbic acid (vitamin C) 500 mg 1 tablet - diltiazem CD (antihypertensive) 240 mg 1 capsule - fexofenadine (antihistamine) 180 mg 1 tablet - hydrochlorothiazide (diuretic) 25 mg 1 tablet - levothyroxine (treats low thyroid) 50 mcg 1 tablet - metformin (diabetic agent) 500 mg 1 tablet - mirabegron ER (treats overactive bladder) 50 mg 1 tablet - multivitamin 1 tablet - Preservision Vitamin supplement for vision) 1 tablet - Colace (stool softener) 100 mg 1 capsule There was no documented evidence that a self-medication assessment was completed for the resident. During an interview on 6/13/23 at 11:33 AM Resident #65 stated their morning pills were late because the facility was short staffed, and they usually received their medication between 8:00 AM and 9:00 AM. At 12:58 PM, the resident stated they were going to take their medications now and they had the same medication on their walker as they did earlier. The resident stated, I don't like to take them on an empty stomach. During an interview on 6/16/23 at 10:22 AM certified nursing assistant (CNA) #4 stated the resident was independent with their care. The nurses took care of their medications and they had never seen Resident #65 take their medications independently before. During an interview on 6/16/23 at 9:59 AM licensed practical nurse (LPN) # 5 stated they always completed the 5 checks (the right resident, the right medication, the right does, the right time, and the right route) before administering medications. Resident #5 was aware of their medications, and sometimes would take them to their room to take. LPN #5 stated Resident #65 did not have a physician's order to self-administer their medications. The LPN stated they administered medications to the resident between 9:30 AM and 10:00 AM most mornings depending on the resident's therapy schedule. On 6/13/23 had administered the resident's medications at 9:46 AM. LPN #5 stated they did not watch the resident take their medications that morning. They stated the risk of not watching could include choking, losing pills, or Resident #65 could forget to take them. During an interview on 6/16/23 at 10:16 AM registered nurse (RN) Unit Manager #2 stated LPN #5 should have watched Resident #65 take their pills. Resident #65 was forgetful. RN Unit Manager #2 stated it was unacceptable for the resident to be walking down the hall with their medications. Residents required a physician order and care plan to self-administer medications and staff would still be required to watch them take medications. RN #2 stated the risk of not doing so could lead to the resident choking, losing their pills or another resident could take the medications. During an interview on 6/16/23 at 11:00 AM the Director of Nursing (DON) stated there were no residents on Unit 1 that could self-administration medications. To self-administer medications a resident required a physician's order and be care planned to self-administer medications. Medication nurses would still be required to watch the resident take the pills and the resident would have to have a locked box in their room. DON #1 stated it was not appropriate for Resident #65 to be walking down the hall with a medicine cup full of pills. They knew that LPN #5 had administered medications without watching the resident and they had spoken to LPN #5 in the past regarding the same issue. DON #1 stated the risk of Resident #65 self-administering and not being watched could lead to the resident choking, losing the pills, or forgetting to take them. 10NYCRR 415.3 (e)(1)(vi)

Based on observation, interview, and record review during the recertification survey conducted 6/13/23-6/16/23, the facility did not ensure the right to reside and receive services with reasonable accommodation of resident needs and preferences for 1 of 1 resident (Resident #39) reviewed. Specifically, Resident #39 was not able to verbally interact with staff and did not have access to communication devices as planned. Findings include: The facility policy Resident Use of iPads/Tablets during COVID-19 Restrictions documented the facility would supply residents with access to iPad's/Tablets for virtual communication with their families and friends. All staff were able to assist residents with use of iPad's and sit with the resident, if necessary, to assist with communication issues. Resident #39 was admitted to the facility with diagnoses including hemiplegia (paralysis on one side of the body) affecting dominant side and aphasia (loss of ability to understand or express speech). The 4/27/23 Minimum Data Set (MDS) Assessment documented the resident had clear speech and used distinct intelligible words; had difficulty communicating some words or finishing thoughts but was able if prompted or given time; was unable to complete a brief interview for mental status due to being rarely/never understood; required modified independence for daily decision making; required supervision with most activities of daily living (ADLs); and had functional limitation impairment of one arm and leg. The comprehensive care plan (CCP) documented: - on 7/23/18 the resident had impaired cognitive function, impaired thought processes, impaired decision making status post stroke, and had difficulty expressing ideas and words. Interventions included to ask yes/no questions to determine the resident's needs, use the resident preferred name, identify yourself at each interaction, face the resident when speaking and make eye contact, reduce any distractions- turn off TV, radio, close door, etc. The resident understood consistent simple, and direct sentences. Provide the resident with necessary cues and stop and return if agitated. Anticipate and meet needs. Allow adequate time to respond, repeat as needed, do not rush, request clarification from the resident to ensure understanding, and use alternative communication tools as needed. The CCP did not include what the alternative communications were. - on 9/11/19 the resident had adjustment/ psychosocial problems, was unable to express themselves making it difficult to determine what was causing the resident to become upset. Interventions included to assist the resident to acclimate to staff and resident environment comfortably. - on 9/30/20 the resident was at risk for psychosocial well-being concerns. Interventions included to provide alternative methods of communication with family/visitors. - on 4/11/21 the activities CCP documented staff were to use communication boards when interacting with the resident if the resident was willing. The 6/30/21 Speech Therapy Evaluation and Plan of Treatment completed by speech language pathologist (SLP) #13 documented the resident was referred to SLP due to decline in ability to effectively communicate needs/preferences and their ability to verbally communicate. The resident required skilled SLP services for cognition/communication to analyze communication abilities and improve language function to enhance the resident's quality of life. The CCP initiated 4/20/20 and revised 10/5/21 documented the resident had an ADL self-care deficit related to a stroke with right sided hemiplegia. Interventions included the resident was being seen by SLP 3 times a week for 30 days starting on 7/2/21; and encourage resident to use iPad application to communicate. The 7/29/21 SLP #13 therapy progress report documented interventions to address verbal expression abilities included skilled training focused on yes/no responses and basic information and resident successfully responded with 50% accuracy without the need for skilled cues. The resident was also trialed with using an iPad to check their ability to select items from a list. The resident was instructed in using iPad to trial ability to answer yes/no questions and select specific words from a list to facilitate improved performance during functional tasks. The 11/19/21 SLP #13 discharge summary documented the resident previously independently used an iPad to communicate with others on minimal occasions (approximately 10-20% of the time). The resident was being encouraged to use the iPad more outside of therapy with others in the building. The resident currently used notepad as a compensatory strategy to communicate when they could not use yes/no responses. The resident was provided skilled interventions including instruction and training in communication strategies to communicate their basic wants and needs. Discharge recommendations included to facilitate optimal cognitive-communication performance strategies which included concrete one step directions by speaker to increase communication. There was no documented evidence strategies were communicated to direct care staff. The undated care instructions documented to ask the resident yes/ no questions to determine the resident's needs. Staff were to allow the resident adequate time to respond, repeat things as necessary, were not to rush the resident, request clarification from the resident to ensure understanding, face when speaking and make eye contact. The television/radio were to be off to reduce environmental noise. If appropriate, use simple, brief, consistent words/cues and use alternative communication tools as needed. They were to provide cues, orient and supervise as needed. Encourage the resident to express feelings of anger or concerns as necessary. The instructions did not include encouragement to use the iPad. The resident was observed: - on 6/14/23 at 9:19 AM, sleeping in a recliner in their room. The room had few personal effects and there were no alternative communication devices in the room. At 12:19 PM, the resident was seated at the nursing station with a scowl on their face. When asked how they were today the resident shook their head and stated No. The resident appeared upset and was unable to effectively communicate. At 12:35 PM, a pad of legal paper was observed on the resident's nightstand in their room. - on 6/15/23 at 11:00 AM, the resident stated I don't know when asked how they communicated with staff. They stated No when asked if they had a communication board and shook their head Yes when asked if they would like something to assist with communication. The resident attempted to speak but only said counted numbers from 1 to 5. The resident drew multiple squares on a notepad on their bedside table when asked about their family. The resident was using their non-dominant hand to draw. The resident was unable to verbalize or write out their thoughts. A 6/16/23 progress note by licensed practical nurse (LPN) #14 documented the resident was at the nursing station counting 1 to 5 and saying, I don't know. The resident had a new order for medication which was different from what they were receiving previously. The resident continued to be agitated, they were unable to be consoled, and went to their room around 12:00 AM. During an interview on 6/15/23 at 9:16 AM, certified nurse assistant (CNA) #4 stated they had been working on the resident's unit for 2 weeks. They stated the resident got frustrated at times when they were trying to communicate. Staff needed to know the resident well to understand what they were trying to say. They stated the resident could form a full sentence at times, but if they were unsure, they