Based on observations, interviews, and record review during the recertification survey from 5/22/2023 to 5/30/23, the facility did not ensure residents had a right to a dignified existence for one of 2 residents screened for dignity. Specifically, Resident #20 had a sign above the bed, on the wall, which contained instructions for staff about the resident's wounds and incontinence pads, which was visible from the roommate's side of the room. The findings are: The facility policy Resident Rights, revised 12/2022, documented the resident had the right to be treated with dignity, respect and consideration at all times and have a right to privacy in the treatment and care of personal needs. Resident #20 was admitted with diagnoses including dementia, pressure ulcers, anxiety, and weakness. The admission Minimum Data Set (MDS, an assessment tool), dated 05/16/2023, revealed the resident was cognitively impaired and needed extensive assistance of one person with bed mobility and dressing. The resident was dependent on staff for toileting and was incontinent of bowel and bladder. Resident #20 was observed on 5/24/2023 at 9:30 AM and 5/26/2023 at 10:16 AM, in bed with an 8-inch by10 inch hand written sign that noted Do not put dressing on her hips. Do not close her diaper while in bed. These wounds must be left open to air to heal- The Wound Team. The sign was visible from the resident's side of the room and the roommate's side including families, visitors, and staff. During an interview on 05/26/2023 at 10:23 AM, the Registered Nurse Unit Manager (RNUM) #1 stated they did not know how long, or who, put the sign on the wall at the top of Resident #20's bed. RNUM #1 stated it provided too much personal information and was a privacy issue. During an interview on 05/26/2023 at 1:41 PM, the MDS Coordinator #1 stated they made rounds with the wound Physician Assistant and was unaware of the sign above Resident #20's bed. The MDS Coordinator stated they would never put a sign up over a resident's bed as it contained private confidential information.

Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure all residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent a further decrease in range of motion for 1 of 3 residents (Resident #9) reviewed for range of motion/position mobility. Specifically, Resident #9 was observed without the use of physician ordered hand splints. The findings are: The Policy and Procedure titled Assistive Devices effective 2008 documented all assistive devices including positioning devices, skin protection items and feeding supports were listed on the daily assignment sheet. Every shift assigned aide was to check that devices were in place as ordered. Resident #9 was admitted to facility 5/27/08 with diagnoses including but not limited to Aphasia, Non-Alzheimer's Dementia, and Spastic Quadriplegia. The 5/10/21 Physician Order documented right-hand and left-hand splints on at the beginning of day shift and removed at 11 PM by the evening shift. The 5/11/23 Quarterly Minimum Data Set (MDS) Assessment documented Resident #9 had severe cognitive impairment and had functional limitation in range of motion of the bilateral upper and lower extremities. There was no documented evidence in the April 2023 and May 2023 Treatment Administration Record (TAR) to address the application and removal of the right and left hand splints. There was no documented evidence in the May 2023 Certified Nurse Assistant Care Card Instructions to address the application and removal of the right and left hand splints. The 10/26/17 Care Plan titled Activities of Daily Living (ADL) Self-Care Performance Deficit with a 5/20/21 revision date documented apply left and right hand splints in the beginning of the day shift (by staff who has been in serviced) and removed at the end of the day shift. The 4/5/23 Occupational Therapy (OT) discharge note documented Resident #9 continues to have limitations in the bilateral upper extremities, requiring splinting. During observation on 5/23/23 at 11:59 AM, 5/25/23 at 2:27 PM and 5/26/23 at 11:22 AM Resident # 9 was observed without the left hand resting splint in place and a hand roll in the right hand. During an interview on 5/26/23 at 11:07 AM Certified Nurse Assistant (CNA) #1 stated Resident #9 had splints that should be worn for contractures. CNA #1 stated the resident is supposed to wear the splint every day and they are removed at night. CNA #1 stated there are 2 splints, but they do not appear to be the same. CNA #1 stated they did not have to document for the application of the splints. CNA #1 had no explanation as to why the splint was not being worn. During an interview on 5/26/23 at 11:22AM Licensed Practical Nurse (LPN) #1 stated that Resident #9 used a hand roll but was not aware of any other devices that Resident #9 required. LPN #1 looked in the electronic medical record (EMR) and stated there was a physician order for bilateral hand splints. LPN #1 stated they were not aware that Resident #9 had an order for the splints and when they checked the Treatment Administration Record (TAR) there was no indication for the application of and removal of the left and right hand splints. During an interview on 5/26/23 at 11:44 AM the Director of Nursing (DON) stated they did not know why the order for left and right-hand splints for Resident #9 were missing from the Treatment Administration Record (TAR) and the Certified Nurse Assistant (CNA) Care Card Instructions. The DON stated they have not been made aware of issues regarding physician's orders being populated into the TAR. 415.12(e)(1)

