Based on observation, interview, and record review conducted during a Recertification Survey completed on 7/13/22, the facility did not ensure that for two (Resident #7 and Resident # 10) of two residents reviewed, each resident had the right to receive visitors of their choosing at the time of their choosing and in a manner that does not impose on other residents. Specifically, the facility had posted visiting hours, limited the number of visitors per resident, and required advanced scheduling of visitors. This is evidenced by the following: The Center for Medicare and Medicaid Services issued QSO-20-39 NH, revised on 3/10/22, documented facilities must allow indoor visitation at all times and for all residents as permitted under the regulations. While previously acceptable during the Public Health Emergency, facilities can no longer limit the frequency and length of visits for residents, the number of visitors, or require advance scheduling of visits. Additionally, the document included that facilities may ask about a visitors' vaccination status, however, visitors are not required to be tested or vaccinated as a condition of visitation. The facility Visitation Policy, last revised 1/7/22, documented that visitation hours were from 10 a.m. to 6 p.m. Monday through Friday, and 10 a.m. to 4 p.m. on Saturday and Sunday. Special accommodations, such as visiting outside of visitation hours, or compassionate care visits, could be made with the Administrator. In order to ensure proper social distancing and infection control guidelines, residents will be allowed two visitors at a time in resident rooms, and four visitors at a time in common areas. Visitation area visits can be restricted to designated areas only as determined by Administration and the New York State Department of Health. During an observation on 7/7/22 at approximately 8:15 a.m., a sign was located on the right-hand side of the second set of doors leading into the main entrance of the facility. The sign was visible from the first set of doors and included in large font Woodside Manor is open for Visitation! Visitation Hours are Monday through Friday 10:00 a.m., to 6:00 p.m., Saturday and Sunday 10:00 a.m. to 4:00 p.m. When interviewed on 7/7/22 at 8:52 a.m., the Front Desk Receptionist (FDR) stated that visitation was from 10 a.m. to 6 p.m. Monday through Friday and 10 a.m. to 4 p.m. on weekends. At 12:07 p.m., the FDR stated that upon entrance to the facility visitors are screened and tested for COVID-19 and then must wait 15 minutes for the results. The FDR stated that if the resident is assigned to a private room, they can have a visit in their room and if the resident resides in a shared room the resident is brought to the lobby for the visit in order to allow for social distancing. 1.During an interview on 7/7/22 at 8:57 a.m., Resident #7 (identified by the medical record as cognitively intact) stated that their family had to call ahead of time before they visit. Resident #7 stated that the week before they had a family member die and their family was coming to tell them in person, but they forgot to call ahead and were required to do a window visit instead of coming into the facility. The resident stated that they did not know what the visiting hours were because they changed all the time and that there were multiple restrictions. 2.During an interview on 7/8/22 at 11:57 a.m., the family members of Resident #10 stated that they had to make an appointment to visit and that they have asked staff when they were going to do away with all the rules. They said that about a month ago they were visiting and had to go outside for the visit because they had more than two visitors. When interviewed on 7/12/22 at 8:04 a.m., the Director of Nursing (DON) stated that if a resident is in a private room, visitation can take place in the room with up to two visitors. The DON stated if a resident is in a semiprivate room, one of the residents can have a visit in their room if social distancing can be maintained. The DON stated that if visitors call in the morning requesting to schedule a visit, 99.9% of the time they can visit that day. The DON stated that schedules for visitation are arranged but if someone wants to visit outside of those times, they can be accommodated by alerting the DON as to what time the visitors are coming and how many because there cannot be too many people in a semiprivate room. When interviewed on 7/13/22 at 9:06 a.m., the Director of Social Work (DSW) stated visits do not need to be scheduled, but the visiting hours are Monday through Friday 10 a.m. to 6 p.m. and Saturday and Sunday 10 a.m. to 5 p.m. unless the resident is on compassionate care, palliative care, or hospice. The DSW stated that visiting hours help control the number of people in the building for infection control purposes and allow for COVID-19 testing. When interviewed on 7/13/22 at 9:18 a.m., the Administrator stated that visitation was open with visitation hours from 10 a.m. to 6 p.m. Monday through Friday and 10:00 a.m. to 4 p.m. on the weekends. Families were asked to call ahead for visitation to come outside the visitation hours as a heads up but it was okay if they did not. The Administrator stated that they wanted to make sure there were enough staff available for COVID-19 testing. The Administrator stated that room visits were limited to two people per resident room and four people per common area for infection control purposes. The Administrator stated that they had let family members know verbally and had sent out a mailing indicating that they can come after visitation hours. The Administrator stated that a copy of the updated policy was also sent to family members and/or resident's Health Care Proxy. The Administrator stated that they had notified staff via email that visitation was open. 10 NYCRR 415.3(c)(2)(iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey completed on 7/13/22, it was determined that for one (Resident #32) of five residents reviewed, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition. Specifically, Resident #32 did not receive the assistance with eating per their Comprehensive Care Plan (CCP). This is evidenced by the following: Resident #32 had diagnoses including vascular dementia, dysphagia, and left-hand arthritis. The Minimum Data Set Assessment, dated 6/15/22, documented that the resident had severely impaired cognition and required supervision and one-person physical assist for eating. The current CCP and the Certified Nursing Assistant (CNA) [NAME] (drives daily care) for eating revealed Resident #32 required assistance with feeding, and staff were to alternate liquids and solids, cut up food into bite size pieces, and assist with finger foods. Additionally, the CCP documented that the resident was at