**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the abbreviated (NY00339441) survey the facility did not ensure residents at risk for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing and promote wound healing for 1 of 5 residents (Resident #293) reviewed. Specifically, Resident #293 developed a Stage 2 (partial-thickness skin loss) facility-acquired pressure ulcer when incontinence care was not provided routinely or as planned and treatments to the area were not consistently administered. Subsequently, the pressure injury progressed to an unstageable pressure ulcer (full thickness tissue loss in which the base of the wound is covered with dead tissue). Findings include: The facility policy, Prevention of Pressure Ulcers/Injuries, revised 1/2024, documented residents' skin was to be inspected daily when staff were performing or assisting with personal care or activities of daily living. Any signs of developing pressure injuries would be identified. Inspect pressure points (heels buttocks, elbows, sacrum), wash skin after any episode of incontinence using pH balanced cleanser, keep skin clean and free of exposure to urine or fecal matter, moisturize dry skin daily, and reposition the resident as indicated on their care plan. Residents who were chair/bed bound or dependent on staff for positioning would be repositioned at least every 2 - 3 hours or more frequently, as needed. All staff was responsible for reporting any changes to a resident's skin. All alterations in skin integrity would be reported immediately to the nurse, Unit Manager and/or Nursing Supervisor as well as the medical professional. Treatment orders would be obtained and initiated as ordered. Resident #293 had diagnosis including non-traumatic subarachnoid hemorrhage (bleeding in the brain) from a ruptured aneurysm. The 3/30/2024 Minimum Data Set assessment documented the resident had moderately independent decision making skills, had unclear speech, rarely/never understood others or made self-understood, did not reject care, was dependent on staff for all activities of daily living, was frequently incontinent of bladder and bowel, was at risk for pressure ulcers, did not have current unhealed pressure ulcers, had moisture associated skin damage (damage from prolonged moisture on the skin), applications of ointments/medications other than to feet, and had a pressure reducing device for the chair. The comprehensive care plan documented: - initiated 3/26/2024 and revised on 4/8/2024 the resident had impaired skin integrity related to moisture associated skin damage of the coccyx (tailbone) and buttocks and a Stage 2 pressure ulcer to the right buttocks. Interventions included monitor/document/report signs and symptoms of infection, document wound measurements weekly, apply zinc ointment (protects from moisture) to the buttocks with each incontinent episode and cover with abdominal pad (a thick, absorbent dressing), no tape, encourage to turn and position every 2-3 hours, air mattress, and no incontinence pads over the air mattress. - initiated 3/26/2024 the resident had bowel incontinence related cerebral vascular accident (brain injury). Interventions included check resident every 2-4 hours and as needed and assist with toileting as needed. Provide peri-care after each incontinent episode. The resident's [NAME] (care instruction) active as of 6/27/2024 documented keep skin dry, clean, and well lubricated; provide peri-care after each incontinent episode; incontinence brief check/change every 3-4 hours and as needed; check resident every 2-4 hours and as needed, assist with toileting as needed; and apply zinc oxide to buttocks and coccyx every shift and with each incontinence episode. The 4/1/2024 through 4/7/2024 certified nurse aide Documentation Survey Report did not document the resident was provided toileting hygiene on 4 of 7 dates (7 of 18 shifts). The 4/7/2024 at 9:07 AM Licensed Practical Nurse #20 progress note documented a certified nurse aide (unidentified) informed them at 8:00 AM that Resident #293 had dried feces on their buttocks, their bed was soaked with urine from the night before. The resident was cleaned, and they now had a skin tear to their right buttock. The 4/7/2024 at 12:00 PM Registered Nurse Unit Manager #47 wound assessment documented the resident had moisture associated skin damage to the right buttock measuring 7 centimeters x 5 centimeters. There was scant amount of serosanguinous (blood tinged serum) exudate (drainage) present. The wound had no odor, and the surrounding tissue was bright red and macerated (moisture damage). The resident tolerated the assessment and dressing change well (there was no documentation of what the dressing was). The 4//7/2024 at 9:35 PM Physician Assistant #22 progress note documented they were notified by staff that Resident #293 had skin irritation on the buttocks due to urinary incontinence that had developed into a Stage 2 pressure ulcer. Zinc ointment was to be applied to the area with each incontinence episode and wound care was to follow up with the resident. The 4/8/2024 Initial Wound Evaluation and Management Summary completed by Wound Physician #23 documented the referring provider requested a wound care assessment. The resident had a Stage 2 pressure ulcer on the right buttock that measured 8 centimeters x 4 centimeters x 0.1 centimeter with light serous (clear fluid) drainage. The development of the wound and the context surrounding the development were considered. Relevant conditions including dementia, urinary incontinence, and fecal incontinence were addressed. The treatment pan included: off-load wound; reposition per facility protocol; turn side to side in bed every 1-2 hours if able; apply zinc ointment every shift and as needed; and evaluation by wound care specialist within 7 days with further intervention as indicated. A 4/8/2024 physician order documented cleanse right buttock with wound wash and pat dry. Apply zinc every shift and as needed for wound care. The 4/2024 Treatment Administration Record documented cleanse right buttock with wound wash and pat dry. Apply zinc every shift and as needed for wound care with a start date of 4/8/2024 and a discontinue date of 4/15/2024. There was no documented evidence the treatment was administered 4/9/24 on the 11:00 PM-7:00 AM shift; on 4/10/2024 on the 3:00 PM-11:00 PM and 11:00 PM-7:00 AM shifts; on 4/11/2024 on the 3:00 PM-11:00 PM shift; on 4/12/2024 on the 7:00 AM-3:00 PM shift; and on 4/14//2024 on the 11:00 PM-7:00 AM shift. The 4/8/2024 through 4/15/2024 certified nurse aide documentation of care did not document the resident was provided with toileting hygiene on 6 of 8 days (9 of 24 shifts). The 4/15/2024 Wound Evaluation and Management Summary completed by Wound Physician #23 documented a Stage 2 pressure ulcer of the right buttocks that measured 7 centimeters x 3.5 centimeters x 0.1 centimeter. Treatment included: off-load wound, reposition per facility protocol, turn side to side in bed every 1-2 hours if able, and application of zinc ointment every shift and as needed. The wound had improved as evidenced by decreased surface area. The 4/15/2024 physician order documented cleanse bilateral buttocks with wound cleanser, pat dry. Apply barrier cream every shift and as needed for wound care. The 4/2024 Treatment Administration Record documented cleanse bilateral buttocks with wound cleanser, pat dry. Apply barrier cream every shift and as needed for wound care with a start date of 4/15/2024 and a discontinue date of 4/17/2024. The treatment was not documented as completed on 4/16/2024 on the 11:00 PM-7:00 AM shift. Physician orders documented: -On 4/17/2024 cleanse bilateral buttocks with wound cleanser, pat dry. Apply Vitamin A&D every shift and as needed for wound care. -On 4/19/2024 cleanse bilateral buttocks with wound cleanser, pat dry. Apply barrier cream every shift and as needed for wound care. The 4/16/2024 through 4/22/2024 certified nurse aide documentation of care did not document the resident was provided with toileting hygiene on 6 of 7 dates (10 of 21 shifts). The Comprehensive Care Plan initiated on 4/8/2024 and revised on 4/19/2024 documented the resident had an actual pressure ulcer related to impaired mobility and incontinence. On 4/15/2024 the resident had a Stage 2 pressure ulcer on the right buttocks and moisture associated skin damage on both buttocks; on 4/19/2024 the moisture associated skin damage was improved. The skin was pink, and there was a small scab on the right buttock. Interventions included pressure relieving devices for bed; assess wound weekly; document wound measurements, wound bed appearance, odor, drainage, and surrounding tissue; monitor wound daily for signs and symptoms of infection; monitor/document/report to physician as needed, changes in skin status. The 4/22/2024 Wound Evaluation and Management Summary completed by Wound Physician #23 documented a Stage 2 pressure ulcer of the right buttocks that measured 6.5 centimeters x 6.0 centimeters x 0.1 centimeters. Treatment included: off-load wound, reposition per facility protocol, turn side to side in bed every 1 - 2 hours if