would count out loud, 1,2,3,4. The resident repeated words and could answer yes or no questions. They did not know if the resident could write on paper. They stated new employees would have to ask a staff member that was familiar with the resident if the new employee could not understand what the resident was trying to say. During an interview on 6/15/23 at 1:40 PM, LPN #6 stated the resident was aphasic and had a hard time communicating with staff. The LPN stated they had a hard time understanding the resident's wants and needs. They had never observed the resident using an alternative communication device, such as an iPad. During an interview on 6/15/23 at 2:09 PM registered nurse (RN) Unit Manager #2 stated Resident #39 could not speak, was aphasic, and could occasionally make a few words. RN #2 stated there were a couple of employees that could understand the resident's needs, but it was difficult to understand the resident. RN #2 stated the resident was cognizant but could not express anything. The RN Unit Manager stated they thought the resident would benefit from a picture board or some sort of communication device and they had never seen them used by the resident. During an interview on 6/16/23 at 1:46 PM Recreation Director #18 stated Resident #39 could not speak. They stated the resident counted and made hand gestures to communicate and staff would have to be trained on the resident's routine to understand them and their needs. Recreation Director #18 stated the resident used a picture board when they were first admitted to the facility, had used an iPad to play games but did not have their own personal iPad. Recreation Director #18 stated the resident used their personal cell phone to communicate with their family, and staff did not use an iPad to communicate with the resident. They stated the facility had several iPads available for the resident and staff to use. Telephone contact with SLP #13 was attempted on 6/16/23 at 12:06 PM and 2:24 PM without success. 10NYCRR 415.5(e)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 6/13/23-6/16/23, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 5 residents (Residents #10 and 69) reviewed. Specifically, Resident #10 was not assisted with toileting and Resident #69 was not assisted with bathing. Findings include: The facility policy ADLs revised 1/2019 documented residents would be encouraged to maintain living skills at the highest practicable level as their physical, mental, psychosocial condition permitted. Resident's ADLs were evaluated through the Interdisciplinary Team (IDT) assessment, and care plans were developed to identify, evaluate, and intervene to maintain, improve, or prevent an avoidable decline in ADLs. The IDT was to develop and implement interventions in accordance with the resident's assessed needs, goals for care, preferences, and recognized standards of practice that addressed the identified limitations in ability to perform ADLs. 1) Resident #10 was admitted to the facility with diagnoses of hemiplegia and hemiparesis (paralysis and weakness on one side of body) following a stroke, diabetes, and dementia. The 4/13/23 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and required extensive assistance of 2 for toileting. The comprehensive care plan (CCP) revised 5/3/23 documented the resident was incontinent of bowel and bladder. Interventions included to offer toileting before and after meals, offer toileting every 2 hours, offer to lie down in afternoon if resident agreed, use disposable briefs, clean peri-area with each incontinence episode, and use extensive assistance of 2 persons with gait belt for transfers. The 6/2023 [NAME] (care instructions) documented Resident #10 used incontinence briefs, required incontinence care, check skin, and keep dry, follow facility policies/protocols for prevention/treatment of skin breakdown, toilet every 2-4 hours overnight, and use extensive assistance of 2 persons with toileting using gait belt and grab bar. During observations on 6/13/23 at 10:22 AM, Resident #10 was observed in the TV lounge area sitting in a recliner covered with a camouflage blanket. At 11:39 AM, the resident was transferred into a wheelchair by certified nurse aides (CNA) #3 and #4 and wheeled to the dining room for lunch. At 12:58 PM, after lunch the resident was wheeled back to the TV lounge area from the dining room and no toileting assistance was offered to the resident. During a continuous observation on 6/14/23 from 9:19 AM until 12:00 PM, Resident #10 was in the TV lounge sitting in their wheelchair sleeping. At 12:00 PM the resident was brought to the dining room for lunch. At 12:40 PM, the resident was brought back to the TV lounge area after lunch by CNA #3. The resident stated they did not want to watch TV and CNA #3 placed the resident outside of their room in the hall. No toileting assistance was provided. On 6/14/23 at 13:59, CNA #4 documented in the resident's ADL record that toileting did not occur. During an observation on 6/15/23 from 9:22 AM to 11:33 AM, Resident #10 was sitting in the TV lounge in their wheelchair. No staff interactions or toileting were offered. From 11:43 AM to 1:10 PM, Resident #10 was observed sitting in the TV lounge area. No staff interaction and no toileting assistance was offered. At 1:10 PM, CNA #4 brought the resident to their room and was observed changing the resident's brief and performing peri-care. At 1:16 PM, CNA #4 exited the resident's room with a soiled brief and wet clothing. On 6/15/23 there was no CNA ADL documentation for toileting. During an interview on 6/16/23 at 9:45 AM, CNA #3 stated they checked incontinent residents every 2 hours during the day as care planned and every 4 hours during the evening; Resident #10 was incontinent and should be checked every 2 hours during the day. If a resident was observed in the TV lounge area for more than 4 hours, they probably were not toileted. Resident #10 could have skin breakdown if they were not checked and changed as planned. CNA #3 stated if the resident was not toileted, there would be no initials on the ADL documentation and should be documented the task was not done. CNA #3 stated there was no place in the electronic health record to document a resident had been checked every 2 hours, there were only check marks stating yes or no that the resident was checked during the shift. During an interview on 6/16/23 at 9:55 AM, licensed practical nurse (LPN) #5 stated LPNs and registered nurses (RNs) were responsible for overseeing that CNAs completed their assignments, Resident #10 was incontinent and required toileting every 2 hours. If they were not toileted, they could be at risk for skin breakdown. LPN #5 stated it was not acceptable for the resident to sit in the TV lounge area for more than 2-4 hours without being checked and toileted. During an interview on 6/16/23 at 10:30 AM, RN Unit Manager #2 stated they were responsible for overseeing the unit's nursing staff, ensuring that assignments were being done, and rounding on the residents every morning. RN #2 stated Resident #10 required assistance for toileting, was completely flaccid on one side, and was planned to be toileted every 2 hours. RN #2 stated they expected staff to follow the resident's care plan and toilet them every 2 hours to help prevent incontinence episodes and prevent skin breakdown. During an interview on 6/16/23 at 11:15 AM, the Director of Nursing (DON) stated they were responsible for overseeing the facility's nursing staff. They were familiar with Resident #10 who required total assistance with ADLs due to a stroke. The DON stated if a resident required total assistance and was incontinent, they should be toileted every 2 hours as planned to prevent skin breakdown and to maintain dignity. They stated it was not appropriate for a resident to go more than 5 hours without being toileted. 2) Resident #69 was admitted to the facility with diagnoses including dementia, anxiety, and polyneuropathy (malfunction of nerves). The 4/12/23 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and required extensive assistance of 2 for most ADLs. Bathing did not occur during the assessment period. The 12/21/22 Minimum Data Set (MDS) assessment documented choice of bathing methods was somewhat important to the resident. The comprehensive care plan (CCP) revised 5/15/23 documented the resident had impaired cognition and ADL deficits. Interventions included extensive assistance of 1 for bathing, dressing, and personal hygiene. The resident transferred via mechanical lift with assistance of 2. The 6/15/23 [NAME] (care instructions) documented assist the resident to the bathroom, weigh Wednesday evenings, bathing, dressing, bed mobility, and personal hygiene required extensive assistance of 1, mechanical lift with assistance of 2, and bath every Wednesday evening. The 5/4/23 6/16/23 nursing progress notes did not document personal hygiene or bathing refusals. The 5/24/23-6/16/23 bathing task sheet documented: - on 5/24/23 at 9:59 PM the resident required total dependence for bathing. - on 5/31/23 the activity did not occur - on 6/7/23 at 9:59 PM the resident required total dependence for bathing. - from 6/8/23-6/16/23 there was no documentation bathing occurred. The resident was observed: - on 6/13/23 at 11:59 AM, dressed and sitting in a Broda (positioning) chair. The resident's hair was uncombed and had a greasy appearance. - on 6/14/23 at 9:18 AM and 2:51 PM, lying in bed with greasy appearing hair. - on 6/15/23 at 8:46 AM, sitting in a Broda chair in the unit dining room and at 1:52 PM sitting dressed in a Broda chair in their room. The resident's hair appeared greasy. The resident stated their hair needed to be washed as it had not been done since before the weekend. - on 6/16/23 at 9:14 AM, sitting in a Broda chair in the unit dining room, dressed and groomed. Their hair was greasy in appearance. During an interview on 6/16/23 at 10:34 AM, certified nurse aide (CNA) #7 stated the resident required total care of 1 for ADLs. The resident refused care at times but allowed it when reapproached. The resident should receive a bath every Wednesday evening in the whirlpool. The resident should be washed head to toe and was totally dependent on 1 for bathing. The CNA stated if a resident's hair was greasy, they should have a bed bath with a hair wash. If a bath was unable to be performed, staff should inform the unit nurse and the CNA should document it was not done. The next shift was notified until the bath was given. They stated refusals were also documented in the resident's record. The CNA stated they had wet the resident's hair that morning because the resident had multiple straggling hairs. During an interview on 6/16/23 at 11:08 AM, licensed practical nurse (LPN) #10 stated all residents' ADLs were to be completed by 9:30 AM. Each resident was to receive a weekly bath that included washing hair and shaving. CNAs were able to wash a resident's hair in bed if their hair appeared greasy. Staff should tell the unit nurse if a resident refused a bath or hair washing and document it in the resident's chart. The LPN stated no CNA had informed them the resident refused a bath or hair washing. If the