a nutritional/dehydration risk, had significant weight loss, and was at risk for additional weight loss related to dementia with a decline in self-feeding, language barrier, missing teeth, and dysphagia (difficulty swallowing) with food holding requiring an altered consistency and adult failure to thrive. During an observation of the lunch meal on 7/8/22 from 12:23 p.m. through 1:15 p.m., Resident #32 was seated in a wheelchair at a dining room table drinking a 4-ounce (oz.) cup of strawberry shake. Resident #32's meal tray also included a bowl of three bean salad, tuna salad on a croissant, and a slice of apple pie. Resident #32's meal ticket included two 4 oz. cups of orange BOOST (liquid supplement) which was not included on the tray, finger foods and soft ground consistency. Resident #32 finished the strawberry shake and then continued to attempt to drink from the empty cup. At approximately 12:30 p.m., a staff person removed the empty cup from Resident #32's hand but did not offer any additional food or drink. At 12:52 p.m., another staff member started to sit down next to Resident #32 but was called away prior to offering the resident any food or drink. Resident #32 sat at the table without eating or drinking anything until 12:59 p.m., when CNA #1 sat down and fed the resident several bites of food without offering any liquids. At 1:17 p.m., CNA #2 stated that the kitchen staff usually put the BOOST supplements on resident meal trays but if not, then staff should ask the kitchen staff or nurses to get it. CNA#2 then retrieved two 4 oz. cups of orange BOOST for Resident #32 who immediately began drinking independently. During an observation on 7/11/22 at 9:26 a.m., Resident #32's untouched breakfast tray was on top of a meal cart with two 4 oz. cups of orange BOOST, a white thickened drink, dry cereal, and a breakfast sandwich. At 9:31 a.m., RN #1 delivered the tray to Resident #32 overbed table (resident was sitting up in bed) and left without offering the resident any food. Resident #32 was not eating or drinking. At 9:40 a.m., RN #1 returned to the resident's room and gave Resident #32 a half of the breakfast sandwich. During an observation of the lunch meal on 7/11/22 at 1:14 p.m., the Director of Nursing (DON) was seated next to Resident #32 assisting and encouraging them for a short period and then left the resident with a 4 oz. glass of orange BOOST in their hand. Resident #32 was tipping the glass and not drinking it. No other staff were observed assisting the resident until the DON returned at 1:26 p.m. When interviewed on 7/13/22 at 9:41 a.m., the Senior CNA stated that they often care for Resident #32 and that the resident required assistance throughout the meal including encouragement, cues, and at times needed to be fed the entire meal. The Senior CNA stated Resident #32 goes to the dining room for meals due to the need for assistance, eats mostly handheld foods, should be offered one item at a time, and should switch between solids and liquids. When interviewed on 7/13/22 at 10:23 a.m., the DON stated that Resident #32 needed to eat their meals in the dining room (vs in their room) with staff sitting next to them or checking on them frequently. When surveyor observations of meal times were discussed, the DON stated that Resident #32 should have received more frequent assist. [NYCRR 415.12 (a)(3)]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during the Recertification Survey completed on 7/13/22, it was determined that for one (Residents #7) of 37 residents reviewed for food allergies and one (Resident #15) of one resident reviewed for preferences, the facility did not ensure that food was provided that accommodated resident allergies, intolerances, and preferences. Specifically, Resident #7's lunch tray that was ready to be served prior to Surveyor intervention, contained seafood that Resident #7 had a noted allergy to, and Resident #15 was not care planned for or offered a diet specified by their religious preference. The findings are: 1.Resident #7 had diagnoses including Parkinson's disease, muscle weakness, and Type 2 diabetes. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #7 was cognitively intact and required supervision and set-up help for eating. The Comprehensive Care Plan (CCP) last reviewed 7/7/22, documented that Resident #7 was at risk for allergic reaction presenting with swelling related to allergies to blueberries, strawberries, seafood, and shellfish. An interdisciplinary progress note dated 4/17/21 and signed by the Registered Dietician (RD) documented that Resident #7 was at risk for allergic reaction presenting with swelling related to allergies to blueberries, strawberries, seafood and shellfish and that meal tickets alert staff to these allergies and offers a safe substitution when these items are on the menu. An interdisciplinary progress note dated 6/9/21 and signed by the RD documented that dietary continued to avoid strawberries, blueberries, seafood, and shellfish on Resident #7's tray. During an observation on 7/8/22 at 12:19 p.m. during lunch service preparation Resident #7's tray ticket documented an allergy to blueberries, strawberries, seafood, shellfish, and diet condiments all highlighted in red, and instructions to staff to read ticket thoroughly to ensure tray is allergen free. The tray ticket further included that the resident was to receive tuna salad on a croissant for their meal. A tuna salad on a croissant was plated by the cook for Resident #7's room tray and given to a dietary aide who placed it onto the tray carrier. After surveyor intervention, the tray was removed from the carrier and the tray ticket given to the cook for review. In an interview at the time, the cook stated that Resident #7's tray ticket included a fish allergy and that allergies are noted in red on the ticket. Further observation in the kitchen included a sign above tray line that read Be sure to check tray tickets for red or yellow precautions or allergies. In an interview on 7/8/22 at 12:22 p.m. the Food Service Director (FSD) stated that the kitchen's ticket programming system should have been programmed to not have tuna salad show up to serve Resident #7 if there was a seafood allergy noted. The FSD stated that the Dietician should audit the meal tickets. In an interview on 7/8/22 at 12:41 p.m. and again at 3:37 p.m., Resident #7 stated that if they eat tuna fish their face swells up requiring a trip to the Doctor. Resident #7 stated that they have had strawberries and blueberries served to them several times since they have been at the facility which they are also allergic to. In a telephone interview on 7/8/22 at 2:23 p.m. the RD stated that residents with food allergies should have an order and an individualized meal ticket. If a resident is allergic to seafood, the allergy would be indicated at the top of the ticket and if an entrée was being served that included something the resident was allergic to, the 'Meal Tracker' (food service electronic system) should have been programmed to indicate to serve the resident something different. The RD stated that Resident #7's tray ticket should not have printed out tuna salad to serve. The RD said the previous Food Service Director was recently let go with one reason being an issue with programming errors in the 'Meal Tracker' system. 