Based on observation and staff interview during the Life Safety Recertification survey, the facility did not ensure all applicable state codes were met. Specifically, the facility did not install a carbon monoxide detector in the kitchen in accordance with section 915 of the 2015 edition of the International Fire Code, as adopted by New York State and contained in the NYS Uniform Code Supplement Section 915.3, which requires carbon monoxide detection in buildings with fuel-burning appliances. The findings are On 09/10/2020 at 12:20 p.m. a tour of the First Floor revealed the facility's main kitchen had a gas range/oven and a carbon monoxide detector was not installed in the kitchen or throughout the entire First Floor. Furthermore, the First Floor contained one resident-use physical therapy room and the main dining room. In an interview on 09/11/2020 at approximately 3:30 p.m., the Administrator stated carbon monoxide detection was not installed in the skilled nursing facility. 10 NYCRR: 415.29 (a)(2), 711.2 (a)(1); 42 CFR: 483.70 (b), 2015 IFC: Section 915, 915.1, 915.1.4, Section 1103.9

Based on record review and interview conducted during a recertification survey, the facility did not properly establish and / or maintain an Infection Prevention and Control Program designed to provide a safe and sanitary environment. Specifically, (1) the facility did not have a site-specific water management plan for legionella, (2) the facility did not have an annual facility risk assessment for legionella, and (3) the facility did not have an annual legionella culture sampling and analysis. The findings are: Review of the facility Policy on Healthcare Associated Legionnaire's Disease initiated on 04/2018 and revised on 04/2019, 04/2020 and 09/09/2020 documented that the facility shall conduct surveillance to identify cases to ensure that legionellosis is considered in the differential diagnosis of any resident who develops healthcare associated pneumonia. There is not documented evidence of a water management plan that would describe the facility water distribution system, control measures, and actions to be taken if control measures are not met. There is no documented evidence that a facility risk assessment for legionella was completed annually. Review of Weschester County Department of Laboratories and Research Microbiological Services Laboratory Report dated 07/23/2018 (collected 07/10/2018) and 05/01/2017 (collected 04/20/2017) revealed negative test results for legionella. There is no documented evidence that a legionella culture sampling and analysis was completed after the water sampling that was done in 07/10/2018. There is no documented evidence of a facility contract with a vendor for water sampling. Review of an email between the facility and Special Pathogens laboratory revealed a communication dated 09/09/2020 at 1:26 PM. Review of the facility infection / antibiotic line listing from 07/2018 to 09/14/2020 revealed there were no residents in the facility that has presented symptoms consistent with legionella and there were no residents in the facility who was treated for legionnaires disease or legionella associated symptoms. Review of the Infection Control QAPI Study for Legionella Pneumonia 2019 dated 09/14/2020 documented by the Medical Director revealed that in 2019 the facility had seven cases of Pneumonia, but the seven residents had no symptoms consistent with legionella disease. The MD also documented that there is no reason to suspect Legionella pneumonia was an etiology for the seven cases that they had. An interview conducted with the Administrator on 09/09/2020 at 02:30 PM revealed that he oversees the legionella requirements and not his director of maintenance. He stated that the facility did not have testing in 2020 but he made some calls and a vendor will be coming to do water sampling on 09/10/2020. He stated he does not have a contract with any vendor but that it would be arranged as soon as they come in the following day. A follow up interview conducted with the Administrator on 09/11/2020 at 11:30 AM revealed that there were no changes to all the policies that he submitted since 04/2018. A follow up interview conducted with the Administrator on 09/14/20 at 11:19 AM revealed that he made a mistake because he thought that his brother had the Legionella Testing done in July 2019. He stated that he finally was able to contact Weschester County and they stated there are no records that any testing was done in 2019 for the facility. He stated that the last time water sampling was done was 07/23/2018. He stated that the Medical Director documented for their QAPI study that there was no resident that had symptoms consistent with Legionella disease since 2019. An interview conducted with the Director of Nursing on 09/14/20 at 11:54 AM revealed that they had no residents that displayed symptoms of any Legionnaires diseases from July 2018 to present. She stated that they have been doing infections surveillance regularly and they never had any cases of legionnaires disease or any legionella associated symptoms. 415.19(b)(4)

Based on record review and staff interview conducted during a recertification survey the facility did not develop a person-centered care plan that included measurable objectives, time frames and interventions based on the comprehensive assessment to address anemia for 1 of 2 residents (#37) reviewed for nutrition and pressure ulcers. The finding is: Resident #37 has diagnoses and conditions including Anemia, Pressure Ulcer on the left heel, and Gastroesophageal Reflux Disease (GERD). The admission Minimum Data Set (MDS; a resident assessment tool) of 6/18/18 documented that the Care Area Assessment Summary (the section of the MDS that indicates the care areas triggered for further assessment and evaluation) documented that nutritional status and feeding tube were triggered. The laboratory reports on the following dates were reviewed and revealed a progressive decrease in the levels of red blood cells (RBC), hemoglobin (Hgb) and hematocrit (Hct) as follows: - 6/14/18 - RBC 4.37mcL (normal range is 4.7 - 6.1), Hgb 11.9g/dL (normal range is 13.5 - 17.5) , and Hct 37% (normal range is 45-52%); - 7/9/18 - RBC - 3.52, Hgb - 9.4, and Hct - 32; and on - 7/26/18 - RBC - 3.21, Hgb - 8.8, and Hct - 27. The resident was subsequently assessed on the Significant Change in Status (SCS) MDS of 9/13/18 which indicated a diagnosis of Anemia. The comprehensive person-centered care plan revealed no documented evidence that a plan of care with measurable objectives, time frames and interventions was developed to address the care of this resident with diagnosis of anemia. The unit Registered Nurse (RN #2) was interviewed on 10/31/18 at 3:00 PM and was asked regarding whether a care plan was initiated to address anemia. RN #2 responded there was none and that the missing care plan would be developed at that time. 415.11(c)(1)