able, and application of house barrier every shift and as needed. The wound was improved as evidenced by decreased surface area. The 4/23/2024 through 4/29/2024 certified nurse aide documentation of care did not document the resident was provided with toileting hygiene on 4 of 7 dates (5 of 21 shifts). The 4/29/2024 Wound Evaluation and Management Summary completed by Physician #23 documented an unstageable (full thickness tissue loss in which the base of the wound is covered with dead tissue) pressure ulcer of the right buttocks that measured 1.0 centimeter x 2.0 centimeter x unknown due to necrotic tissue (dead tissue that appeared black in color). Treatment included: off-load wound, reposition per facility protocol, turn side to side in bed every 1-2 hours if able, application of honey (medical grade honey used for wound healing) once a day and as needed, and application of barrier cream to peri wound every shift. The progress of the wound and the context of the wound were considered. Relevant conditions including fecal incontinence were addressed through treatment changes or investigations. The wound was chronic and stable with an insignificant amount of necrotic tissue and no signs of infection. The 4/29/2024 physician order documented cleanse right buttocks with wound cleanser and pat dry. Apply barrier cream to peri-wound (surrounding area of wound). Apply honey to wound bed and cover with border gauze daily and as needed every shift for wound care. The 4/2024 treatment administration record documented apply barrier cream to peri-wound. Apply honey (medical grade honey used for wound treatment) to wound bed and cover with border gauze daily and as needed every shift for wound care with a start date of 4/29/2024 and a discontinue date of 5/3/2024. There was no documentation the treatment was administered on 4/29/2024. A 5/2/2024 at 7:30 PM Registered Nurse #48's progress note documented they were notified by the front desk receptionist the resident's family called Emergency Medical Services and had the resident sent to the hospital. The registered nurse attempted to speak with the family, but the family dismissed them. The resident was sent to the hospital per the family wishes. The on-call provider and the Director of Nursing were notified. During an interview on 6/28/2024 at 11:02 AM, Licensed Practical Nurse #20 stated Resident #293 was on hourly checks and toileted every 2-3 hours. The resident was incontinent, and staff would check on them frequently and their incontinence brief would already be soaked with urine. They remembered on 4/7/2024 the certified nurse aides notified them during AM care that the resident had dried stool on them and had a small skin tear. They notified a supervisor, and a treatment was started. They did not recall who the supervisor was. During an interview on 6/28/2024 at 11:36 AM, Nurse Practitioner #25 stated they knew Resident #293 and a Stage 2 pressure ulcer was not usually from a single incident. A Stage 2 was not significant and was like the surface of the skin that came off. They stated it was not likely that Resident #293 sustained any harm from the incident, but the family was upset, and it was corrected immediately. During an interview on 6/28/2024 at 11:58 AM, Licensed Practical Nurse Unit Manager #6 stated they expected dependent residents to be checked and changed every 2 - 3 hours and as needed. They were not aware of staff not providing appropriate care, and they did not remember much about Resident #293. They expected staff to follow the resident's care plan and [NAME] (resident care instructions). Staff should check the [NAME] at the beginning of each shift in case changes were made to care. During an interview on 6/28/2024 at 12:13 PM, the Director of Nursing stated Resident #293 was dependent on staff for all their care, and they did not remember any family complaints about incontinence. They stated Resident #293 never had an order to be up, out of bed, or for a specific amount of time and it was not in their care plan or [NAME]. Resident #293's pressure ulcer could have developed from not being toileted or repositioned as planned, but usually a one-time occurrence would not have caused it. During an interview on 7/9/2024 at 8:48 AM, Licensed Practical Nurse #47 stated all treatments were highlighted in the computer to let the unit nurse know what was due. They usually did the treatments after the morning medication pass or after lunch. The nurse doing the treatment should sign for it after completion. They always signed for the treatment if they did it and would