2.Resident #15 had diagnoses including adult failure to thrive, depression, and anxiety disorder. The MDS assessment dated [DATE], documented that Resident #15 had moderately impaired cognitive skills. The current CCP, under nutritional status approaches, included that Resident #15 was noted to have changing food and religious preferences. There was no documentation to address Resident #15's religious preference of maintaining a kosher diet or that Resident #15 preferred to keep meat separated from diary. During a meal observation on 7/7/22 at 12:53 p.m., Resident #15 expressed concerns to the Director of Nursing (DON) regarding their meal. Resident #15 stated they were unable to eat their ice cream because they were unsure if it was kosher. The resident stated they wanted to give their ice cream to their tablemate and the DON replied that other residents had their own ice cream and to just leave it. Resident #15 was observed to eat their turkey and tomato sandwich but not did consume the ice cream. At no time was Resident #15 offered a substitute or an offer to check the ice cream to see if it was kosher. Review of Resident #15's meal ticket at this time included no pork, no cheese with meat and small servings. The meal ticket did not identify the resident's religious preferences. During an interview 7/7/22 at 1:25 p.m., Resident #15 stated they did not consume their ice cream because they cannot mix meat with diary. Resident #15 stated they have been served meat with dairy in the past and that they had notified the charge nurse about this. During an interview on 7/8/22 at 9:40 a.m., the Line [NAME] stated that dietary preferences were communicated to the dietician and then the dietician notifies the kitchen about preferences and dietary needs which are placed on the meal tickets. The Line [NAME] stated that they were unaware of any residents within the facility that maintain a kosher diet. During an interview on 7/8/22 at 2:15 p.m., the Registered Dietician (RD) stated that food preferences are completed upon admission and menus should be based on preferences. The RD stated that Resident #15 was sometimes kosher but sometimes not. The RD stated that Resident #15 had not been consistently kosher by mixing meat with dairy at times if the resident saw another resident having meat with dairy. The RD stated that they have offered Resident #15 matzo ball soup which was accepted. The RD said that they had not informed the kitchen that Resident #15 was kosher or put it on their care plan. During an interview on 7/11/22 at 9:39 a.m., the Certified Nursing Assistant (CNA) stated that Resident #15 does not eat pork because they are Jewish. The CNA stated that once in a while non-kosher items will come on Resident #15's meal tray but to their knowledge Resident #15 has never tried to not eat kosher. The CNA stated that Resident #15's faith to maintaining a kosher diet has been consistent and important to them. 10NYCRR 415.14(d)(4)

Based on observations, interviews, and record reviews conducted during a Recertification Survey and complaint investigation (#NY00282014), completed on 7/13/22, it was determined that the facility did not establish and consistently maintain an infection control program designed to prevent the development and transmission of disease and infection. Specifically, for one (Resident #19) of two residents reviewed for wound care the facility staff did not complete appropriate hand hygiene and glove changes to maintain a clean environment, for one (Resident #27) of two residents reviewed for urinary catheters (catheter inserted directly into the bladder to drain urine into a drainage bag) staff did not ensure the catheter tubing and drainage bag did not touch the ground or was positioned properly to avoid infections, and for one of one glucose monitoring observations staff did not disinfect a glucometer (machine used for testing blood glucose) after use and prior to storing with clean supplies. This is evidenced by the following: 1. Resident #19 had diagnoses that included peripheral venous insufficiency (improper flow of blood in veins) and protein calorie malnutrition. The Minimum Data Set (MDS) Assessment, dated 6/24/22, documented that Resident #19 had moderately impaired cognition and was at high risk for pressure ulcers but had no current skin issues. The facility policy, Infection Control/Prevention Program, dated April 2021, documented that hand hygiene would be performed before and after moving from contaminated body sites to clean body sites. Physician orders, dated 7/5/22, included orders to the left wrist skin tear which were to apply antibiotic ointment, cover with a telfa (non-adhering pad) and kling (gauze wrap). Orders for the right lower extremity (right leg) skin tear included a xeroform (petroleum based fine mesh gauze used to treat wounds), cover with a telfa pad and wrap with kling. Physician orders also included to apply a lidocaine patch to the left knee daily for pain. During an observation of wound care on 7/8/22 at 10:05 a.m., Licensed Practical Nurse (LPN) #1 applied gloves, removed the soiled wound dressing (gauze and three steri strips) from the left wrist, and without changing gloves, cleansed the wound with wound cleanser from a spray bottle and gauze, applied antibiotic ointment with a cotton swab, then covered the wound with gauze and tape. LPN#1 then removed their soiled gloves and without performing hand hygiene applied a clean pair of gloves. LPN #1 removed the soiled dressing from the right lower leg skin tear, picked up the same bottle of wound cleanser and sprayed the wound to cleanse, applied a xeroform gauze, covered the wound with a telfa pad, gauze and tape. Without changing their gloves or perform hand hygiene, LPN #1 applied a Lidocaine patch to Resident #19's left knee. LPN #1 then removed their gloves and performed hand hygiene. During an interview on 7/8/22 at 10:30 a.m., LPN #1 did not provide an answer when asked if gloves should be changed when going from soiled dressings to clean or different areas of the body or touching the wound cleanser bottle. LPN #1 stated that the wound cleanser was used for other residents. During an interview on 7/11/22 at 10:22 a.m., the Director of Nursing (DON) stated that the nurse should have changed gloves after removing the wound dressings, before cleaning and applying a new dressing, and again before treating a different wound. During an interview on 7/11/22 at 1:28 p.m., the LPN/Educator stated that nurses are expected to change gloves when moving from a dirty (soiled) dressing to clean (new) dressing. 