Based on observations, record review, and interviews during the recertification survey conducted 5/12/2025-5/16/2025, the facility did not provide the necessary services and treatment for indwelling urinary catheter use for one (1) of three (3) residents (Resident #8) reviewed. Specifically, Resident #8 was not receiving staff assistance with changing or emptying their urinary drainage collection bag as planned. Findings include: The facility policy Indwelling Urinary Catheter Care and Management, revised 11/18/2024 documented to monitor for changes in urine output, notify the medical provider of abnormal findings, empty the drainage bag reguarly, inspect the catheter system to ensure it was a sterile continous closed system, and replace the system with a sterile no-touch technique if disconnection occurred. If patient teaching occurred documentation of indwelling catheter care and management should include teaching provided to the patient, understanding of that teaching, and follow up teaching that was needed Resident #8 had diagnoses including obstructive and reflux uropathy (urine obstruction and backflow) and urinary tract infections. The 2/24/2025 Minimum Data Set assessment documented the resident had intact cognition, had an indwelling urinary catheter, and was independent with most activities of daily living. The Comprehensive Care Plan created 3/7/2025 documented the resident required assistance to complete activities of daily living related to obstructive uropathy and the need for an indwelling urinary catheter. Interventions included urinary catheter care with morning and evening care, switch the leg drainage bag to a regular urinary drainage bag at night, and the resident required maximal assistance with the management of their indwelling urinary catheter. The following observations and interviews with Resident #8 were made: - on 5/12/2025 at 2:53 PM, they stated their indwelling urinary catheter caused discomfort and would clog up at times. Their overnight urinary drainage bag was lying in a pink basin next to the bathroom sink with 600 milliliters of dark yellow urine and the end of the connection tubing was not capped. - on 5/13/2025 at 1:26 PM, lying in their reclining chair with a leg drainage bag in place on their lower left leg. Their overnight urinary drainage bag was lying in a pink basin next to the bathroom sink with 400 milliliters of yellow urine and the end of the connection tubing was not capped. They stated they did not receive any training but was able to empty their own urinary drainage bags. They switched out their overnight urinary drainage bag with a leg drainage bag in the morning, put it in the basin during the day, and emptied the urine and cleaned the overnight urinary drainage before reconnecting it at night without any staff assistance. - on 5/14/2025 at 9:26 AM, the overnight urinary drainage bag was lying in a pink basin next to the bathroom sink with 300 milliliters of cloudy yellow urine and the end of the connection tubing was not capped. - on 5/15/2025 at 9:13 AM, lying in their reclining chair with their leg drainage bag attached on their lower left leg. Their overnight urinary drainage bag was lying in a pink basin next to their bathroom sink with 200 milliliters of yellow urine and the end of the connection tubing was not capped. There was no documented evidence the resident received education for management of their indwelling urinary catheter and was able to safely and approrpriately manage their own care. During an interview on 5/16/2025 at 11:01 AM, Certified Nurse Aide #9 stated the care plan included everything regarding the resident's care including their toileting status and if they had an indwelling urinary catheter. They were familiar with Resident #8, and had cared for them that week. Resident #8 was independent with managing their indwelling urinary catheter. The resident changed out their urinary drainage bag for their leg drainage bag in the morning and emptied their leg drainage bag throughout the day. The resident would tell them how much urine they emptied so they could document it. They stated they did not monitor the resident to ensure they were managing it appropriately. The nurses were responsible for providing education to the resident and determining if the resdient could be independent with managing their indwelling urinary catheter. They were not aware the resident's care plan documented the resident required maximal assistance with their catheter management. They stated they should not have assumed the resident was independent. If the resident was not managing their indwelling urinary catheter correctly it could put them at risk for infection. During an interview on 5/16/2025 at 11:17 AM, Certified Nurse Aide #10 stated Resident #8 had an indwelling urinary catheter and could manage it independently. They did not monitor the resident performing their urinary drainage bag changes, and the resident would empty their leg drainage bag throughout the shift and let the staff know the total so they could document it. The Registered Nurse Managers provided all of the education and determined if the resident could independently manage the care for their indwelling urinary catheter. They were not aware the residents care plan documented they required maximal assistance. They stated if Resident #8 was not provided education for completing their indwelling urinary catheter care properly it could put them at risk to get an infection. During an interview on 5/16/2025 at 12:02 PM, Registered Nurse/Charge Nurse #11 stated Resident #8's care plan documented they required maximal assistance with their indwelling urinary catheter management. Maximal assistance meant staff provided hands-on assistance with emptying the urinary drainage bags, monitoring the urine output and color, changing the urinary drainage bag over to a leg drainage bag, and