bath was not documented, then it was not done. The LPN stated each unit's nurse was responsible for the CNAs completing resident care and they would usually check while passing medications and doing unit rounds. During an interview on 6/16/23 at 11:29 AM, the Director of Nursing (DON) stated staff should reapproach the resident if they refused care and have another staff member try to perform the care. They should document the refusal after 3 tries. The DON expected unit staff to inform the nurse of any refusals. The unit nurse should document refusals in a progress note. Hair should be washed at the hairdressers or with baths, including bed baths, as hair washing was part of the bathing task. If the care was not documented, then it was not done. During an interview on 6/16/23 at 12:06 PM, RN #9 stated each resident should have care done by 9:30 AM every day. The CNA should inform the nurse if a resident refused care, if other attempts were to be made, and the continued refusal should be documented in the resident's record by both the CNA and the nurse. The RN stated CNA #11 was assigned to the resident on their bath day this week. If a resident had greasy hair, the RN expected the assigned CNA to wash the resident's hair, no matter what shift it was. The RN stated that since the bath was not documented, it was not done. 10NYCRR 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated (NY00318179) surveys conducted 6/13/23-6/16/23, the facility did not ensure residents received adequate supervision to prevent accidents for 1 of 2 residents (Resident # 14) reviewed. Specifically, Resident #14 was able to access a used phlebotomy needle (used to draw blood), placing themself and/or others at risk for injury, and the incident was not investigated to determine how the resident came to possess a used phlebotomy needle. Findings include: The undated facility policy Incident and Accident Reports the facility would ensure that the resident environment remained as free from accident hazards as is possible, and that each resident received adequate supervision and assistive devices to prevent accidents. An avoidable accident was an accident occurring because the facility failed to identify environmental hazards and individual resident risk of an accident, including the need for supervision, and /or evaluating/analyzing the hazards and risks, implement interventions, including adequate supervision, consistent with a resident's needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident; and/or monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current standards of practice. Resident #14 was admitted to the facility with diagnoses including dementia and anxiety. The 3/16/23 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, exhibited behavioral symptoms not directed toward others 1-3 of 7 days, wandered 1-3 of 7 days, walked in their room and corridor with supervision and 1 person assistance, required limited assistance with personal hygiene, and used a walker for a mobility device. The comprehensive care plan (CCP) revised 9/13/22 documented the resident had an activity of daily living self-care performance deficit related to Alzheimer's disease. The resident required limited assistance of 1 with ambulation and ambulated to all areas on the unit with a four wheeled walker. The resident had impaired cognitive function related to Alzheimer's disease. Interventions included to cue, reorient, and supervise the resident as needed. The undated care instructions ([NAME]) documented to look through the resident's walker and remove any food or unnecessary items that were in the walker; cue, reorient, and supervise as needed. During an interview on 6/15/23 at 9:33 AM, the resident's health care proxy (HCP) stated during a visit with the resident on 6/11/23 at approximately 10:00 AM they found a used phlebotomy needle with the safety cover engaged, wrapped inside a rubber glove in the resident's walker (the walker had a seat that flipped open for storage). The HCP stated they always checked the resident's walker when they visited as the resident gathered things that did not belong to them. The HCP stated they could not be sure how long the resident had possession of the used phlebotomy needle. They reported the observation to licensed practical nurse (LPN) #10 that day. LPN #10 told the HCP they had seen the resident messing around near the treatment cart earlier that day. The HCP stated the sharps container on the treatment cart was positioned low on the side, and it was locked to the cart. The nurse disposed of the phlebotomy kit but did not seem to take the incident seriously. The HCP stated they noticed a bruise on the resident's finger, took a picture of the bruised finger, and notified nurse practitioner (NP) #15 via text message. The HCP was concerned with the frequent change in staff and felt that it was difficult to get resolution to concerns. Nursing progress notes for 6/11/23 did not document the resident was found with a phlebotomy needle or had bruising on their finger. There was no documented evidence the incident was investigated to determine how the resident came to possess a used phlebotomy needle or sustained a bruise to their finger. Resident #14 was observed: - on 6/14/23 at 9:16 AM ambulating with a four wheeled walker on the unit; at 10:51 AM the resident was weepy and looking for their mother; and at 4:11 PM the resident's rolling walker contained 2 plastic flowers. There was no bruising noted on either of their hands including all fingers, palms, and the backs of their hands. - on 6/15/23 at 9:55 AM the resident's walker contained a plastic cup and a bottle cap under the seat. No bruising was noted on their hands or fingers. During an interview on 6/15/23 at 5:24 PM NP #15 stated they received a text message on 6/12/23 from Resident #14's HCP. The HCP stated Resident #14 had a bruised finger, and possibly came into contact with sharps. The NP stated they would see Resident #14 for a monthly visit and would order blood borne pathogen testing. The facility had not notified them of an incident regarding a used phlebotomy needle found in the resident's walker. The NP would expect to be notified of any such incident. If they had been made aware of the incident, they would have made a recommendation sooner. A resident should not have access to sharps, as it would put them at risk for exposure to infection. During an interview on 6/16/23 at 9:35 AM, LPN #10 stated they were the medication nurse on the resident's unit during the day shift on 6/11/23. Registered nurse (RN) coverage on the weekend was 10:00 PM-10:00 AM and they were always available by phone. LPN #10 stated they were supposed to call RNs for falls, if vital signs go bad, and to report any changes. They would use phone calls or texts to communicate concerns to the RN. Phlebotomy was done by nurses in the building and labs were not usually drawn on the weekends. All supplies from phlebotomy should go into the sharps container for disposal to prevent possible exposure to infection. Sharps containers were locked to both the treatment and medication carts and were to be changed when they were more than half full. The sharps container on the treatment cart was positioned low. The LPN stated they had seen residents try to mess around with the sharp's container at times. On 6/11/23 Resident #14's HCP came to them with a rubber glove containing a used phlebotomy needle with the safety engaged. The HCP did not mention any bruising on the resident's hands. The LPN disposed of the phlebotomy needle in the sharp's container. The LPN remembered on 6/11/23 the Activity Director moved the treatment cart because they had observed Resident#14 messing near the sharp's container that morning. The LPN stated they reported the incident to the next shift to try to make staff aware to monitor the sharps container. They stated they did not report it to an RN or the NP and did not write a progress note. They should have reported it because it could have been an infection control issue. Resident #14 may have come in contact with someone else's blood and should have received follow up by the facility. The LPN stated when someone disposed of the phlebotomy kit it probably did not go all the way down in the sharp's container. A resident would not have been able to get their hand down inside the sharps container if the phlebotomy needle had been disposed of properly. During an interview on 6/16/23 at 10:04 AM, the Director of Recreation stated they had worked on 6/11/23. They observed Resident #14 near the sharp's container on the treatment cart. The sharps container was positioned low, and the resident was in a chair right next to the cart. They heard staff say to the resident, don't touch that. The Director of Recreation stated they moved the treatment cart away from the resident. They did not notice anything in the resident's hands, and they did not check the walker at the time. The resident's walker should be checked often because the resident gathered things frequently and would put them in the walker. A resident could get puncture wounds and would be at risk for infections if they came in contact with a used sharp. ' During an interview on 6/16/23 at 10:18 AM, the Assistant Director of Nursing (ADON) stated all staff should report falls, refusal of medications, not sleeping, anything that happened on their shift on the 24-hour report. If a resident was found with a used phlebotomy needle it should have been reported. It could be an infection risk to residents due to a potential exposure. The NP should have been made aware in case labs were needed. An investigation should have been done to determine how the incident occurred and to prevent it from happening again. The ADON was not aware that Resident #14 had a phlebotomy needle found in their walker. LPN #10 should have notified the RN, or the RN on call to do an assessment. LPN #10 should have documented in a progress note. Phlebotomy was done by nurses in the facility. They stated sharps should be disposed of immediately in the sharps container to prevent any possible exposure to infection. The sharps container should have been checked to make sure supplies were disposed of properly. Resident #14's walker was checked at least daily as the resident collected items from all over the unit and put them in their walker. During an interview on 6/16/23 at 10:36 AM, the Director of Nursing (DON) stated staff orientation was provided to all employees on hire. It included information to be reported regarding accidents or incidents. A resident with a used phlebotomy kit should be reported to an RN immediately. The resident could be at risk for possible exposure to blood borne pathogens. It had not been reported that Resident #14 was found with a used needle. They had not been made aware that residents were observed touching the sharps container on the treatment cart. Sharps containers should be changed when full so that disposed of items were not accessible to residents. It could be possible that something wrapped in a glove may not have gone down properly in the sharps container and should have been checked. 10NYCRR 415.12 (h)