2. Resident #27 had diagnoses including congestive heart failure, urine retention due to enlarged prostate, and a history of urinary tract infections. The MDS Assessment, dated 6/13/22, documented that the resident had moderately impaired cognition and required an indwelling urinary catheter. Review of the facility policy Catheter Care, Urinary Procedure, dated March 2019, revealed that the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder (causing an infection). In addition, the policy documented that the catheter tubing and drainage bag were to be kept off the floor. Current physician orders included indwelling urinary catheter care per facility policy/protocol. During an observation on 7/8/22 at 9:15 a.m., Resident #27 was seated in a wheelchair in the hallway with the urinary catheter collection bag positioned touching the floor (including the drainage port). The catheter tubing was dragging on the floor. During an observation on 7/8/22 at 11:57 a.m., Resident #27 was seated in a wheelchair in the hallway with the urinary catheter collection bag hanging from underneath the wheelchair seat without a cover and the drainage port was again touching the floor. During an observation 7/11/22 at 3:09 p.m., Resident #27 was seated in a recliner in their room. The urinary catheter collection bag was hanging from the resident's bedside table, well above the level of the resident's bladder. During an interview on 7/11/22 at 3:35 p.m., Registered Nurse (RN) #1 stated that urinary catheters should drain to gravity, and the collection bags should be below the level of the bladder, but not touching the floor. During an interview on 7/12/22 at 8:54 a.m., Certified Nurse Aide (CNA) #1 stated that the urinary catheter collection bag should hang from the level of the bed and the collection bags should never touch the ground. During an interview on 7/12/22 at 10:00 a.m., the LPN/Educator stated that staff are educated to position the urinary catheter collection bag below the level of the bladder and to place covers on it, so it is not touching the ground. The LPN/Educator also stated that if the urinary catheter collection bag is above the level of the resident's bladder it could pose a risk for infection. 3. During an observation of medication administration pass on 7/8/22 at 12:38 p.m., RN#1 performed a blood glucose point of care test on Resident #9 using a glucometer. After the testing was completed, RN#1 brought the glucometer machine out of the resident's room and placed it in a bin with clean supplies without cleaning it. When interviewed at this time, RN#1 stated they clean the glucometer with bleach wipes before each use. RN#1 stated that she did not clean the glucometer after use and that the clean items in the bin would need to be disposed of. During an interview on 7/11/22 at 10:12 a.m., the DON stated that the expectation is to wipe the glucometer machine with bleach wipes after each use. Review of the facility policy Checking BGs and disinfecting glucometers, last revised December 2019, revealed that blood glucose meters must be cleaned and disinfected after every use using a bleach wipe following product label instructions to disinfect the meter. 10 NYCRR 415.19(b)(4)

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of one resident groups, the facility did not ensure that concerns and recommendations of the resident group relating to care and life in the facility were acted upon promptly. Specifically, voiced concerns in Resident Council Meetings regarding food snacks, ambulation of residents, dining room seating, and rough towels were not resolved. This is evidenced by the following: Review of the July 23, 2019 Resident Council Minutes revealed the following: a. Residents complained that their seating was frequently changed in the dining room and they were not told why. The Social Worker (SW), who was present at the meeting, told the Resident Council it was done to improve the efficiency for residents and staff. The residents stated they understood but asked that they be told beforehand and requested that residents that can have conversations with one another be seated together. The documentation for the follow-up of the 7/23/19 Resident Council Meeting revealed that the Director of Dietary will notify residents one day before changes in the dining room seating occurs by announcing it in the dining room. b. Residents would like nursing staff to walk with them when they are not on therapy services. Residents feel as though they improve with therapy and then lose it all when therapy ends. They would like to know more about the walking schedule that therapy and nursing were working on. The documentation for the follow-up of the 7/23/19 Resident Council Meeting revealed that if a resident was interested in walking, then the resident should talk to nursing and the Certified Nursing Assistant (CNA). The nursing staff would be willing to walk residents with therapy approval. Therapy was also willing to give residents independent exercises to do on their own if they were interested. c. The residents have expressed that the towels feel like sandpaper, and a request to use fabric softener was made. Residents would like an afternoon snack. The Administrator discussed the idea of an afternoon snack cart that goes around to able residents. Residents were accepting and excited about that idea. The documentation for the follow-up of the 7/23/19 Resident Council Meeting revealed that fabric softener was being used on all towels. The idea of a snack cart in the afternoon will be brought up when a new Recreation Director was hired. Review of the August 22, 2019 Resident Council Minutes revealed that a resident expressed the desire to walk and asked for an update on the walking schedule. The SW explained that nursing and therapy were working on the logistics and she would notify residents when there was a plan. The SW also explained that the Director of Recreation position was still open. A Resident Council Meeting was held on 10/28/19 at 2:07 p.m., and the residents stated that issues and concerns that were voiced in July 2019, August 2019, and September 2019 have not been resolved. The residents said the dining room seating continues to change and they are not told why. The residents said they keep asking for nursing to walk them, but it is not happening. The residents said that the towels are like steel wool and the snack cart never happened. When interviewed on 