providing a new urinary drainage bag and privacy bag weekly. The therapy team determined if the resident could independently manage their indwelling urinary catheter. The charge nurse or supervisor were responsible for providing the resident with education on caring for the catheter appropriately, documenting education was provided, and the resident was able to perform a return demonstration. Resident #8 should not have completed their own indwelling urinary catheter care. They stated they were not made aware the residnet was doing their own care. The resident was not educated and if they were not doing the care properly it put the resident at a higher risk for a urinary tract infection. During an interview on 5/16/2025 at 12:16 PM, Registered Nurse Supervisor #12 stated Resident #8's care plan documented they required maximal assistance with indwelling urinary catheter management which meant the certified nurse aides should empty the urinary drainage bags, ensure the bag was below the level of the bladder and in a privacy bag. If the resident was not deemed independent or did not receive education, it put them at risk for developing a urinary tract infection. There was no documentation Resident #8 was trained or could complete their indwelling urinary catheter care independently. The certified nurse aides should have followed the care plan and let the nurses know the resident wanted to complete their care independently so they could have followed up with the resident or provided training. 415.12(d)(1)

Based on observations, record review, and interviews during the recertification survey conducted 5/12/2025-5/16/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for one (1) of three (3) residents (Resident #33) reviewed. Specifically, Resident #33 had poor oral intake with significant weight loss and was not assessed by the registered dietitian and the facility medical providers were not made aware of the weight loss. Findings include: The facility policy Mealtime Monitor and Nourishment Monitor Records, revised 1/27/2025, documented the unit meal and nourishment intakes were recorded by the nursing staff in the electronic medical record which was used for resident clinical assessments. The clinical nutrition staff were to be notified of residents who were eating poorly for several days or not taking nourishments well. The facility policy Nutrition/Nursing-Weight Change, revised 1/28/2025, documented nursing staff were responsible for obtaining a monthly weight for each resident and the charge nurse would review the weights and request reweights as necessary. Dietary reviewed the weights and evaluated if the resident had experienced any undesirable weight losses or gains during the past month and six-month period. If the weight change was not planned change, the physician would be notified. The clinical nutrition staff would review significant weight changes and work with the treatment team to develop a plan to identify the problem and formulate goals and interventions regarding the change. The facility policy Full Nutritional Assessments/Quarterly Notes/Nutrition Risk Notes/Care Plans/Revision of Nutritional Needs, revised 05/02/2025, documented residents at increased nutrition risk were reviewed monthly at a minimum. Risk notes were recorded in the interdisciplinary portion of the resident's medical record by the nutrition practitioner. A revised estimation of nutritional needs may have been required between full assessments or quarterly notes based on significant weight changes, changes in skin integrity, laboratory values, or with diagnosis that affected nutritional needs. Resident #33 had diagnoses including Alzheimer's disease and chronic obstructive pulmonary disease (lung disease). The 3/10/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, had wandering behaviors that occurred daily, was independent with eating, had no swallowing conditions, and had a significant weight loss while not on a physician-prescribed weight loss regimen. The 7/22/2024 Comprehensive Care Plan documented: - the resident required assistance with their activities of daily living due to the diagnosis of Alzheimer's dementia with impaired cognition. Interventions included the resident was independent with eating with set up assistance as needed and required a non-skid placemat. - revised 3/11/2025, the resident was at risk for alterations in nutritional status/needs, oral intakes, and appetite. The resident seldomly attended breakfast, was at risk for weight loss, preferred small portions, and had a 17-pound decline or 10.6% weight loss in six months on 3/11/2025. Interventions included a regular diet with thin liquids; provide fluid and snack of choice in the morning and before bed; provide Boost Breeze (a nutrition supplement) juice twice a day; and monitor weight and intakes via the electronic medical record, direct care staff report, and random meal rounds. The resident's weight record documented: - on 12/5/2025 158.4 pounds; - on 1/8/2025 148.8 pounds (6% weight loss in 1 month) with no documented reweight. - on 2/12/2025 150 pounds, The 3/11/2025 Registered Dietitian #2 quarterly progress documented the resident was on a regular diet with thin liquids. They received small portions and their intakes were poor. Their lunch and supper meals averaged about 38% consumption and the resident skipped breakfast routinely. The resident had a significant weight loss of 17-pounds or 10.6% in 6 months and was down 4.5% or 6.8 pounds in one month. The resident's snacks in the evening and at bedtime had fair acceptance while morning and late-night snack acceptance was poor. The resident had moderate malnutrition was a high nutritional risk. The plan was to trial Boost Breeze juice twice a day between meals at the evening and bedtime snack times. The 3/12/2025 weight record documented the resident weighed 142.6 pounds (4.9% decrease