Based on observation, interview, and record review during the recertification and abbreviated (NY00308935) surveys conducted 6/13/23-6/16/23, the facility did not ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 1 of 1 resident (Resident #124) reviewed. Specifically, Resident #124 was unable to feed themself due to bilateral arm immobility, was on isolation precautions and required meals in their room due to COVID-19, had inadequate fluid intake, and was hospitalized for dehydration. Findings include: The facility policy Hydration revised 7/16/18 documented each resident was to be provided with sufficient fluid intake to maintain proper hydration. The resident's estimated fluid needs would be determined. Staff would identify risk factors for volume depletion, place of formal intake and output (I&O) at any time, provide a minimum of 8-12 ounces of fluids at each meal, provide fluids at nourishment and medication passes, provide ice and water once per shift within resident reaching distance, document fluids consumed, and calculate average fluid intakes weekly. Residents that consumed less than 90% of their fluid needs would be placed on hydration risk charting and communicated to nursing. Reasons for decreased fluid intake would be investigated and documented along with symptoms of fluid depletion, and the physician would be notified. The facility policy Dehydration revised 12/2018 documented risk factors for dehydration and clinical signs of insufficient fluid intake were assessed through continual nursing assessments. Staff were to assure that adequate fluids were provided for those at risk for dehydration; monitor intake and output per protocol; provide access to fluid at all times; provide assistance to drink as needed; and encourage fluids each time the resident was turned and positioned every 2 hours. Resident #124 was admitted to the facility with diagnoses including right shoulder dislocation, left upper arm fracture, and right brachial plexus injury (injury to a network of nerves in the shoulder that carries movement signals from the spinal cord to the arms). The 1/12/23 admission Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance of 2 for bed mobility, transfers, walking in room, dressing, toilet use, and personal hygiene, extensive assistance of 1 for eating, had functional limitation in range of motion in both arms, used a wheelchair, had almost constant pain that effected day-to-day activities, weighed 141 pounds, was on a therapeutic diet, and did not receive IV (intravenous) fluids while a resident. The MDS Care Area Assessment (CAA) Summary did not include dehydration/fluid maintenance as a triggered care area. The 1/5/23 admission Observations completed by registered nurse (RN) #21 documented the resident was alert and oriented. The resident was unable to use a call bell, bed control, and TV due to having slings on both arms for immobilization; and required assistance with eating. The comprehensive care plan (CCP) initiated 1/5/23 documented: - the resident had an ADL self-care performance deficit related to limited mobility and non-weight bearing (NWB) of bilateral upper extremities. Interventions included sling to left arm, NWB, remove for hygiene and then reapply; right wrist orthotic (splint used to immobilize), remove for hygiene and reapply, may lift items that weigh about what a cup of coffee does; eating extensive assistance, encourage the resident to hold drinks in the right hand and give themself drinks with the right hand, drinks need to be placed in the resident's hand, hand over hand with the use of utensil to bring food to mouth. - the resident had nutritional problems related to dislocation of right shoulder and fractured left humerus. Interventions included monitor for signs of difficulty swallowing and refusing to eat. The resident appeared concerned during meals; monitor labs/diagnostic work as ordered; provide a calm, quiet setting at mealtimes with adequate eating time; provide and serve diet as ordered; provide supplements as ordered, sugar free Mighty Shakes at breakfast, lunch, and dinner; RD (registered dietitian) to evaluate and make diet change recommendations as needed; and fluid requirements were 2240 cubic centimeters (cc) per day (35 cc/kilogram). - on 1/7/23 the resident was COVID-19 positive. Interventions included place on droplet/contact/airborne precautions per physician recommendations; place in a single occupancy or designated COVID-19 room; provide all care in room; provide all meals in room. Physician orders documented: - on 1/5/23 no concentrated sweets diet with thin liquids, record fluid intake with medication passes every shift, and bilateral immobilizer slings on at all times. - on 1/6/23 non-weight bearing both upper extremities. - on 1/9/23 droplet isolation due to COVID-19 - on 1/10/23 trial fluids via IV (intravenous). The 1/6/23 nutrition progress note by RD #19 documented the resident was admitted to the facility on a no concentrated sweet (NCS) diet with regular textures and thin liquids. The resident was seen for food/fluid preferences. The plan was to follow up with a full nutrition assessment. There was no documentation of the resident's ability to feed themself. A 1/8/23 at 1:32 AM progress note by licensed practical nurse (LPN) #14 documented the resident was on contact precautions related to testing positive for COVID-19, bilateral upper extremities were immobilized in slings, and the resident was able to move fingers on the left and right hands. A 1/9/23 at 3:32 AM MDS note by LPN #22 documented the resident was dependent on staff for feeding. Laboratory results reported on 1/9/23 at 4:57 PM documented blood urea nitrogen (BUN, measures the amount of the waste product urea nitrogen in the blood) was 66 milligrams(mg)/deciliter(dl) (normal range 10-20 mg/dl); and creatinine (a waste product, determines how kidneys are functioning) was 1.41 mg/dl (normal range 0.57-1.11 mg/dl). The 1/5/23-1/9/23 fluid intake record documented the following intakes: - on 1/5/23 480 milliliters (ml) - on 1/6/23 1380 ml - on 1/7/23 900 ml - on 1/8/23 840 ml - on 1/9/23 1080 ml. The 1/10/23 at 1:57 PM nutrition progress note by RD #19 documented the resident had no noted chewing or swallowing difficulties; had intact skin; 1//9/23 labs were pending; and the 1/5/23 weight was 141.2 pounds. Daily nutritional needs were assessed as 1346 calories, 51-64 grams of protein, and 1920 cubic centimeters (cc) of fluids (30 cc/kilogram). The house diet was in place and provided approximately 1800-2000 calories and 75 grams of protein, as well as 6 ounces (oz) milk, 6 oz juice, and a banana at breakfast. Average meal intakes were 77%. Average fluid intake was 1821 cc/day (fluids from food included), and the resident was meeting 95% of estimated fluid needs. The 1/10/23 physician #17 admission History and Physical documented the resident had a right shoulder dislocation requiring closed reduction (a procedure to set a broken bone without cutting the skin) and a right arm fracture (should have been left arm) that was treated non-operatively and was non-weight bearing to that extremity. Due to the right shoulder dislocation the resident had a brachial plexus injury and had difficulty using their right hand. The resident's kidney function improved with hydration in the hospital. The resident also had asymptomatic COVID-19. The resident was functionally very limited. Because of their bilateral upper extremity injuries, the resident was unable to use their upper extremities and could not feed themself at this time. The care plan was discussed with the nursing staff. There was no documented evidence the physician was made aware of the resident's fluid intakes. The 1/10/23-1/12/23 fluid intake record documented the following intakes: - on 1/10/23 820 ml; - on 1/11/23 1050 ml; and - on 1/12/23 100 ml. A 1/11/23 at 12:45 PM progress note by the Director of Nursing (DON) documented the resident's goal was short term rehabilitation status post hospitalization for right shoulder dislocation. The resident was non-weight bearing in both arms and was receiving PT (physical therapy) and OT (occupational therapy) to learn compensatory techniques to meet ADL (activities of daily living) needs. There were no nursing progress notes from 1/5/23-1/12/23 addressing the resident's feeding ability or fluid intake. A 1/12/23 at 10:34 AM progress note by RN #9 documented they were called to the resident's room due to the resident being lethargic and unable to follow directions. The resident had scattered wheezes throughout their lungs. The LPN took vitals, family was called, and the physician was informed of the decline in status. The physician and the resident's family agreed to send the resident to the hospital for evaluation. The 1/16/23 hospital discharge summary documented the resident was admitted from the nursing facility with dehydration due to poor intake with subsequent acute kidney injury (AKI). The resident was treated with IVF (intravenous fluids) hydration with resolution of AKI. The 1/19/23 at 1:00 PM RD #19 progress note documented the resident was readmitted from the hospital related to dehydration and acute kidney injury. The resident required feeding assistance due to injuries to both shoulders. The resident's new fluid needs were 2,240 ml/day The resident's intakes were not meeting their needs and averaging 1,477 ml/day, meeting 66% of estimated fluid needs. They would alert nursing to family concerns about the resident getting enough help to drink as the resident was not able to pick up food items and cups. The 1/24/23 physician #17 progress note documented the resident was readmitted to the facility after a hospitalization. The resident was hospitalized with acute kidney injury secondary to dehydration due to poor po (per os, by mouth) intake. This was resolved with IV hydration. The resident required total care including feeding. The care plan was discussed with nursing staff. During an interview on 6/14/23 at 3:58 PM, the resident's family member stated the resident was very lethargic, went to the hospital, and was admitted for severe dehydration. The resident had tests done at the hospital that were abnormal and confirmed this. There were times there was only 1 certified nurse aide (CNA) assigned for 36 residents on the unit. During an interview on 6/15/23 at 11:12 AM, CNA #20 stated the resident was admitted with 2 dislocated shoulders. The resident had to have help eating and drinking and staff needed to put food and drinks in the resident's hands and then the resident was able to bring it to their mouth. The resident was a good drinker and was able to ask for fluids. The resident became sick shortly after admission, was lethargic and went to the hospital. During an interview on 6/15/23 at 1:06 PM, the Director of Nursing (DON) stated the resident was on COVID-19 precautions when admitted and went to the hospital shortly after admission. The resident was lethargic when transferred to the hospital. Staff had to assist the resident with drinking due to both resident's shoulders being injured. The resident was averaging 1,000 ml of fluid intake per day. The DON expected staff to report low intakes to the Unit Manager or RN Supervisor. During an interview on 6/16/23 at 11:58 AM, the Assistant Director of Nursing (ADON) stated a dehydration assessment should be done if a resident was not taking in enough fluids. The physician should be notified, and fluids were to be encouraged. The facility had the ability to give IV fluids. The ADON stated they were not very familiar with the resident, but they were aware the resident had bilateral arm slings and could not feed themself. The slings were to remain on the resident at all times. The ADON stated they would be concerned after 2 days if the resident was only taking in 50% of their recommended fluid needs, a RN assessment and labs should have been done. During an interview on 6/16/23 at 2:44 PM, physician #17 stated they were not able to look at the resident's record during the interview. The physician stated the facility could have provided the resident with IV fluids if their po fluid intake was low. Staff should have notified a medical provider and kept them up-to-date about intake and signs of dehydration and monitored the resident's vital signs. The physician was unsure what the resident's baseline BUN and creatinine were before the 1/9/23 labs. 10NYCRR 415.12(i)(1)