10/30/19 at 1:59 p.m., the SW said she was the grievance officer. She said that she did not treat the issues brought up in Resident Council Meetings as complaints or grievances because she addresses their issues at the next meeting. The SW said that the snack cart was not done because they did not have a new Director of Recreation. She said that if a resident wants snacks at bedtime, they can ask for them. She said the ambulation was being worked out with Physical Therapy and nursing. She said they created a list and nursing started to walk residents. She said she spoke to the laundry staff and they use fabric softener. During an interview on 10/31/19 at 10:00 a.m., the Administrator said she has only been at the facility for two weeks, but her expectation would be that any issue or concern brought up at the Resident Council Meeting be investigated like any other grievance. She said the issue or concern should be investigated and the resolution should be reported to the residents at the next meeting. Interviews conducted on 11/1/19 included the following: a. At 11:20 a.m., the laundry staff said they use dryer sheets in the dryer. b. At 2:00 p.m., the Assistant Director of Nursing said they are working on an ambulation list. [10 NYCRR 415.5(c)(6)]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #16) of two residents reviewed for Activities of Daily Living (ADLs), the facility did not ensure that each resident's care plan was revised to reflect the resident's current condition. Specifically, the resident's care plan was not revised to include resident-specific interventions for refusals of care and getting out of bed. This is evidenced by the following: Resident #16 was admitted to the facility on [DATE] and had diagnoses including adult failure to thrive, advanced dementia with behaviors, and post-polio syndrome. The Minimum Data Set Assessment, dated 9/5/19, included that the resident had severely impaired cognition, was totally dependent on staff for transfers, and rejected care on one to three days over the seven-day look back period. The current Comprehensive Care Plan and the Certified Nursing Assistant (CNA) Resident Profile included under ADLs that the resident transferred with two assist and a mechanical lift, was independent with wheelchair mobility approximately 75 percent of the time. The care plans included that there was no behavior plan, and neither care plan included any instructions related to refusals of care or refusals to get out of bed. During multiple observations on the day shift between 10/29/19 and 11/1/19, the resident was in bed, wearing a hospital gown and eating breakfast and lunch on all occasions. Additionally, neither the television or the radio were on. On multiple occasions the resident was heard singing to herself, pleasantly confused talking non-sensically to herself, and was waving staff and visitors into her room when passing by in the hall. Review of the interdisciplinary progress notes and the CNA ADL computer documentation, from 10/1/19 through 10/31/19, revealed that the resident was transferred out of bed on six occasions for the month. On 10/5/19, the nursing progress note included that the resident was wheeling herself around the facility and eating lunch in the dining room. There was no documentation of refusals to get out of bed. In an interview on 10/30/19 at 2:30 p.m. and again on 10/31/19 at 3:30 p.m., the CNA stated the resident often refuses care but not so much with her and was usually very good when she cares for her. When asked why she never got out of bed that week, the CNA said that the resident said no when asked. When interviewed on 11/1/19 at 10:35 a.m., the Registered Nurse Manager stated that the Licensed Practical Nurse asks the resident daily if she wants to get out of bed. She said staff should re-approach the resident or let her know of refusals. She said that the resident's behaviors and interventions should be in the care plan. [10 NYCRR 415.11(c)(2)(iii)]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of five residents reviewed for unnecessary medications, and one of three residents reviewed for non-pressure related skin conditions, the facility did not provide services consistent with professional standards of quality. Specifically, the electronic medical record had documentation of Resident #35 having no bowel movements for several shifts and the facility had not assessed the resident's condition or initiated the bowel protocol. For Resident #12 staff did not identify or report bruising. This is evidenced by the following: 1. Resident #35 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's dementia with behaviors and anxiety. The Minimum Data Set (MDS) Assessment, dated 10/10/19, revealed that the resident had severely impaired cognition, was incontinent of bladder and bowel, and required extensive to total assist of staff for toileting and personal hygiene. The facility policy, dated as last reviewed 1/22/14, included that night staff are to check the bowel movement book for any resident who had not had a bowel movement by the morning of day three and inform the day shift who are to initiate the bowel protocol starting with prune juice and continuing with physician orders. During an observation of toileting on 10/30/19 at 1:45 p.m., the resident was attempting to get out of her reclined geriatric chair stating over and over that she had to go to the bathroom. The resident was toileted by two staff and incontinent of a small amount of urine and extremely agitated during the whole procedure requiring a third staff member to help transfer her. Review of the current Comprehensive Care Plan and Certified Nursing Assistant (CNA) Resident Profile revealed that the resident was incontinent, to toilet per request, and to check and change the resident. The current physician orders and Medication Administration Records (MARs) for October 2019 included Milk of Magnesia and Dulcolax (laxatives) as needed for constipation. Neither medication was signed off as given from 10/1/19 through 10/30/19. The MARs did include that the resident had a large liquid stool on 10/27/19 (day shift). Review of the point of care 'vitals' report (electronic medical record form used by CNAs to document bowel movements every shift) revealed that none was documented for bowel movements for all shifts from 10/8/19 through 10/21/19 and from 10/27/19 (evening shift) through 10/31/19 (day shift- total of 12 shifts). In an interview on 10/31/19 at 1:30 p.m., the Licensed Practical Nurse (LPN) stated that the resident was not on any bowel alert list at that time and she was not aware that the resident had gone 12 shifts recently with no recorded bowel movements. When pointed out (by surveyor) where on the electronic medical record the bowel alerts were located, the