in 1 month) with no documented reweight. The 4/7/2025 Nurse Practitioner #3 progress note documented the resident's intakes were at baseline, their weight was stable, and they had no acute illnesses. The 5/2/2025 Physician #4 progress note documented the resident had chronic abdominal discomfort and was a poor historian due to dementia. There was no documentation of the resident's intakes or weight loss. There was no documented evidence the medical providers were made aware of the resident's weight loss. The 5/7/2025 weight record documented the resident weighed 132.2 pounds, a loss of 7.29 % in one month and a 16.54 % Loss in 6 months. There was no documented evidence of a nutritional assessment and plan after the resident's significant weight loss on 5/7/2025. The resident's meal intake record for 5/2025 documented did not occur for: - breakfast meals on 5/1/2025 to 5/12/2025 and on 5/14/2025. - lunch meals on 5/1/2025 to 5/8/2025, 5/10/2025 to 5/12/2025, and on 5/14/2025. - dinner meal on 5/2/2025 and 5/9/2025. The resident's meal intake record for 5/2025 documented intakes of 50% or less for the following meals: - breakfast meal on 5/13/2025. - lunch meals on 5/9/2025 and 5/13/2025. - dinner meals on 5/3/2025, 5/5/2025 to 5/7/2025, and 5/10/25 to 5/14/2025. The resident's snack intake record for 5/2025 documented did not occur for: - evening shift snacks on 5/1/2024 to 5/2/2025, 5/9/2025 to 5/11/2025, and 5/14/2025. - night shift snacks from 5/1/2025 to 5/11/2025 and 5/13/2025. - day shift snack 2 on 5/1/2025 to 5/2/2025, 5/4/2025, 5/6/2025 to 5/8/2025, and 5/10/2025 to 5/14/2025. - evening shift snack 3 on 5/7/2025 and 5/10/2025. The resident was observed on: - 5/12/2025 at 1:00 PM, curled up in bed with a blanket pulled over their head. They did not come out to the dining room for lunch and there was no lunch tray in the room. - 5/14/2025 at 11:41 AM, lying on their bed facing the door. At 12:28 PM, they were asleep facing the door with their blanket pulled up to their nose. At 12:48 PM, the dining staff were cleaning up the lunch meal, no tray had left the dining room for the resident. At 12:49 PM, the resident was asleep on their bed with no meal tray or alternative meal in their room. During an interview on 5/16/2025 at 10:27 AM, Certified Nurse Aide #5 stated if a resident refused a meal, it was documented as did not occur and they should report it to the nurse. Resident #33 often refused meals but got snacks in-between. The resident was not big on the breakfast meal. They stated it was not concerning for the majority of Resident #33's breakfast and lunch meals to be documented as did not occur for 5/2025 as the resident was not usually up for breakfast and sometimes it was not worth the fight to get the resident to come out to the dining room for lunch. The resident was more of an evening person and staff would give the resident a snack. Weight changes that were plus or minus 5 pounds from the previous weight were reported to the nurse. During an interview on 5/16/2025 at 10:51 AM, Licensed Practical Nurse #6 stated the percentage of meals eaten by residents were documented by the certified nurse aides who tracked the meals on paper and input them into the electronic medical record. If a resident refused a meal, they were notified by the certified nurse aide. If a resident refused both breakfast and lunch, they should notify the charge nurse or the nursing supervisor. They should also write a progress note and pass it along to the next shift. The certified nurse aides reported to the nurse if there were changes in a resident's weight and they would pass the information on to a supervisor. During an interview on 5/16/2025 at 10:56 AM, Registered Nurse Charge #7 stated Resident #33 was mostly up in the afternoon and night eating. They were aware Resident #33 was refusing most of their breakfast, lunch and most of their morning and afternoon snacks. They were unaware the resident's intakes for their supper meals was minimal if they ate at all as it had not been reported to them. They would have notified he medical providers if they had known. The registered dietitian kept track of a resident's weights and received an email if there was a weight change. It was concerning Resident #33 had lost 10 pounds in a month and had been refusing meals. Nutrition had a list of malnourished residents they kept track of. They stated they had not received any emails or notifications regarding Resident #33. Resident #33's health could decline further if they consistently refused meals, had poor intake, and was losing weight. During an interview on 5/16/2025 at 11:15 AM, Registered Dietetic Technician #8 stated they and the registered dietitians followed the residents' weights. If a resident was identified as high risk, they were assessed and followed by the registered dietitians. The residents identified as high risk were followed monthly at a minimum, but it also depended on the resident's needs. If a resident was consistently refusing breakfast, lunch, their morning snack, afternoon snack, they expected to be notified. They checked resident weights weekly at a minimum. Registered Dietitian #2 followed Resident #33. If a resident had a significant weight loss, they would assess the resident, write a report, and then discuss the situation with the medical providers. During an interview on 5/16/2025 at 11:42 AM, Nurse Practitioner #3 stated they were unaware Resident #33 was refusing breakfast, lunch, their snacks, and had poor intakes. The consistent refusals of meals were something they should be notified of. They were unaware the resident had lost 10 pounds in one month or had significant weight loss over six months and they should have been notified. If Resident #33 continued refusing meals, having poor intakes, and losing weight, they could become dehydrated, their lab values could be off and overtime the