Based on observation and interview during the recertification survey conducted on 6/13/23-6/16/23 the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for one walk in cooler in the main kitchen. Specifically, the diamond plate flooring and two sections of wooden 2 x 4 studs holding up bottom shelves of baker's racks in the walk in cooler were not smooth and easily cleanable. Findings include: The facility weekly cleaning schedule documented the main cooler was scheduled to be cleaned out on Monday evening shifts. During observations on 6/14/23 at 12:18 PM, the walk-in cooler floor panels (diamond plate) were lifted with gaps not seamed together causing food debris to accumulate under the panels. The panel edges were unclean and soiled with food debris on one side and jagged and irregular in shape all along the seam between the two unclean panels. There were two 12 inch long wooden 2 x 4 stud sections used to hold up the bottom shelves of two baker's racks on the right side and left side of the walk in cooler. The flooring sections and the wooden studs were not smooth and easily cleanable. During an interview on 6/14/23 at 12:18 PM, the Director of Clinical Nutrition stated they had not noticed the flooring was separating from the floor under the cooler. They stated the floor would not be considered smooth and easily cleanable. They stated there should be no wood in the cooler as it was not considered smooth and easily cleanable. During an interview on 6/14/23 at 2:50 PM, the Director of Environmental Services stated they were unaware of the condition of the flooring panels in the walk in cooler and there were no work orders submitted by staff. They stated the floor should be smooth and seamed together for cleaning. [NAME] studs should not be used in the cooler because they were not cleanable. 10NYCRR 415.14(h)

Based on observation, interview, and record review during the recertification survey conducted 6/13/23-6/16/23, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional standards for 2 of 2 medication carts (1st and 2nd floor) and 2 of 2 medication rooms (1st and 2nd Floor) observed. Specifically, the 1st and 2nd floor medication carts and the 1st and 2nd medication storages room had expired medications. Findings include: The facility policy Storage, Maintenance, Labeling, Initialing and Dating of Medications dated 5/2019 documented: - Once a medication had been opened, the nurse should write the date it was opened, and initial so that medications would be used in the accepted time frame which was 30 days (except for insulin which had a shelf-life of 28 days), unless otherwise indicated by the pharmacy. - If medications were past the open expiration date written on the bottle, they were to be disposed of per policy and a new container of medication was opened, dated & initialed. - If the medication was past the manufacturer's expiration date, dispose of the expired medication per policy and open a new one, and if a new one was not available order medication from the pharmacy During an observation on 6/13/23 at 1:47 PM, the 1st floor medication cart and medication storage room had the following expired medications: - one opened bottle of guaifenesin (cough syrup) 400 milligram (mg) labeled with open date of 4/22/23 and manufacturer expiration date of 2/23 in the medication cart. - one opened 50 milliliter (ml) vial of Lidocaine (local anesthetic) 1%, with no opened date in the medication cart. - one unopened bottle of melatonin (over the counter sleep aide) 1 mg with manufacturer expiration date of 4/2023 in the medication storage room. - one unopened bottle of Vitamin C 500 mg, with manufacturer expiration date of 3/2023 in the medication storage room. At the time of observation, licensed practical nurse (LPN) #5 stated the medications from the medication room and cart were past their expiration date. The vial of Lidocaine was not labeled with an opened date and was only good for 30 days once it was opened. Medications should be discarded the last day of the expiration month. They stated they usually go through the medication cart and medication room the last week of the month. There was not one person that was assigned to check the medication carts and medication rooms for expired biologicals. During an observation on 6/13/23 at 2:03 PM, the 2nd floor medication cart and medication storage room had the following expired medications: - one bottle of zinc (mineral supplement) 50 mg in the medication cart. - one bottle of melatonin 1 mg with manufacturer expiration date of 2/2023 in the medication cart. - one opened bottle of cetirizine HCL (over the counter allergy relief medication) 10 mg with a manufacturer expiration date of 3/2023 in the medication cart. - one opened bottle of Vitamin B-12 100 mcg (micrograms) with a manufacturer expiration date of 3/2023 in the medication cart. - one unopened bottle of Vitamin B-12 with a manufacturer expiration date of 3/2023 in the medication storage room. - one unopened bottle of melatonin with manufacturer expiration date of 4/2023 in the medication storage room. During an interview at the time of observation, LPN #6 stated the observed medications were expired. They stated every shift nurse should be going through the medication carts and rooms looking for expired medications. They thought the medications should be discarded at the end of the month before the expiration month. During an interview on 6/14/23 at 2:32 PM, the Director of Nursing (DON) stated there should be no expired medications in the medication carts or rooms. The carts and rooms should be clean and orderly, and the medication expiration dates were supposed to be checked routinely. The night shift nurses were responsible to the check the medication carts and rooms monthly. The medications should be pulled and reordered by the end of the month of the manufacturer's expiration date. The DON stated there should be an audit sheet that should be signed by the staff person doing the checks. Medication bottles were to be dated by the nurse opening the bottle. The DON stated each nurse was responsible for checking the medication's expiration date prior to administering the medication and no expired medication should be given to a resident. Resident specific expired medications should be returned to the pharmacy and if an expired medication was given to a resident, it would be considered a medication error. The stock vials such as the Lidocaine should be dated when opened by the nurse and were only good for 30 days once opened. 10 NYCRR 415.18 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification conducted on 6/13/23 - 6/16/23, the facility did not ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 2 resident units (Units 1 and 2) and for 2 of 2 (Residents #15 and 57) resident wheelchairs reviewed. Specifically, hot water temperatures were outside the acceptable range of 95-120 degrees Fahrenheit (F) on 6/15/23; and Residents #57's and #15's wheelchair armrests were in disrepair. Findings include: The undated facility policy Incident and Accident Reports documented hot water may reach hazardous temperatures in hand sinks, showers, and tubs. Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long term care facilities have conditions that may put them at increased risk for burns caused by scolding. These conditions include decreased skin thickness, decreased skin mobility, and decreased ability to communicate. The degree of injury depends on factors including the water temperatures, the amount of skin exposed and the duration of exposure. The facility policy Water and Air Temperature Readings (included with the water and air temperature audit forms) documented water and air and water temperature readings would be audited monthly. The hot water supply used by residents, or the public shall be regulated to maintain hot water temperature within the range of 90-120 degrees F. Water Temperatures The following hot water temperatures were measured on 6/15/23, using an internal probe thermometer (thermocouple): - At 11:18 AM, resident room [ROOM NUMBER] at the bathroom sink was 137 F. - At 11:21 AM, resident room [ROOM NUMBER] at the bathroom sink was137 F. - At 11:24 AM, in the 2nd floor shower room at the shower head was 138 F. - At 11:28 AM, in resident room [ROOM NUMBER] at the bathroom sink was 140 F. - At 11:31 AM, in resident room [ROOM NUMBER] at the bathroom sink was138 F. - At 11:33 AM, in resident room [ROOM NUMBER] at the bathroom sink was 139 F. - At 11:35 AM, in the 1st floor shower room at the shower head was138 F. At 4:55 PM, water temperatures in rooms 3, 23, 73, 93, 96, the 2nd floor shower and the 1st floor shower returned to below 120 F and ranged from 104 F to 107 F. The monthly water temperature reading audits for January 2023-May 2023 documented all recorded temperatures were within acceptable ranges. The temperatures ranged from 105 F to 112 F. During an interview on 6/15/23 at 11:15 AM, the Director of Environmental Services stated they were not aware of any high water temperatures. Hot water temperatures were measured monthly at random locations through the facility and normally measured at 112 F, which was what the mixing valve was set to. They stated on this date staff were notified to discontinue the use of hot water until they consulted with the vendor. Maintenance would monitor temperatures until the plumbing vendor could address the issue or temperatures were brought back into normal ranges. They stated hot water temperatures that measured that high could have the potential to burn residents if staff were not paying attention when bathing residents. During an interview on 6/15/23 at 12:15 PM, certified nurse aide (CNA) #7 stated they noticed the water in resident bathrooms and the staff bathroom seemed hot on this day. They did not report what felt like hot water to anyone. They stated resident's skin was fragile and could be injured by hot water. The CNA stated they had not given any showers today. Water temperatures did not feel hot yesterday and they did not know of