document any refusals in a progress note. Resident #293's treatment frequently to their buttocks frequently changed. They did not know why the treatment was not signed for on 4/3/2024, 4/5/2024, and 4/10/2024. During an interview on 7/9/2024 at 9:01 AM, Licensed Practical Nurse #48 stated Resident #293 was admitted with a wound to their bottom, and it had improved by the time the resident was sent to the hospital. They were unsure why there were times the treatment was not signed for. Sometimes the nurse reported to work at 6:00 AM and that was why they signed for it on the night shift as being done. If a treatment was not done regularly, the wound could get worse. If something was not signed for, technically it was not done. During an interview on 7/9/2024 at 9:25 AM, Certified Nurse Aide #49 stated Resident #293 was dependent for all care, was able to help with turning, and only needed assistance of 1 at times. If there was only 1 nurse aide on duty, the unit nurse assisted with care. Sometimes there was not time to sign for provided care by the end of the shift. They did not remember if Resident #293 had an open area on their buttocks. During an interview on 7/9/2024 at 10:13 AM, Certified Nurse Aide #50 stated they documented care that was provided twice a shift unless they were the only one assigned to the unit. The unit nurse assisted with care during the night. During 4/2024, the 2nd aide on the unit frequently got pulled to another unit during the shift and that may have been why the care did not always get signed for by the end of the shift. Resident care came before documentation. The aides were allowed to put stock barrier cream on a resident, but the nurse would have to do it if there was a physician order. During an interview on 7/9/2024 at 4:56 PM Wound Physician #23 stated the definition of an unstageable pressure ulcer was one covered with necrotic (dead) tissue and could not be accurately staged. It had to be a Stage 3 or 4 under the necrosis. They expected all physician orders to be followed or staff were to notify them if a treatment could not be done and the reason why, so they could provide further guidance to the nurses. Resident #293's buttock wound was small and had dead tissue over it. They were not sure why they did not debride it (remove dead tissue) prior to hospitalization. Without debridement they could not determine what the actual stage of the wound was or if it worsened. The resident did not return to the facility from the hospital. They were unable to determine if the missing treatments made the wound worse as the residents many comorbidities could come into play in that aspect. 10NYCRR 415.12(c)(1)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00330066) surveys conducted 6/24/2024-6/28/2024, the facility did not ensure residents had the right to a dignified existence for 2 of 18 residents (Resident #28 and #44) reviewed. Specifically, Residents #28 and #44 were referred to with undignified labels (feeders); and Resident #44 was assisted with eating while staff stood over them. Findings include: The facility policy, Quality of Life-Dignity, reviewed 1/2024, documented residents would be treated with dignity and respect at all times. Ttreated with dignity meant the resident would be assisted in maintaining and enhancing their self-esteem and self-worth and staff should speak respectfully to residents at all times, including addressing the resident by their name of choice and not labeling or referring to the resident by their room number, diagnosis, or care needs. 1) Resident #28 had diagnoses including dementia, cerebral infarction (stroke), and bipolar depression. The 4/26/2024 Minimum Data Set assessment documented the resident had severely impaired cognition and required extensive assistance of one for eating. The comprehensive care plan, revised 3/4/2024, documented Resident #28 required assistance with self-care related to dementia and limited mobility, and was dependent for eating. The 6/24/2024-6/28/2024 Unit 100 staff assignment sheet documented Residents #28 and #44 as Feeders. During an observation on 6/24/2024 at 12:00 PM, Resident #28 was on Unit 100, seated in a reclining chair in the dining area. Licensed Practical Nurse #3 was observed assisting the resident with eating. Certified Nurse Aide Instructor #13 asked if a nurse aide student could assist with the resident and the Licensed Practical Nurse Unit Manager #3 stated no, the resident was a difficult feeder. Certified Nurse Aide Instructor #13 asked if there were other feeders they could assist with eating. The conversation could be heard by others in the vicinity. 