resident could decline further. They expected a resident identified as a malnutrition risk be followed closely by the registered dietitian. During an interview on 5/16/2025 at 1:07 PM, Physician #4 stated they were made aware when a resident had significant weight loss or was identified as a malnutrition risk. For their 60-day federally mandated visits they reviewed the resident's chart which included the resident's weight. When a resident lost weight, they were usually contacted the same day. If a resident triggered for significant weight loss in six months and was identified as a high risk, they expected to be notified. They stated with Resident #33's dementia they were expected to lose weight as the disease progressed but they still expected to be notified of weight loss so the resident could be assessed. They were unaware of the resident's recent weight loss. During a telephone interview on 5/16/2025 at 2:03 PM, Registered Dietitian #2 stated they should notify the medical providers if a resident had a significant weight loss over six months. The protocol for residents who were on weekly weights was to check the weight every week, but they checked the weights every day. If a resident was weighed on 5/7/2025 they likely looked at the weight on 5/8/2025 or 5/10/2025. They were unsure if they were aware of Resident #33's recent significant weight loss. It had been a while since they assessed Resident #33 as they were only doing the assessments required for the Minimum Data Set which were quarterly. If a resident lost over 5% in a month, they should assess the resident, consider new interventions, and place the resident on the high-risk list. They had not kept up the high-risk list due to being short staffed. They stated currently they were mainly doing quarterly assessments and assessments on the new admissions. They were unaware Resident #33 was not eating their breakfast, lunch, daytime snacks, and their supper intake was variable. They would have alerted the medical providers and tried new interventions. If Resident #33 was not eating and their weight continued to decline the resident's overall health could decline. 10NYCRR415.12(i)(1)

Based on interview, observation, and record review during the abbreviated survey (NY00331758), the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were investigated or reported to the New York State Department of Health as required for 1 of 4 resident (Resident #1) reviewed. Specifically, Resident #1 had a bruise and fracture of unknown origin and an investigation to rule out abuse, neglect, or mistreatment was not initiated. In addition, the injuries of unknown origin were not reported to the New York State Department of Health as required. Findings include: The facility policy Abuse, Neglect, Mistreatment dated 11/28/2017, documented the facility was to ensure all residents were free from abuse, neglect, or exploitation. Injuries of unknown origin were any injury not observed or could not be explained by the resident. Incidents of abuse, neglect, mistreatment, and injuries of an unknown source were to be investigated thoroughly and promptly. Resident #1 had diagnosis including stroke with hemiplegia (paralysis on one side), chronic obstructive pulmonary disease (lung disease), and atrial fibrillation (abnormal heartbeat). The 1/4/2024 Minimum Data Set assessment documented the resident had moderate cognitive impairment, was dependent on staff for most activities of daily living, had an indwelling catheter (drains urine from the bladder), received tube feedings (a tube in the stomach that provides nutrition), and did not have falls prior to admission. The 12/29/2023 admission fall risk assessment screen completed by Physical Therapist #12 documented the resident was at medium risk for falls. The 12/29/2023 comprehensive care plan documented Resident #1 had decreased strength and functional mobility related to a stroke. They received physical therapy, was dependent on staff for mobility, and was at medium risk for falls. Interventions included to ensure the resident's call bell was within reach when the resident was in their room. The comprehensive care plan was updated on 1/10/2024 to include the resident had a fall, was at high risk for falls, and staff were to complete frequent monitoring. The 1/10/2024 at 12:17 PM, Registered Nurse #15's progress note documented Resident #1 was observed on the foot pedals in front of their wheelchair at around 12:00 PM. The resident was visibly upset and reported they tried to move to a different, more comfortable chair. No injuries were observed, and range of motion was at baseline. The resident reported they did not hit their head and they had right sided weakness per baseline. The resident was calmed and placed back into the wheelchair for lunch. The 1/10/2024 at 12:00 PM, facility investigation completed by Registered Nurse #15 documented the resident was last observed at 11:50 AM. At 12:00 PM, the resident was observed near the nursing station on the foot pedals in front of their wheelchair. The resident reported they tried to get into the chair next to them as it looked more comfortable. An assessment was completed with no noted injuries. There was no reason to suspect abuse, neglect, or mistreatment occurred. Nursing progress notes from 1/10/2024 at 7:27 PM through 1/15/2024 documented the resident did not have any apparent injury, bruising, or pain from the fall on 1/10/2024. The 1/15/2024 at 10:53 AM progress note by Physician #4 documented Resident #1 was noted by physical therapy to have right ankle bruising. Physical Therapy was reluctant to increase weight bearing at that time and the resident denied symptoms and tenderness. An x-ray was ordered. The 1/15/2024 x-ray report documented the resident had an acute non-displaced right distal fibula fracture (fracture of the lower leg bone). There was no documented