Based on observation, record review and staff interview the facility did not provide the treatment services to address the care of a resident with diagnosis of anemia. Specifically, a resident with a progressive decline in the blood laboratory values that may indicate anemia (hematocrit and hemoglobin) did not receive interventions to address this decline. The finding is: Resident #37 has diagnoses including Anemia, Pressure Ulcer on the left heel and Gastroesophageal Reflux Disease (GERD). The admission Minimum Data Set (MDS; a resident assessment tool) of 6/18/18 documented that the Care Area Assessment summary (the section of the MDS that indicates the care areas triggered for further assessment and evaluation) documented that nutritional status and feeding tube were triggered. The laboratory reports on the following dates were reviewed and revealed a progressive decrease in the levels of red blood cells (RBC), hemoglobin (Hgb) and hematocrit (Hct): - 6/14/18 - RBC 4.37mcL (normal range is 4.7 - 6.1), Hgb 11.9g/dL (normal range is 13.5 - 17.5) , and Hct 37% (normal range is 45-52%); - 7/9/18 - RBC - 3.52, Hgb - 9.4, and Hct - 32; and on - 7/26/18 - RBC - 3.21, Hgb - 8.8, and Hct - 27. There were no clinical progress notes to address these decreasing laboratory values. The resident was subsequently assessed on the Significant Change in status (SCS) MDS of 9/13/18 which indicated a diagnosis of Anemia. The comprehensive person-centered care plan revealed no documented evidence of a plan of care with measurable objectives, time frames and interventions was developed to address Anemia. The attending physician (MD) was interviewed on 10/31/18 at 10:00 AM and stated that the resident was not exhibiting symptoms of anemia. He stated further that he will closely monitor the resident. The attending MD stated that the hemoglobin and hematocrit were going down because the resident had been properly hydrated and that he will order blood work the next day. Following this interview, the physician documented in his progress that the resident has progressive anemia on the last blood blood count report and there were no signs and symptoms of anemia; there was no chest pain, shortness of breath or palpitations; and will recheck CBC (complete blood count), stool for guaiac (to determine presence of blood in the stool) iron, Vitamin B12 and folate levels. The unit Registered Nurse (RN #2) was interviewed on 10/31/18 at 3:00 PM and was asked regarding whether a care plan was initiated to address Anemia which was identified during the above SCS assessment. RN #2 responded that the missing care plan would be developed at that time. The Registered Dietitian (RD) was also interviewed at that time and stated that the resident is taking vitamin supplements daily. (Centrum multivitamins with minerals liquid- the iron content of this supplement contains only 9 mg of iron). The RD had no response when asked as to what other interventions were in place to address the resident's nutrition in light of the abnormal or low blood count. 415.12

Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5%. This was evident for 2 of 6 residents (#1 and #47) observed during a medication pass for a total of 2 out of 29 opportunities for error resulting in an error rate of 6.9%. The findings are: 1. Resident #1 has diagnoses including Schizoaffective Disorder, Diabetes, and Nutritional Deficiency. A medication observation was conducted on 10/26/18 at 10:09 AM on the 3rd floor unit. The Licensed Practical Nurse (LPN #1) administered one multivitamin with minerals tablet from a stock bottle. The physician's orders form dated 10/9/18 revealed that the resident should have received one multivitamin tablet orally daily for nutritional deficiency. The mineral ingredient of the medication that was administered was not part of the physician's order. LPN #1 was interviewed on 10/26/18 at 1:13 PM following review of physician's orders and stated that she administered the multivitamin with minerals tablet because it could be crushed and the one ordered by the doctor could not be crushed. 2. Resident # 47 has diagnoses including Major Depression and Vitamin D Deficiency. A medication observation was conducted on 10/26/18 10:36 AM on the 3rd floor unit. LPN #1 administered Vitamin B-12 1,000 mcg tablet from a stock bottle. The physician's orders dated 10/4/18 revealed that the resident should have received Vitamin B complex tablet orally daily for nutritional deficiency. The current October 2018 Medication Administration Record revealed that the ordered medication was dispensed by the pharmacy and was available for use. The medication cart revealed that the ordered Vitamin B Complex medication was available in the cart, along with the resident's other medications. LPN #1 was interviewed on 10/26/18 at 12:45 PM following review of the physician's orders and stated that the Vitamin B 12 medication that she administered from the stock med was what the facility uses. LPN #1 stated she had administered the ordered Vitamin B Complex medication, the day prior, from the dispensed package, but did not realize that the medication was available on the day of the medication observation. She stated that she was unsure if the medication that she administered was the same as what the physician ordered. 415.12(m)(1)