2) Resident #44 had diagnoses including dementia without behavioral disturbances, adult failure to thrive, and protein-calorie malnutrition. The 5/28/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment and was dependent on staff for eating. The comprehensive care plan revised 3/5/2024 documented Resident #44 required assistance with self-care and mobility related to confusion and dementia. Interventions included the resident was dependent on staff for eating. During an observation on 6/24/2024 at 12:11 PM, Resident #44 was seated in a recliner chair in the Unit 100 hallway. Certified Nurse Aide #12 placed the resident's lunch tray on a bedside table and stood over the resident while feeding them. During an interview on 6/27/2024 at 9:10 AM Certified Nurse Aide #12 stated Resident #44 was a feeder. They stated feeder meant the resident was dependent on staff for eating. They stated they should not have stood over the resident when assisting them with eating as it was undignified. 10NYCRR 415.5 (a)

Based on interview and record review during the recertification survey conducted 6/24/2024-6/28/2024, the facility did not ensure that residents with newly evident or possible serious mental disorders, intellectual disabilities, or a related conditions were referred for a Level II Pre-admission Screening and Resident Review (PASARR, a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities were not inappropriately placed in nursing homes for long term care and a Level II PASARR identifies the specialized services required by the resident) for 1 of 2 residents (Resident #101) reviewed. Specifically, there was no documentation Resident #101 was referred for a Level II Preadmission Screening and Resident Review when the resident was newly diagnosed with a serious mental health disorder. Findings include: The New York State Department of Health Instruction Manual for DOH-695 (2/2009) documented if a Residential Health Care Facility resident is newly diagnosed with a mental illness, a new SCREEN and Level II referral must be completed within 14 calendar days. Resident #101 was admitted to facility 8/22/2022 with diagnoses of anxiety and depression. The 6/4/2024 Minimum Data Set assessment (a health assessment screening tool) documented resident had intact cognition, had no behaviors, was independent with most activities of daily living, had active diagnoses including schizophrenia, and was taking an antipsychotic and antidepressant medication daily. The Preadmission Screening and Resident Review dated 8/22/2022 documented the resident did not have a serious mental illness. The resident's face sheet documented the resident's schizoaffective disorder diagnosis had an onset date of 1/25/2024. A 1/25/2024 at 12:47 PM progress note by Nurse Practitioner #25 did not include documentation of newly diagnosed schizoaffective disorder. The Comprehensive Care Plan initiated 11/1/2023 and revised on 1/25/2024 documented the resident had diagnoses of anxiety, depression, and psychosis. Interventions included administer psychotropic medications as ordered, encourage resident to remain social with peers and staff, encourage participation in activities offered, monitor for changes in mood, provide support and reassurance, and psychological services as needed. A 3/3/2024 physician #46 progress note documented a current diagnosis of schizoaffective disorder and was receiving antipsychotic medications. There was no documented evidence a new Screen Level I had been completed when the resident was diagnosed with schizoaffective disorder and no documented evidence of a Level II referral. During an interview on 6/28/2024 at 11:26 AM, Director of Social Work #9 stated they did not review The Preadmission Screening and Resident Reviews until after a resident had been admitted . Any new resident diagnosis was reported to the interdisciplinary team at the daily morning meeting. They would not initiate the process to get a new Preadmission Screening and Resident Review for a newly reported serious mental health diagnosis, but they would start the referral process for a psychiatric evaluation. The only time they would obtain a new screen was if a resident were transferring to another facility as a lateral transfer. They would contact the Regional Director of Social Work who was responsible to complete those screens. They believed Resident #101 had a serious mental illness diagnosis that was not new. After they referred to the medical record, they stated they did not see a schizophrenia diagnosis at the time of admission, that a serious mental illness was indicated on the initial screen, or that a new screen was performed. They did not believe a new screen was necessary, but they might need to be educated on the process. It was important residents were screened appropriately for the safety of all residents and to ensure appropriate placement as people should be placed in the least restrictive environment possible. During an interview on 6/28/24 at 12:35 PM the Director of Nursing stated new mental health diagnoses were brought forward during team meeting each morning or whenever needed. 10NYCRR 415.11(e)