evidence the bruising or fibula fracture was investigated to rule out abuse, neglect, or mistreatment. The comprehensive care plan, revised 1/17/2024, documented the resident returned from the hospital with a Controlled Ankle Motion boot (a boot worn to stabilize a fracture) to the right foot that was to be worn at all times. The boot was to be removed for skin checks, hygiene, or range of motion. Circulation, sensation, and movement checks were to be completed. During a telephone interview on 6/10/2024 at 10:19 AM, Registered Nurse #15 stated Resident #1 was admitted to the facility with periods of confusion and forgetfulness. On 1/10/2024, the resident was seated in a wheelchair at the nursing station, slid from the chair onto the foot pedals, and reported they were attempting to move to a more comfortable chair. The resident was assessed with full range of motion and no evidence of pain, injury, or bruising, and the resident offered no complaints. They were off for the following few days, was not aware the resident had bruising to the right ankle and did not know if an investigation was initiated related to the bruising or fracture. During a telephone interview on 6/10/2024 at 10:25 AM, Physical Therapist #12 stated Resident #1 slid from their wheelchair to the floor on 1/10/2024 (Wednesday). The therapy aide worked with the resident the rest of the week. During therapy on 1/15/2024 (Monday), Physical Therapist #12 noted Resident #1 had bruising to the right ankle area. The bruising was in different stages of color with green, yellow, and some purple. They immediately notified the medical provider and requested an x-ray due to concerns of the resident's weight bearing. The x-ray showed a fracture. They reviewed the nursing notes to see if there was any documentation of bruising before that day and did not find any. During a telephone interview on 6/10/2024 at 10:32 AM, Director of Nursing #6 stated Resident #1 slid from their wheelchair on 1/10/2024 (Wednesday), was assessed without injuries, and had no complaints of pain, or bruising. They stated the nursing progress notes did not document the resident had bruising or discomfort after the incident. On 1/15/2024, physical therapy noted the resident had bruising to the right ankle, the medical provider was notified, and an x-ray was ordered that showed a fracture. The Supervisor was responsible for reporting the bruising and fracture, and initiating an investigation to rule out abuse, neglect, or mistreatment. The Director of Nursing stated an investigation was not completed into the resident's bruising or fracture and they were not reported. During a telephone interview on 6/10/2024 at 11:18 AM, Certified Nurse Aide #16 stated they worked during the day shift and took care of Resident #1 when they worked. They were in the area when Resident #1 slid from the wheelchair onto the foot pedals on 1/10/2024 (Wednesday). Registered Nurse #15 assessed the resident and there were no injuries or bruising at the time of the fall. They returned after the weekend and approximately one day later (could not recall exactly when), they noted the resident had some tenderness in the right foot with some swelling and bruising. They reported that to the nurse on duty (could not recall who) and an x-ray was done showing a fracture. They did not recall if they provided any statements about the bruising at that time, did not know if an investigation was completed, and the nurses would have the investigation if one was done. 10NYCRR 415.4(b)(1)(ii)

Based on observation, record review, and interview during the recertification and abbreviated (NY00317113) surveys conducted 10/2/2023-10/6/2023, the facility did not ensure residents received and the facility provided a diet in a form designed to meet individual needs for 1 of 1 resident (Resident #79) reviewed. Specifically, Resident # 79 was provided food items that were not consistent with their physician ordered diet. Findings include: The facility policy Communication of Dietary Orders and Resident Nutrition revised 7/6/2023 documented that purpose of the policy was to ensure accurately prescribed diets are followed. The medical provider writes the diet order in the activities of daily living (ADL) Optimum Order Entry section of the electronic medical record. The facility Clinical Nutrition Care Manual revised 12/28/2015 documented a Mechanical soft diet had food items modified in texture and consistency. The diet was used for an individual who required ground or very soft foods with swallowing problems that created a potential for aspiration (inhaling food into the lungs). The physician may order any combination of consistencies or textures that meet the residents' needs. A consistency modification could be combined with a diet order. Resident #79 was admitted to the facility with diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease (COPD, lung disease), and dysphagia (difficulty swallowing). The 8/11/2023 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, was independent with eating after set up, did not have a swallowing disorder, and was on a mechanically altered diet. The 4/20/2023 medical order by nurse practitioner (NP) #19 documented a mechanical soft diet with nectar thick liquids, no thin liquids, and may have a hot dog split lengthwise. The comprehensive care plan (CCP) initiated and 3/3/2023 and updated 4/20/2023 documented the resident was at nutritional risk related to diagnoses including dysphagia and required altered consistency solids and liquids. Interventions included a mechanical soft diet with nectar thick liquids, may have a whole hot dog split lengthwise, and no thin water. The 5/23/2023 at 8:35 AM Accident/Incident Summary completed by registered nurse Supervisor (RNS) #22 documented: - Resident #79 was observed by social worker #23 with a red face and coughing on coffee. Licensed practical