any resident complaints or skin injuries from hot water. During an interview on 6/15/23 at 12:23 PM, licensed practical nurse (LPN) #10 stated today the water in resident rooms felt hotter than usual. They did not report what felt like hotter than normal water to anybody. Residents had more sensitive skin and could get burned. They stated they should have told maintenance when they noticed the water felt hot. They were not aware of any resident skin injuries or complaints of hot water. During an interview on 6/15/23 at 12:30 PM, the Director of Environmental Services stated the plumbing vendor told them to run the hot water and that should help flush the system. The vendor believed the problem to be scale buildup on the internal screens within the mixing valve, which would cause hot water to rush past the mixing valve and into the domestic water supply. The Director stated the hot water flush seemed to have helped as temperatures were coming down into normal ranges. During an interview on 6/16/23 at 12:55 PM, the Administrator stated the measured water temperatures were too hot and had the potential to burn residents. They stated they had an action plan they were able to establish quickly. Wheelchairs The following observations were made of Resident #57's wheelchair: - on 6/13/23 at 2:42 PM, the arm rest was cracked, and stuffing was protruding from the arm. - on 6/15/23 at 3:53 PM, there were jagged rips in the vinyl coverings on the right side arm rest with white stuffing exposed. The following observations were made of Resident #15's wheelchair: - on 6/13/23 at 3:23 PM, the arm rests had cracks and foam was exposed. - on 6/15/23 at 3:55 PM, there were jagged rips in the vinyl coverings on the right and left arm rests with white stuffing exposed. During an interview on 6/15/23 at 1:33 PM, licensed practical nurse (LPN) #5 stated wheelchairs were cleaned by night shift aides usually in the shower rooms on each unit and left to dry. First shift aides brought the wheelchairs back to residents in the morning. Staff should use the green work order slips on the units if wheelchairs needed to be looked at or fixed. During an interview on 6/15/23 at 3:55 PM, the Director of Environmental Services stated the wheelchair arm rests should not be damaged to the extent they were. They expected to have received work orders to replace the arm rests. They had no work order for either identified resident wheelchairs. Maintenance was responsible for the replacement of arm rests. All work orders for wheelchairs that were submitted had been addressed. CNAs should have noticed the condition of the wheelchairs during cleanings or treatments and submitted a work order. 10 NYCRR 415.29 f (6)

**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 residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 residents (Resident #8) reviewed. Specifically, Resident #8 was observed unshaven for 4 days. Findings include: The facility ADL Policy, revised 1/2019 documents the responsibility of nursing and IDT (interdisciplinary care team, nursing, social work, therapy, nutrition, activities) included: - Recognizes and assesses a resident's inability to perform ADLs; and - Develops and implements interventions in accordance with the resident's assessed needs, goals for care, preferences and recognized standards for practice that address the identified limitations in ability to perform ADLs. Resident #8 had diagnoses including vascular dementia, intellectual disability, and major depression. The 2/27/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, did not exhibit any behavioral symptoms, did not reject care, and required extensive assistance for personal hygiene. Nursing progress notes from 4/1/21 to 5/7/21 did not contain any documentation the resident refused or resisted care. The 5/7/21 [NAME] Report (care instructions) documented the resident required limited assistance of one person for personal hygiene and to encourage as much participation/interaction by the resident as possible during care activities. The [NAME] did not include shaving preference or a schedule for shaving. The 5/2021 certified nurse aide (CNA) task documentation included the resident was bathed on 5/3/21 and required the assistance of one person. The resident received assistance of one person for personal hygiene on 5/4-5/7/21. The resident was observed with thick stubble on their face and neck on 5/4/21 at 10:49 AM and 12:04 PM; on 5/5/21 at 9:59 AM, 1:02 PM, 1:45 PM, 2:45 PM, and at 3:44 PM; on 5/6/21 at 8:57 AM, 9:18 AM, 10:32 AM and at 10:36 AM, 11:00 AM, 12:18 PM and 1:15 PM; and on 5/7/21 at 10:42 AM and 11:06 AM. During an interview on 5/7/21 at 11:50 AM, CNA #2 stated they had provided care to Resident #8 this week and had not offered or attempted shaving. The resident was able to participate in some of their ADL care like washing their face but needed guidance and ongoing cueing to complete tasks. The resident did not refuse care and was not able to identify their grooming needs. The CNA stated residents were shaved on bath days and was not aware if the resident had a bath this week. The CNA stated the resident appeared to need a shave and the CNA did not ask the resident or offer to shave when providing care. There was no particular care plan or CNA task for shaving, and it was part of daily hygiene and care. The CNA worked on the unit as their regular assignment and had not previously shaved the resident. The CNA accompanied the surveyor to the resident's room and located an electric razor in the resident's drawer. It was functional and had facial hair on it. The CNA stated the resident would not be able to use the razor without assistance and CNAs should offer daily shaving. During an interview on 5/7/21 at 2:03 PM, registered nurse (RN) Unit Manager #1 stated there was no specific care plan or CNA task to address shaving and specific grooming needs of residents. CNAs were expected to assist residents with shaving during daily routine care unless otherwise specified on the care plan. Resident #8 was not able to state their desire to be shaved and relied on staff for personal grooming and hygiene. There were no reports from staff the resident refused care or shaving. The resident appeared very scruffy and in need of a shave. 10NYCRR 415.12(a)(3)

Based on observation, interview and record review during a recertification and an abbreviated survey (NY00266833), the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #147) reviewed. Specifically, Employee # 3 did not receive training and education on the use of assistive devices, provided a walker to Resident #147, did not assist the resident while ambulating with the walker as planned and the resident fell resulting in a laceration and skin tear. Findings include: The facility's undated Beginning Employment Policy documents new employees serve a three-month introductory period and includes: - The employee's supervisor/manager will work closely with the individual to provide the required training, answer questions, and assist them specific to their department, which includes a general orientation check list. - The Human Resources Department will present a general orientation for new employees to the organization. The undated job duties for a Recreation Leader includes: - Conducting facility activities as directed by the Director of Recreation. - Responsible for fulfilling the social needs of all the residents. - Provide residents with conversation and sensory stimulation. - Work with all staff to ensure all residents are involved according to their ability. - Recognize and report abnormal signs and symptoms which may require nursing evaluation. The job description did not include any ADL (activities of daily living) assistance that could be provided by the Recreation Leader or required training. Resident #147 was admitted to the facility with diagnoses including dementia and arthritis. The 8/8/20 Minimum Data Assessment (MDS) documented they were cognitively intact and required extensive assistance of 1 person for transfers and limited assistance of 1 person for ambulation. They required a walker for ambulation and used a wheelchair for long distances on the unit. The comprehensive care plan (CCP) updated on 10/12/20 documented the resident was noncompliant with transfers and ambulating and was at risk for falls. Interventions included to keep the walker out of reach of the resident. The facility incident report dated 11/3/20 documented: Resident #147 was found on the floor in their room in a supine (lying face up) position with Employee #3. Resident #147 had a laceration on the right cheek and right eyebrow and a skin tear to the dorsal aspect (top) of right hand. The resident was at risk for falls and was given their walker to use the bathroom. The resident was care planned as assistance of 1 with walker for ambulation. Employee #3 documented they went to Resident #147's room to paint the resident's nails and the resident asked for the walker so they could go to the bathroom, and Employee #3 gave the walker to the resident. The resident then fell forward on their face. Employee #3 documented they were not aware the resident could not walk on their own. Employee #3's personnel file documented they were hired on 11/30/2015 as a food service worker, with the potential to be around residents. The file also included the following documentation: -9/17/18 a written warning was issued for not following a resident care plan and giving a resident the wrong diet consistency. -6/3/19 a second written warning was issued for not following a resident's care plan and giving a resident the wrong diet consistency. -11/21/19 a typed statement documenting Employee #3 would be removed from the dietary department and transferred to the recreation department due to having multiple written warnings for giving residents the wrong diet consistency. -11/22/19 the employee had a position transfer from dietary aide to recreation aide. -4/29/20 a signed acknowledgment by the employee for review of the employee policy manual. -8/19/20 the employee had a position transfer from recreation and leisure department to dietary aide. -9/21/20 the employee had a position transfer from dietary aide to recreation and leisure leader. -11/5/20 a final written warning for violation of a resident care plan regarding the incident with Resident #147 on 11/3/20 (providing a walker). -11/6/20 (after the 11/3/20 incident), a signed, updated job description, with additional job details documented in handwriting which included cannot help with transfers or ambulation. Employee #3's annual performance evaluation, dated 11/2020, documented the employee needed improvement in areas of job knowledge, quality of work and dependability. There was no documented evidence of orientation and/or supervision for Employee #3 when transferred from dietary aide to recreation leader on 9/21/20. A training transcript for Employee #3 documented the following trainings were provided to Employee #3: - On 11/17/20 Care Planning in Nursing Facilities. - On 5/5/21 Blood-borne pathogens, hazardous chemicals, trauma, informed care, fire safety, and resident rights. On 5/5/21at 9:25 AM Employee #3 was observed in the dining room on