LPN stated that she did not realize where to look as it was a new computer system but that yes, the resident was on the bowel alert list. The LPN stated that the resident had been very agitated lately and it could be that she needs some Milk of Magnesia. In an interview on 10/31/19 at 1:55 p.m. and again on 11/1/19 at 10:35 a.m., the Registered Nurse (RN) Manager stated that the nurses are to monitor the computer every shift for alerts, start the bowel protocol, and call the provider. She said that the LPN was looking in the wrong place for the alerts. The RN Manager said that it could just be a lack of documentation, but she would want to be notified in order to assess the resident and she was not. 2. Resident #12 was admitted to the facility on [DATE] and had diagnoses that included ataxia (impaired coordination), hemiparesis ( muscle weakness on one side) and osteoarthritis. The MDS Assessment, dated 8/16/19, revealed the resident was cognitively intact, required the extensive assistance of two staff members for bed mobility, transfers and toileting and one staff member for hygiene. The Comprehensive Care Plan, dated 2/19/19, directed to observe the resident's skin and report any changes. Review of the nursing progress notes, dated 10/16/19 and 10/31/19, revealed that the resident had no skin issues. During an observation on 10/29/19 at 10:16 a.m., the resident was sitting in bed and had two reddish purple colored areas on the base of the right thumb. The resident stated that the bruises were from the bedrail. During a joint observation with the surveyor and RN Manager on 10/31/19 at 11:08 a.m., the resident was observed with a purple colored area that was approximately 1 centimeter in diameter at the base of the right thumb and two purple colored bruises were on the resident's mid right forearm underneath two identification bracelets. The resident stated the bruises on his forearm were from the overbed table. During an interview on 10/30/19 at 1:24 p.m., the CNA stated she provided personal care to the resident and she did not see any bruises. Interviews conducted on 10/31/19 included the following: a. At 10:52 a.m., the LPN said that the resident did not have any bruises. b. At 11:08 a.m., the RN Manager stated the resident did not have any bruising, and no one reported any bruising to her for the resident. She stated the CNAs observe the residents' skin daily with cares and would bring any skin issues to the nurse's attention who would in turn report them to me. She said that an incident report and investigation would need to be completed. [10 NYCRR 415.12]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one of one resident reviewed for vision and hearing, the facility did not ensure each resident received timely treatment and/or assistive devices to maintain hearing. Specifically, Resident #29 did not have an audiology appointment scheduled for 14 months, and the audiologist recommended amplification devices which were not attempted despite the facility having them on-site. This is evidenced by the following: Resident #29 was admitted to the facility on [DATE] with diagnoses including hearing loss, osteoarthritis and chronic obstructive pulmonary disease. The Minimum Data Set Assessment, dated 9/20/19, revealed the resident had severely impaired cognition, was sometimes understood, sometimes understands, had moderate difficulty with hearing, and did not have hearing aids. The nursing admission Assessment, dated 7/16/18, included to speak loudly to the resident, as hearing was highly impaired. An admission Hearing Aid Assessment, dated 7/16/18, included that (per hospital nurse) hearing aids were lost prior to hospitalization. The Comprehensive Care Plan for impaired communication related to hearing impairment was initiated on 9/17/18 and last revised on 10/11/19. Approaches include to use communication devices as needed when communicating. The Certified Nursing Assistant (CNA) Care Card, dated 2/19/19, revealed that the resident was very hard of hearing and did not have hearing aids. A Nurse Practitioner (NP) order, dated 9/20/19, requested an audiology referral. The audiology consult note, dated 10/21/19, revealed that the resident had severe to profound hearing loss in both ears. Recommendations included amplification device, to consider a pocket talker which can be purchased online or at an electronic store and uses standard head phones instead of aids. Hearing aids can be purchased but family would have to be present for testing. Observations on 10/30/19 included the following: a. At 11:41 a.m., the resident was in activities, in a circle of residents who were drinking water and talking. Resident #29 did not speak to anyone and did not have any head phones or amplifier present. b. At 11:56 a.m., the resident was seated at the dining room table. Her eyes were closed, and she did not respond when spoken to loudly. The tablemate said, She cannot hear you. c. At 2:07 p.m., the resident was in the hallway and appeared to be sleeping. She did not respond when spoken to. During an interview on 10/30/19 at 1:22 p.m., the CNA said the resident loves to eat and loves activities but does not usually participate as she is very hard of hearing. She said she uses hand gestures and a loud voice. She said it is better if you look straight at the resident to speak, and that she does read lips sometimes. She said the resident does not have hearing aids. Interviews conducted on 10/31/19 included the following: a. At 9:18 a.m., the unit clerk said the resident went for a hearing appointment because someone was interviewing her and having difficulty and thought she was very hard of hearing. She said audiology was ordered and an appointment was made but it took several months before she went. b. At 1:44 p.m., the Social Worker said she spoke with the resident's family and told them to call the audiology office to review the recommendations. She said she told the family the facility had a head phone amplifier. She said she did not make a suggestion to try the facility one first. She said she told the family they could buy one on their own, and the family member said they would discuss it with other family members. Interviews conducted on 11/1/19 included the following: a. At 10:11 a.m., the NP said she made the audiology referral because the resident told her she was having difficulty hearing. She said she had not seen the audiology consult but that an amplifier would be great for the resident. She said she did not know the facility had one, but it should be attempted. b. At 11:14 a.m., the Registered Nurse Manager said the audiology referral was given to the NP. She said no one provided any follow through and that they should have. [10 NYCRR 415.12(3)(b)]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two (Residents # 136 and #10) of two residents reviewed for Nutrition and Hydration, the facility did not ensure that residents maintained an acceptable parameter of nutritional status, such as body weight, unless the resident's clinical condition demonstrated that was not possible. Specifically, there was a lack of timely reweights for two residents with significant weight loss. This is evidenced by the following: The facility policy, Weight Monitoring Guidelines, dated March 2017, revealed weights will be obtained and recorded weekly for four weeks for admissions and readmissions. If a resident's weight changes by five pounds or more, the weight will be repeated. Weekly weights will be reviewed by the Nurse Manager, and the Registered Dietician will review admissions and readmission weights. 