nurse (LPN) #24 noticed the coffee was thin liquid and the diet was mechanical soft with nectar thick liquids. The thin coffee was removed. The resident was assessed the medical director was notified. The care plan was not followed, and staff were to be educated on fluid consistency. - A statement by cook #17 documented they were assisting with eggs to order on 5/23/2023 from 7:00 AM- 8:10 AM and there were no unit assistants. They started to pour drinks so the meal would be served on time. Resident #79 asked for a cup of coffee, and they did check the resident's ticket. The resident was on thickened consistency, and they served the resident thin liquids. - An attendance sheet dated 5/23/2023 documented staff were educated on how to read a meal ticket, and they understood the importance of serving the correct diet and fluid consistency to each resident at each meal. The attendance sheet was signed by cook #17. A three page training outline documented staff were educated from 5/23/2023 until 6/19/2023 on the importance of reading meal tickets before giving residents food or fluids and following dietary recommendations for diet orders and consistency. Documentation included residents on nectar thick diets could not have food that became liquid at room temperature, like ice cream. They could have Magic Cups (frozen nutritional supplements) in place of ice cream. Nectar thick liquids were described as liquids that would coat a fork and quickly sink through the prongs. Staff should not give residents food if they were unsure of their diet. A resident's diet could be found on the meal ticket and in the electronic medical record. An example of where to find information on the meal ticket was included in the training. The 6/12/2023 at 2:15 PM speech language pathologist (SLP) #16 progress note documented Resident #79 was screened for dysphagia secondary to a coughing incident on baked cake as they had a history of dysphagia and COPD. The resident was observed during mealtime intakes and agreed to give up cakes and baked muffins secondary to the dryness of those items. The SLP documented they modified the diet order to the medical provider and discussed with nursing and dietary. The 6/12/2023 medical order by NP #19 documented a mechanical soft diet with nectar thick liquids and extra sauces and gravies, a hot dog split lengthwise, 4 oz of thin milk on oatmeal, no thin water, and no cake or muffins. There was no documented evidence the CCP was updated to include no cake or muffins at the time of the medical order. The 8/3/2023 at 1:15 PM Accident/Incident Summary completed by RN #13 documented they were notified that food service worker #10 gave Resident #79 an ice cream sandwich during lunch. Staff attempted to remove the ice cream sandwich. RN #13 assessed the resident, and the resident had diminished lung fields. A food service staff had asked another employee if the resident could have an ice cream sandwich without communicating food consistency. The resident consumed the sandwich without issue. - An 8/3/2023 (A&I documented 8/3/2023) statement by food service worker #10 documented they went to get an ice cream sandwich for Resident #79 and asked food service worker #9 if it was ok and food service worker #9 said to ask an aide. - An 8/2/2023 (A&I documented 8/3/2023) statement by food service worker #9 documented food service worker #10 asked them if it was ok for Resident #79 to have an ice cream sandwich. Food service worker #9 asked registered dietitian (RD) #11 if it was ok and they said yes. - An 8/31/2023 statement by RD #11 documented a food service worker called out to them and asked if Resident #79 could have an ice cream sandwich. They did not know the resident and the food service worker told them the resident was a mechanical soft. RD #11 replied yes, mechanical soft can have an ice cream sandwich. There was no mention of thickened liquids. The 8/4/2023 at 1:58 PM SLP #16 progress note documented they received a request for a screening secondary to early pneumonia. Resident #79 had a history of repeated pneumonia and was tolerating current textures without overt symptoms of aspiration when evaluated. SLP recommended elevating the head of the bed and keeping upright after meals with the diet remaining the same. The CCP was updated on 8/4/2023 and documented the resident was to have mechanical soft diet with nectar thick liquids and extra sauces and gravies, a hot dog split lengthwise, 4 oz of thin milk on oatmeal, no thin water, and no cake or muffins. The 8/16/2023 quarterly nutrition assessment completed by dietitian student #4, documented the resident received a mechanical soft diet, nectar thick liquids, extra gravies, may have whole hotdogs split lengthwise, no thin water, may have 4 oz thin milk on oatmeal, no cake, and no muffins. The resident received an altered diet consistency due to oropharyngeal dysphagia (swallowing problems that occurred in the mouth and/or throat). The undated certified assistant nursing (CNA) book documented Resident #79 was on a mechanical soft diet with nectar thick liquids, extra sauces/gravies, may have a whole hot dog split lengthwise, no thin water, may have 4 ounces of thin milk on oatmeal, and no cake or muffins or water unless thickened. The following observations of Resident #79 were made on 10/3/2023: - at 3:56 PM at a table in the activities area with a cup of thickened coffee and a piece of cake that was missing a section near their fork. Recreational therapist (RT) #12 stated they gave the cake to the resident. - at 4:03 PM, at the table in the activity area with cake missing two pieces and a fork on a plate in front of them. There was no staff in the area. - at 4:06 PM, Resident #79 remained at the table in the activities area and stated they planned to eat the cake in front of them. - at 4:14 PM in the dining room LPN #6 was observed asking CNA #7 if