the second floor pushing a resident in a wheelchair. There was no documented evidence Employee #3 was provided education or training on safe wheelchair transport of residents. During an interview with the Director of Human Resources on 5/4/21 at 11:53 AM, they stated Employee #3 was hired on 11/30/15. On 11/22/19 they were transferred to recreation after there was an issue as a dietary aide. On 8/19/20, Employee #3 was transferred back to food service in a non-resident contact position. On 9/21/20, Employee #3 was provided a full-time position in recreation and leisure as a recreation leader. During an interview with the Director of Recreation on 05/06/21 at 8:11 AM, they stated Employee #3 was a recreation leader which involved providing activities to all the residents. Employee #3 assisted with menus, calendars, newspapers, nail care and BINGO. Employee #3 must be provided written instructions, so they knew Employee #3 understood the job expectations. They stated if recreation staff does not know about a resident's assistance or ambulation status, they must ask nursing staff. Recreation staff are not able to assist residents that require a gait belt or assistance of one. They stated Employee #3 was oriented to the recreation department and shadowed the Director of Recreation for a week. Employee #3 was trained by a recreation staff member who was no longer working at the facility. They stated they did not have any formal documentation of the employee's training. During an interview with Employee #3 on 5/6/21 at 9:15 AM, they stated they were currently a recreation leader. They recalled giving Resident #147 a walker on 11/3/20 and they were not aware they should not have provided Resident #147 their walker. They thought they were being helpful, but now know this is not a part of their job description. They were unable to remember what type of training they received for their current position as recreation leader. They recalled receiving training a while ago regarding abuse and neglect. They explained their daily routine was to provide newspapers and one-on-one visits with the residents. They stated they received resident safety training after the 11/3/20 incident with Resident #147. During a second interview with the Director of Human Resources on 05/06/21 at 9:37 AM, they stated they are responsible for new hire training only and would provide staff with their job description. Each department head was responsible for training their team members. Employee #3 worked in recreation/leisure and the director of that department would have been responsible for ensuring that Employee #3 was trained. They stated their only documented training for Employee #3 was the job description, revised and signed after the incident on 11/3/20. During a second interview with the Director of Recreation on 5/06/21 at 11:24 AM, they said they check in with Employee #3 frequently throughout the day. The Director stated when they had a day off, Employee #3 worked without supervision and was comfortable asking nursing staff specific questions about residents. The Director would give Employee #3 details of their daily work tasks in writing if it was something different from their usual daily activities. During an Interview with the Director of Nursing (DON) on 5/06/21 at 1:10 PM, they stated the incident with Resident #147 involving Employee #3 occurred on 11/3/20. The resident required assistance of 1 for transfers and had fallen when after Employee #3 provided them a walker. Resident #147's care plan documented to set aside the walker in the corner of the room so the resident would not self-transfer as the resident had a history of getting up without staff assistance. Recreation staff should never assist a resident with personal care or transfer/ambulation assistance. 10 NYCRR 415.12(h)(2)

Based on observation, interview, and record review during the recertification survey, the facility did not ensure a resident who needed respiratory care was provided such care consistent with professional standards of practice for 1 of 1 resident (Resident #8) reviewed. Specifically, Resident #8 became acutely ill and was placed on oxygen without a physician order for its use. Findings include: The facility Oxygen Administration policy revised 3/2015, documents: - When recording oxygen (O2) orders, specify liter flow rate, route (nasal cannula/mask), rationale, and specific titration (process of monitoring and adjusting) parameters if applicable. - Licensed nursing staff are to titrate O2 to keep O2 saturation (sat, concentration of oxygen in the blood) greater than 90 percent for all residents, except for those diagnosed with chronic obstructive pulmonary disease (COPD) or who have specific parameters outlined in the O2 order. - Oxygen may be started and an immediate call placed to the practitioner to notify them of the resident's condition and to obtain a telephone order for the oxygen. Resident #8 had diagnoses including pneumonia, COPD (chronic obstructive pulmonary disease), and hypertensive heart disease with heart failure. The 2/27/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance of one person for dressing, bed mobility and hygiene, and extensive assistance of two people for transfers. The resident did not receive oxygen therapy at the time of the assessment. The 4/27/21 at 4:07 PM nursing progress note documented registered nurse (RN) Manager #1 assessed the resident who was noted with difficulty breathing and was perspiring. The resident's respirations were 24 (number of breaths taken in one minute), crackles were noted in all lobes of their lungs, O2 saturation (sats) was 82% on room air, and 2 liters (L, flow of oxygen delivered per minute) of O2 was started. Oxygen sats went to 84%, oxygen was increased to 4L via nasal cannula (NC), and O2 sats went up to 93%. The nurse practitioner (NP) was notified and new orders were received for a chest x-ray, antibiotic, and vital signs every shift. The 4/27/21 at 6:33 PM nursing progress note documented the NP was updated with the resident's x-ray results, continue with O2 and vital signs. The resident continued with O2 at 2L via NC. There was no documented evidence a physician order for O2 was obtained. The 4/28/21 NP progress note documented the resident was seen for tachypnea (rapid, shallow breathing) and hypoxia (decreased O2). Staff reported the resident woke yesterday with difficulty breathing, O2 sats were 83%, up to 85% on 2L O2 via NC, then to 93% on 4L. The chest x-ray showed likely right upper lobe pneumonia. The resident was to continue an antibiotic and O2 at 2-4L via NC to maintain sats greater than 90%, vital signs every shift, continue to monitor respiratory status. There was no corresponding order for O2. The 4/2021 TAR did not contain documentation the resident had received oxygen. The Weights and Vitals Summary documented O2 sats: - on 4/27/21 at 3:00 PM, 82% on room air (RA); - on 4/27/21 at 4:07 PM, 95% O2 via NC; - on 4/28/21 at 5:07 AM, 95% on RA; and - from 4/28/21 to 4/30/21, all 96%-98% on O2 via NC. There were no O2 sats recorded from 5/1/21 to 5/7/21. Nursing progress notes documented: - On 4/30/21 at 11:47 AM, the resident's lips very dry, humidification placed on concentrator for more moisture, O2 at 1L via NC, continued to have shortness of breath with ambulation, will continue with O2 at this time; - On 4/30/21 at 1:31 PM, the resident was on O2 at 2L via NC, O2 sats were 98%, dropped level to 1L, sats 97% on 1L; - On 5/2/21 at 1:09 PM, the resident's O2 sats were 90-91% on room air today; - On 5/2/21 at 6:10 PM, the resident was in a chair without oxygen on, eyes wide, mouth breathing, O2 sats 84% on room air, O2 placed via NC at 1L, sat came up to 95%; - On 5/2/21 at 6:40 PM, the resident was lethargic, oxygen was on at 1L, sats were 94%; - On 5/3/21 at 2:56 Am, O2 replaced several times, the resident continued to remove it, O2 was 80%; - On 5/4/21 at 4:52 PM, the resident continued to be tachycardic and lethargic, with O2 at 1L via NC; - On 5/4/21 at 11:53 PM, the resident was on O2 at 1L, but did not always leave it on; - On 5/5/21 at 8:51 AM, the resident was on O2 at 2L, sats were 94%; and - On 5/5/21 at 3:00 PM, the resident remained on O2 at 1L via NC. The 5/2021 TAR did not contain any documentation for oxygen use. The 5/3/21 NP progress note documented the resident was seen for follow up for lobar pneumonia. Staff reported the resident had continued lethargy, confusion with eating, and desaturation to 83% with O2 off. The resident's heart rate was newly irregular and evaluated on exam. Continue on O2 2-4 liters (L) per minute via nasal cannula (NC) to maintain O2 sats greater than 90%. Monitor vital signs (VS) every shift with all parameters and monitor respiratory status. There was no documentation of a medical order for O2. On 5/4/21 at 10:49 AM, the resident was observed lying in bed on their back, moaning and waving their arms. The bed was flat, an oxygen concentrator was away from the bed, with oxygen tubing draped over the overbed table, out of the resident's reach. At 10:50 AM, a CNA walked into the room, asked the resident if they were having a hard time breathing and offered to get the resident up. The CNA left for a moment and returned with another CNA, and they assisted the resident to a recliner in the television area outside the room. The 5/5/21 physician order documented oxygen at 1 liter per minute via nasal cannula to keep oxygen saturations greater than 90%. The resident was observed: - On 5/4/21 at 12:04 PM, in a recliner in the television area, wearing oxygen, the concentrator was by the chair set at 1 liter; - On 5/5/21 at 9:59 AM, in their room, seated in a recliner, wearing oxygen, the concentrator was set at 1 liter; - On 5/5/21 at 1:02 PM and 1:45 PM, 2:45 PM, and 3:44 PM, in a recliner outside their room, wearing oxygen, the concentrator was by the chair and set at 1 liter; - On 5/6/21 at 9:18 AM and 10:32 AM, seated in a stationary chair in the hall near the elevator, wearing oxygen, a portable oxygen tank was next to the chair and set at 2 liters; - On 5/06/21 at 12:18 PM, in a recliner in the hall wearing oxygen with a portable tank next to the chair, set at 2 liters; - On 5/07/21 at 10:42 AM, seated in the hall wearing oxygen, the portable tank set at 2 liters. During an interview on 5/7/21 at 11:06 AM, RN Manager #1 stated when a resident became acutely ill, it was a nursing standard to place oxygen to alleviate the distress and then call the medical provider. A physician's order was required for oxygen use and to clarify parameters and monitor effectiveness. If there was no order, staff would not be aware of the resident's needs for oxygen and monitoring. An order for oxygen would be on the treatment administration record (TAR) and nursing staff would document its use and O2 saturation monitoring. When resident #8 became ill on 4/27/21, RN Manager #1 started the oxygen and it had been used continuously for the resident since then. The order should have been entered and the resident's oxygen saturations monitored every shift. The RN Manager stated the order was entered on 5/5/21 because it was an oversight and it should have been entered on 4/27/21. When interviewed on 5/7/21 at 11:50 AM, CNA #2 stated oxygen use was not on CNA care instructions and was managed by nursing. The CNA knew the resident was on oxygen due to the concentrator in the room and they would replace the nasal cannula if it was off. CNAs did not adjust the settings on portable tanks or concentrators. When interviewed on 5/7/21 at 3:00 PM, NP #7 stated the current oxygen order for Resident #8 should be PRN (as needed). When the resident became ill on 4/27/21, the order for oxygen was 2-4 liters continuous, but the NP just gave verbal orders to wean the resident down. Any orders for oxygen should be entered into the electronic medical record (EMR) when started. An order was required to ensure staff were monitoring and knew the parameters. 10NYCRR 415.12(k)(6)