1. Resident #136 was admitted to the facility on [DATE] with diagnoses including a recent hip fracture, hemiarthroplasty and cellulitis of the lower extremity. The recent BIMS (Brief Interview of Mental Status) revealed that the resident was cognitively intact and required set up for eating. The current Comprehensive Care Plan included that the resident was at nutritional and hydration risk related to confusion. Approaches included to provide increased calories and fluids for healing. Review of the resident's weights revealed that on admission to the facility, the resident weighed 246 pounds (lbs), on 10/22/19, 233 lbs, and on 10/29/19, 226 lbs. Review of all dietary progress notes since admission revealed the following: a. On 10/21/19, the note included that the resident was put on antibiotics for an infection, and therefore, required increased fluids which he should be getting from his trays, medication pass and water pitcher in his room. The note did not include any information related to weights. b. The Initial (admission) Nutrition Assessment, dated 10/25/19, included that the resident's current weight was 233 lbs and his usual body weight was 240 lbs. The resident's weight status was unknown, and his food preferences were unknown. The resident was at risk of dehydration as evidenced by decreased intakes and constipation and to encourage increased fluids. In an interview on 10/29/19 at 8:56 a.m., the resident stated that the food was terrible, and he frequently did not get what he liked or was supposed to get and instead of helping him staff set the tray down and run out of his room. When interviewed on 10/30/19 at 11:13 a.m., the Registered Nurse (RN) Manager stated that weights are done on admission, then weekly for three weeks and then monthly. She said dietary was responsible for monitoring the weights. During an interview on 10/31/19 at 10:35 a.m. and again on 11/1/19 at 8:50 a.m., the Registered Diet Technician (DT) stated that when the weights are entered in the computer, the weight flashes on her computer screen and she reviews that information with nursing. She said the policy used to be that the aides would report to her or nursing with a weight loss but now with the computer that has changed. She said communication sheets are not used anymore. The DT said she did not know the resident had such a large weight loss. She said the resident's weight loss should have been brought to her attention and a re-weight done. The DT said that she usually sees all residents soon after admission, writes a progress note, and then does the full assessment when the Minimum Data Set (MDS) Assessment is due, about 7 to 11 days later. The DT said she did not know why she did not write a note for the resident prior to 10/21/19 but should have. When interviewed on 11/1/19 at 10:35 a.m., the RN Manager said that she was not sure the resident's weights were accurate. She said that the weights do flag in the electronic health record and the nurses need to look at them. 2. Resident #10 was admitted to the facility on [DATE] and had diagnoses that included dementia with behaviors, atrial fibrillation and vertebrae compression fractures. The MDS Assessment, dated 8/13/19, revealed the resident had moderately impaired cognition, a weight loss of five percent or more in one month, or ten percent or more in six months, and was totally dependent on staff for eating. Review of the Electronic Medical Record (EMR) revealed the resident weighed 140.3 lbs on 9/11/19 and 125.9 lbs on 10/7/19. Review of the paper medical record revealed there were no documented weights after April 2019. Interviews conducted on 10/30/19 included the following: a. At 11:10 a.m., the RN Manager stated weights are obtained the first week of each month. She said dietary reviews the weights and then notifies her if a resident requires a reweight. b. At 11:17 a.m., the Registered DT said there was no Registered Dietician. She said weights are entered in the EMR, and she is able to view the weights in her meal tracker. She said if there was a five percent or greater change in weight, she would request a reweight. She said that she requested a reweight for the resident, but did not check to ensure it was done. [10 NYCRR 415.12(i)(1)]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of five residents reviewed for unnecessary medications, the facility did not ensure that each residents drug regime was free from unnecessary medications. Specifically, Resident #23 received an antidepressant and an antipsychotic and there was no documentation of a Gradual Dose Reduction (GDR) attempt or documentation of a clinical contraindication for the use of psychotropic medications. This is evidenced by the following: Resident #23 was admitted to the facility on [DATE] and had diagnoses that included advanced dementia, depression, and diabetes. The Minimum Data Set (MDS) Assessment, dated 9/17/19, revealed the resident had moderately impaired cognition, no behaviors, and received antidepressants and antipsychotic medications in the look back period. A GDR was not attempted, and the physician had documented a GDR was clinically contraindicated on 8/12/19. The resident's PHQ9 (a depression assessment) score was 1 (a score of 1 to 4 means minimal depression). The facility policy, Gradual Dose Reduction Psychotropic Drugs, dated November 2017, revealed that residents who use psychotropic drugs will receive a GDR unless clinically contraindicated. Within the first year after a resident is admitted , or after a psychotropic medication has been initiated, the facility will attempt a GDR in two separate quarters unless clinically contraindicated. After the first year a GDR must be attempted annually and documented. Any resident receiving a psychotropic drug for disorders such as depression, the GDR may be considered clinically contraindicated for reasons such as, but not limited to, the resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician documented the clinical