Resident #79 had any dietary restrictions. After looking at the meal ticket CNA #7 stated Resident #79 was not restricted from cake or muffins. CNA #7 stated they did not know what it meant on the meal ticket no muffins or cakes. LPN #6 asked food service worker #8 why the resident was restricted from cake and muffin and food service worker #8 stated they were not sure but would call a supervisor. Food Service Supervisor #21 returned food service worker #8's call and stated the cake was a choking risk for Resident #79 and they should not have it. - at 4:18 PM, food service worker #8 removed a plate, fork, and cake from the table in front of Resident #79. During an interview on 10/3/2023 at 4:04 PM, recreation therapist (RT) #12 stated Resident #79 was on a restricted diet and required nectar thick liquids. They stated the resident was not restricted from cake or muffins. They stated if the resident was on restrictions from cake and ate cake it could be a safety concern as the resident might choke. During an interview on 10/3/2023 at 4:09 PM, LPN #6 stated they were floated to the unit and were unfamiliar with any dietary restrictions for residents of the unit. They stated if a resident had restrictions, and those restrictions were not maintained, they could choke depending on why the restriction was in place. During an interview on 10/5/2023 at 8:23 AM, RN #13 stated when there was a new order the unit nurse was alerted by the electronic record in the ADL section and advised staff that an order required review. The new order would be noted by the nurse with the date and time recorded and was double checked every 24 hours by the Unit Manager or Nurse Supervisor for every resident to make sure all orders were properly addressed. The nurse updated the care plan if required and the CNA book was updated if appropriate. The CNA book was reviewed every shift by all CNAs prior to working with the residents. When there was a change in the diet order staff that served food and drinks were notified for safety issues. CNAs were trained in new employee orientation about altered diets, food consistencies, and how to read the meal ticket. Diet orders were located on the meal tickets and in nourishment binders that were in the dining room. CNAs and RTs were trained to look in the nourishment binders before serving food to residents for safety reasons. If the diet orders were not followed, residents could choke, develop aspiration pneumonia, or have an allergic reaction. Resident #79 had at least one choking incident. During an interview on 10/5/2023 at 9:02 AM, RD #14 stated every resident was screened on admission by speech therapy who recommended the diet order. The order was reviewed and approved by the physician and sent to dietary who put the order in the computer. The meal ticket was printed by dietary and brought to the kitchens on each unit. The RD or dietary technician entered nutritional information in the care plan which was placed in the door of every room and in the nourishment binder in the kitchen and nurse's station. For safety reasons no one could eat without a diet order, to avoid choking or reaction to a food allergy. They stated it was policy for every staff to look at the meal ticket before they gave any resident food or fluids. Resident #79 should not have had cake because it was on the care plan. They were not sure why the resident could not have cake. During an interview on 10/5/2023 at 9:41 AM, SLP #16 stated they assessed every resident on admission and made a draft recommendation for a diet order. A nectar thickened liquid was ordered when a resident had dysphagia to limit the potential for aspiration pneumonia and was recommended for Resident #79. The order was reviewed by the physician, was an active order, and sent to dietary. Dietary entered the diet order in the care plan, made the ticket, and updated the CNA directives on the unit in rooms and in the nourishment book. The book was located at the nurse's station and in the dining room. No one could eat without an active order because of safety reasons which could include aspiration. The SLP communicated to nursing staff on multiple occasions never to feed a resident without reviewing the dining ticket, because there could be a change in the diet order made between meals. If tickets were not checked before every meal residents could get the wrong texture or consistency. Resident #79 was a high risk for choking and had several episodes of aspiration pneumonia. During an interview on 10/5/2023 at 1:30 PM, RD #11stated they had in-service education about food textures over the years. In 8/2023 when working on an unfamiliar unit they told a food service worker Resident #79 could have an ice cream sandwich after the food service worker stated the resident was on a mechanical soft diet. They were not told the resident was also on nectar thickened liquids which did allow the ice cream sandwich. They resident should have had the ice cream sandwich replaced with a Magic Cup because the ice cream was too thin and could cause aspiration pneumonia. They recalled being re- trained after the incident and would not recommend food or fluids to staff without looking in the nutrition book again. During an interview on 10/5/2023 at 2:00 PM, cook #17 stated they gave Resident #79 thin coffee on 5/23/2023 when the order was nectar thick. The nectar thick was ordered for residents to prevent choking. They stated they were educated following the incident on the importance of reading the meal ticket and following diet orders and was counseled by the Administrator. During an interview on 10/5/2023 at 2:21 PM, the Director of Nursing (DON) stated they were aware Resident #79 received the wrong food and fluid consistencies on three separate occasions. They were not sure why RT #12 was not educated in May on food textures and reading a menu, however they should have