Based on record review and interview during the recertification and abbreviated (NY00269365) surveys, the facility did not ensure they provided or obtained laboratory services to meet the needs of its residents and ensure timeliness of the services for 1 of 3 residents (Resident #30) reviewed. Specifically, Resident #30 had a change in medical status, the medical provider ordered laboratory tests and they were not completed timely. Findings include: The facility Laboratory Policy revised 7/24/19 documents the facility will ensure proper follow through on all medical provider laboratory orders. The nurse is to note and transcribe lab orders into progress notes and the master lab sheet binder. The unit secretary will check the master lab sheet for any new orders and complete lab requirements. Lab requisitions will be placed in designated lab information area on the unit for the lab technician. Resident #30 had diagnoses including heart failure, chronic kidney disease, and history of COVID-19. The 3/26/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, exhibited no behavioral symptoms, and required limited assistance of one person for most activities of daily living (ADLs). The resident took anticoagulant (blood thinner) and diuretic medication 7 out of 7 days of the assessment period. The 12/23/20 nurse practitioner (NP) #7 order documented to obtain a complete blood count with differential (CBC, blood tests to identify a variety of illnesses or disorders that affect the blood), a comprehensive metabolic panel (CMP, chemistry screen of the blood), and a urinalysis (UA) and culture and sensitivity (C&S, tests to identify pathogens in the urine and antibiotic susceptibility) one time for syncope and dizziness. The order status was noted as completed with an end date of 12/24/20. There were no documented medical provider or nursing notes regarding a visit or the order for the blood work or the UA and C&S on 12/23/20. NP #7's 12/30/20 progress note documented the resident was seen, remained on isolation and had a video call with a family member. There was no documentation regarding the ordered labs from 12/23/20. There were no nursing progress notes from 12/24/20 to 12/31/20 regarding blood or urine specimens collected or results received for the ordered 12/23/20 labs. The 12/31/20 laboratory report documented a CBC with differential and CMP were completed, specimens were collected on 12/31/20 at 12:45 PM. There was no documentation the UA or C&S was completed as ordered on 12/23/20. During an interview with Resident #30's family member on 5/6/21 at 12:47 PM, they stated the resident had two events of syncope while also being ill with COVID-19. The family member spoke to NP #7 on 12/23/20 who stated blood and urine laboratory orders were placed and given to the nurse so results would be available the following day. The family member called the facility on several occasions from 12/24/20 to 12/30/20 to find out the results and was told they were not in yet. When speaking to NP #7 on 12/30/20 during a video visit with the resident, the family member was told the blood was drawn that day. When interviewed on 5/7/21 at 11:06 AM, registered nurse (RN) Manager #1 stated when lab orders were received, they were entered in the electronic system, then written in a binder on the unit. The RN Manager stated it was their responsibility to check daily to ensure ordered labs were completed. Specimens should be collected that day or the next, unless otherwise directed in the order. The RN was not aware of the reason the labs were not completed as ordered and stated it should have been done within 24 hours. The lab tracking sheet from 12/23/20 was not in the binder any longer and the RN Manager was not aware of its location. During an interview on 5/7/21 at 1:34 PM, the Director of Nursing (DON) stated laboratory orders should be completed within 24 hours unless otherwise directed. The DON was unaware of any issues with Resident #30's labs in 12/2020 and stated eight days was not timely for the blood specimen to be collected. A courier arrived at the facility twice per day, 11 AM and 4 PM, to transport specimens to the laboratory. The ordered labs should have been completed. If there was a problem with collecting the specimens, the DON would expect nursing to document in a progress note and contact the medical provider. When interviewed on 5/7/21 at 1:45 PM, laboratory team leader #9 stated the facility sent specimens via courier. The requisitions and specimen vials were noted with date and time collected. The blood sample for Resident #30 was recorded as collected by the facility staff (initials) on 12/31/20 at 12:45 PM and received by the lab at 4:47 PM. There were no other lab requisitions from 12/23/20 to 12/31/20. There was no urine sample or requisition for a UA or C&S submitted during that time. When interviewed on 5/7/21 at 3:00 PM, NP #7 stated Resident #30 had a two of syncopal events while they were ill with COVID-19 during 12/2020. Blood and urine tests were ordered on 12/23/20. The NP was unaware of the reason the labs were not completed as ordered and stated they should have been done within 24 hours. 10 NYCRR 415.20

Based on observation, interview, and record review during the recertification survey, the facility did not ensure each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 3 of 3 meals (breakfast, dinner #1, and dinner #2) reviewed. Specifically, meal temperatures were not maintained at acceptable parameters during the 3 meals. Findings include: The undated facility policy Food Safety Management System Hot and Cold Holding documented cold foods must be held and served at a temperature of 40 F or below and hot foods must be held and served at a temperature of 140 F or higher. During an observation on 5/5/21 at 12:05 PM, the lunch food tray was delivered to the first floor. The food tray was delivered to the resident room at 12:18 PM. A replacement tray was ordered for the resident and the original tray was used for testing. Between 12:21 PM and 12:23 PM, the potato salad was measured at 55 Fahrenheit (F), the Italian-style sub sandwich was measured at 59 F, and the milk was measured 55 F. The potato salad was hard, chewy, and not flavorful, and the milk was not cold or flavorful. During an observation on 5/5/21 at 5:00 PM, the dinner food tray cart was delivered to the first floor. The food tray was taken from the tray cart at 5:15 PM and a replacement was ordered. Between 5:18 PM and 5:21 PM, the chicken parmesan was measured at 122 F, and the cream of mushroom soup was measured at 114 F. The chicken parmesan and cream of mushroom soup were not hot to taste. During an observation on 5/5/21 at 5:27 PM, the dinner food cart was delivered to the second floor. The food tray was delivered to the resident at 5:40 PM and a replacement tray was ordered. Between 5:42 PM and 5:48 PM, the ground chicken parmesan was measured at 118 F, the cream of mushroom soup was measured at 106 F, the milk was measured at 60 F, and the sherbet was measured at 38 F. The ground chicken parmesan was not hot, the cream of mushroom soup was lukewarm and very thick, the milk was not cold or flavorful, and the sherbet was soft/liquid consistency. During an observation on 5/5/21 in the main kitchen, between 6:05 PM and 6:10 PM, food service worker #10 verified food temperatures with a facility thermometer: - piece of chicken: facility thermometer 106 F, surveyor thermometer 107 F. - cream of mushroom soup: facility thermometer 121 F, surveyor thermometer 118 F. - milk (from cooler): facility thermometer 43 F, surveyor thermometer 44 F. The 2021 monthly facility cooler temperature sheets documented the facility had been checking the temperature of the coolers. The kitchen's Daily Service and HACCP (Hazard Analysis Critical Control Point) Record temperature log documented the kitchen staff had been documenting the cold and hot food item temperatures prior to preparing the trays in the kitchen. During an interview on 5/6/21 at 9:45 AM, food service worker #10 stated that hot food items should be served at 170 F and cold food items should be served at around 40 F. Milk over 45 F would not be palatable. They stated the temperatures have held steady at 40 F for the walk in cooler in the kitchen. The time it took from trays being plated to delivery to resident hallways 10 to 15 minutes, depending the on the meal. Food service worker #10 did not serve meals in hallways or resident rooms, the CNAs and LPNs do that. Food service worker #10 had not heard any complaints about food flavor, consistency, or temperature issues. The potato salad was made the day before and left in the cooler to be used the next day. They stated they had not checked the if the potatoes were fully cooked before being used in the potato salad. During an interview on 5/6/21 at 11:00 AM, the Night [NAME] Supervisor stated hot food items should be served at 160-170 F, and cold food items should be served at 35 F-40 F. Milk over 45 F was not flavorful and should not be served to residents. The Night [NAME] Supervisor would check food quality/flavor before it would be sent out. When the Night [NAME] Supervisor made potato salad, the potatoes would be cooked longer to ensure they were softer/more palatable. The internal facility test trays were usually done at lunch time. The Night [NAME] Supervisor had not done any test trays for dinners and had not been told of any food quality issues within the last year. The food on the steam table was checked after food service. The steam tables have always kept their hot temperatures by setting the steam tables to max levels when cooking. The time between trays being plated to going to resident hallways was 10 to 15 minutes depending on the meal. During an interview on 5/6/21 at 11:56 AM, the registered dietitian (RD) stated that chicken served to residents should be served over 140 F, out of the temperature danger zone, and for palatable/flavor reasons. The RD did not consider milk over 55 F palatable, as it should be served at 40 F or lower and cream of mushroom soup should be over 140 F. The RD would not want to eat sherbet at 38 F, due to the liquid consistency. The diced potatoes came into the facility parboiled and should be cooked before being served. Cooks should be tasting food before it was served to the residents. They had not heard of any temperature or palatability issues related to the food served. 10NYCRR 415.14(d)(2)