rationale for why any additional attempts would likely impair the resident's function or exacerbate an underlying psychiatric disorder. The current physician orders revealed that that resident receives 30 milligrams (mg) of Lexapro that was started on 1/18/18 and 1 mg of abilify that was started on 8/20/18. A psychiatric consult, dated 12/31/18, revealed the resident was seen for walking out of the building. There was no evidence of exacerbation of depression, psychosis or mania. The resident has used Lexapro for 15 years and declines a lower dose. In August 2018 the addition of a low dose of Abilify was suggested as it was reported there was an increase in depression. Abilify 1 mg was added 10/18/18 and the resident denies a taper. Recommend lowering the Lexapro dose to 20 or 25 mg a day. The Comprehensive Care Plan, dated 2/19/19, included the resident received an antidepressant for depression and to provide non-pharmacological interventions as able. The physician progress note, dated 4/25/19, revealed that the resident was started on Lexapro in January 2018 and Abilify was added for depression. The resident was still experiencing depression and cannot GDR due to persistent symptoms. The Nurse Practitioner (NP ) note, dated 6/19/19, revealed that the resident denied depression. Psychotropic medications were administered for depression and dementia with psychosis, and the resident had no interest in decreasing any of his psychotropic medications or seeing a psychiatrist. The resident had no signs of depression. Pharmacy recommendations, dated 2/22/19 and 7/22/19, suggested decreasing the Lexapro to 20 mg every day. A pharmacy recommendation, dated 8/15/19, revealed the resident did not want any medication changes as documented in the 6/19/19 medical note. Aside from the resident refusal be sure there is enough documentation why a GDR would be clinically contraindicated as we have not had any failed attempts documented, and it is approaching one year on Abilify (started 8/18). The NP note, dated 8/22/19, revealed the resident received Lexapro which was started January 2018 and Abilify for depression. There has been no taper as the resident was still experiencing depression and cannot GDR due to persistent symptoms. A quarterly psychotropic medication review, dated 10/7/19, revealed the resident received Lexapro 30 mg and Abilify 1 mg ( added 8/20/18) every day for depression. A GDR had been attempted however there was no date. The physician documented a GDR was clinically contraindicated on 10/7/19. A physician note, dated 10/24/19, revealed the resident's mood and behaviors were under control with a PHQ9 score previously of one. The resident's psychotropic medications were started 1/18/18 for depression with no taper as the resident was still experiencing depression and the PHQ9 score was increasing. The assessment and plan included a PHQ9 score of zero with no GDR at that time. Review of the nursing progress notes, from 8/12/19 through 10/24/19, revealed no documented symptoms of depression or behaviors. During an interview on 10/30/19 at 1:27 p.m. a Certified Nursing Assistant (CNA) stated the resident had not exhibited any behaviors. When interviewed on 10/30/19 at 2:11 p.m., the pharmacist stated she had asked for a GDR for the Lexapro and it was declined. During an interview on 10/31/19 at 8:33 a.m., the physician stated a GDR was attempted in 2018. The physician said the resident and family were resistant to do a GDR because the resident had a bad experience in the community. [10 NYCRR 415.12(1)(2)(ii)]

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for five (Residents # 9, #14, #22, #23, and #35) of five residents reviewed for unnecessary medications, the facility did not have a consistent process in place to ensure that pharmacy recommendations were reviewed timely and acted upon by the medical provider. This is evidenced by the following: The facility policy, Pharmacy Services, dated November 2017, revealed that the pharmacist will report any irregularities to the attending physician, the facility's Medical Director, and the Director of Nursing, and these reports must be acted upon. Any irregularities noted must be documented on a separate written report that is sent to the attending physician, the facility's Medical Director, and the Director of Nursing and lists at a minimum the resident's name, irregularity and relevant drugs. The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what if any action has been taken to address it. If there is no change, the physician should document the rationale in the resident's medical record. There was no pharmacy recommendation found in Residents # 9, #14, #22, #23, and #35's medical records. Upon request, the facility contacted the pharmacist and provided a copy of her e-mail. Review of an e-mail from the pharmacist, dated 10/30/19 at 1:58 p.m., revealed that the dates identify when recommendations were made for each of the listed residents: a. Resident #35 on 10/30/18, 11/16/18, 3/26/19 and 10/18/19. b. Resident #23 on 2/22/19, 5/17/19, 7/22/19, and 8/15/19. c. Resident #9 11/16/18, 3/26/19, 5/17/19, 6/19/19, 7/22/19, 8/15/19, and 9/19/19. d. Resident #14 on 4/19/19, 5/17/19, 7/22/19 and 10/18/19. e. Resident #22 on 2/22/19 and 8/15/19. The pharmacist provided a copy of a Consultant Pharmacists Medication Regime Review Report for recommendations created between 9/1/18 and 10/30/19 that included the resident's name and recommendation but did not include the date the recommendation was made or the physician response. Interviews conducted on 10/30/19 included the following: a. At 11:55 a.m., the Unit Secretary stated the Nurse Manager (NM) gives the pharmacy recommendations (Pharmacists Medication Regime Reviews) to the Nurse Practitioner (NP). She said that after the NP signs the form, she files it in the resident's medical record. The Unit Secretary then reviewed Resident# 23's medical record and stated there were no pharmacy recommendation forms in the chart. b. At 1:34 p.m., the Director of Nursing said that monthly the pharmacist e-mails the Medication Regime Reviews and then sends that information to the Registered Nurse Manager. She stated she could only provide e-mails for the recommendations made for October 2019. c. At 2:11 p.m., the Consultant Pharmacist stated when she completes the monthly Medication Regime Reviews for each resident, she then generates a report and any recommendations would be e-mailed to the Director of Nursing, the Administrator, and the Medical Director. When interviewed on 10/31/19 at 10:00 a.m., the Administrator stated the facility was unable to provide documentation of the monthly reported drug irregularities or the physician's response for Residents # 9, #14, #22, #23, and #35. [10 NYCRR 415.18(c)(2)]