been included in the training because they gave food and fluids to residents. They stated staff was educated many times about the importance of reading the meal ticket every time before giving residents food or fluid. During an interview on 10/5/2023 at 2:47 PM, RT #12 stated they did not remember being educated about meal tickets or diet consistencies in May. They stated Resident #79 should not have had cake and was given pumpkin spice cake. They stated they did not follow the physician order and the resident had swallowing and breathing difficulties, and aspiration pneumonia in the past. During a phone interview on 10/5/2023 at 5:00 PM, food service worker #9 stated that they were working with food service worker #10 serving ice cream sandwiches to residents after the meal on 8/2/2023. Neither staff was sure if Resident #79 could have the ice cream so food service worker #9 asked RD #11 and was given permission to offer the resident an ice cream sandwich. The resident was given the ice cream sandwich by FS #10. The resident had completely eaten the ice cream sandwich when one of the nursing staff stated the resident was restricted from eating ice cream. During an interview on 10/6/2023 at 9:31 AM, RT #12 stated Resident #79 did not require supervision when eating and on 10/3/2023 ate at least two bites of the cake before it was removed. During an interview on 10/6/2023 at 10:06 AM, RN #18 stated they were responsible for new employee orientation. Food service was discussed with all new employees, and included dining room services, adaptive equipment, allergies, food consistencies, and how to read a meal ticket. Each new employee was given a copy of a meal ticket for an example. They remembered an incident in 5/2023 when Resident #79 choked, and training was completed the following days. The staff educator believed all staff had been trained but did not have signed training sheets available. They stated the DON had all training sheets. If there was a name missing from the sign in sheets it meant they were not trained. 10NYCRR 415.14(d)(3)

Based on record review and interview during the recertification survey conducted 10/2/2023-10/6/2023, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment; and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility annual water Legionella (a type of bacteria usually found in water causing Legionnaires' disease) testing was not completed in 2022 through September 2023; and the annual facility risk assessment and environmental assessment of water systems in healthcare settings was not completed in 2022 as required. Findings include: The facility Sampling and Management plan, effective August 2023, documented: - An environmental assessment will be conducted and updated annually; and - Legionella culture analysis will be performed quarterly by a NYS (New York State) Environmental Laboratory Approval Program (ELAP) certified laboratory. There was no documented evidence of Legionella testing for the domestic well water supply in 2022 to September 2023. Additionally, there was no documented evidence of a facility risk assessment and environmental assessment of water systems for 2022. The last documented annual Legionella testing for the facility domestic well water supply was completed on 10/1/2021. During an interview on 10/2/2023 at 10:45 AM, the Maintenance Director stated they could not find any documented Legionella testing for the domestic well water supply in 2022 through September 2023. During an interview on 10/3/2023 at 2:45 PM, the Administrator stated they were unaware that the Legionella testing for the domestic well water supply had not been completed in 2022 through September 2023. During a second interview on 10/3/2023 at 2:50 PM, the Maintenance Director stated that they were aware that Legionella testing of water was required to be done quarterly for the first year and tested annually thereafter if there was no Legionella identified in the sampled water. They assumed the domestic water had been tested as required by the facility's licensed water operator during one of the monthly tests. During an interview at 10/4/2023 at 10:12 AM, maintenance assistant #1 stated that they had taken over the task of completing the water testing in January/February 2022. They stated that they were never told by their predecessor to complete the Legionella testing or to complete the annual assessment requirement. They became aware of the requirements after a previous federal survey completed in April 2023. Maintenance assistant #1 stated that after the April 2023 survey they had reviewed and updated the facility sampling and management plan and had submitted it to the Maintenance Director for approval. They stated that there was no onsite training of what to do or where to sample for Legionella. Maintenance assistant #1 stated that they could not find the 2022 annual water Legionella testing records or the 2022 annual Legionella risk assessment. They were aware that if Legionella was present in the water, it could infect the nursing home residents. During an interview on 10/4/2023 at 12:20 PM, the Administrator stated it was important to test for Legionella because if Legionella was present in the water, it could potentially make someone sick. During an interview on 10/5/2023 at 11:16 AM, Infection Preventionist #5 stated that they were aware the facility was required to do annual Legionella testing and the maintenance department was responsible for completing the testing. They were not made aware of any Legionella updates when hired in June 2023, the facility's quality assurance meeting was completed monthly, and Legionella had never been addressed the meetings since they were hired. Infection Preventionist #5 stated that the Legionella testing of the water within the facility was done to ensure that the water was safe for the residents and staff. 10NYCRR 415.19(a)