Based on observation, record review, and interviews during the recertification and abbreviated (NY00330066) surveys conducted 6242024-6/28/2024, the facility did not ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 7 residents (Resident #111) reviewed. Specifically, Resident #111 had a physician order for a chopped consistency diet and was served a whole sandwich. Findings include: The facility policy, Food Consistencies and Definitions, reviewed 1/2024, documented diets with a chopped consistency were nearly regular textures with exception of very hard, sticky, or crunchy foods. Foods should be tender and easy to break into pieces with a fork. Lunch/Dinner foods such as meatballs, thinly sliced deli meat, and grilled cheese sandwiches should be chopped. The policy did not include definitions for a mechanical soft diet. The facility policy, Accuracy and Quality of Tray Line, revised 1/2024 documented all meals would be checked for accuracy by the Food and Nutrition staff, and by the service staff prior to serving the meal to the individual. The meal would be checked against the therapeutic diet spread sheet to assure that foods were served as listed on the menu. All meals would be checked for accuracy of following the therapeutic diet extension. 1) Resident #111 had diagnoses of Alzheimer's disease, gastro-esophageal reflux disease (backflow of stomach contents to the esophagus), and dysphagia (difficulty swallowing). The 4/12/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, required supervision/touch assistance with eating, did not have a swallowing disorder, and received a mechanically altered diet. The comprehensive care plan initiated 4/20/2023 and revised 5/5/2023 documented the resident had oral/dental health problems and was edentulous (lacking teeth). Interventions included diet per registered dietitian recommendation and physician order. The Comprehensive Care Plan initiated 4/20/2023 and revised 3/29/2024 documented the resident was at risk for malnutrition related to dysphagia and potential chewing difficulty due to being edentulous (no teeth). Interventions included provide diet and consistency per physician order, regular chopped texture; monitor for chewing and swallowing problems; and refer to the Speech Language Pathologist as needed. The 3/29/2024 physician order documented Resident #111 was to receive a regular diet, chopped consistency, and thin liquids for dementia with behaviors. The 4/24/2024 at 9:30 AM Speech Language Pathologist #26 discharge summary documented the resident had initially been evaluated for reports of food getting ''stuck' when swallowing. Discharge recommendations included close supervision, small bites, slow rate of eating, remain upright for 30 minutes after meals, and mechanical soft/chopped texture consistency for solids and thin liquids. The 4/29/2024 at 11:21 AM Registered Dietitian # 11 Nutrition Assessment documented the resident continued a regular diet with regular textures and no new issues with chewing or swallowing. The care plan was reviewed and updated. The 6/2024 resident care instructions documented the resident required supervision/touch assistance with eating and was to receive diet and consistency per physician order regular, chopped textures and thin liquids. During the lunch meal observation on 6/24/2024 at 11:31 AM, the resident's meal ticket documented a regular-chopped diet with 3 ounces of chopped chicken, 1/2 chopped biscuit, 1/2 cup of chopped vegetables, and 1/2 cup of chopped mixed fruit. There were X's marked through all the items on the meal ticket. The resident's meal tray included a whole meatball hoagie, 1/2 cup of spinach, 1/2 cup of mixed fruit, and a whole grilled cheese sandwich. The resident ate a few bites of each sandwich before leaving the table. The food was not chopped or cut up. During an interview on 6/27/2024 at 9:35 AM, Certified Nurse Aide #27 stated a chopped consistency diet meant the food should be cut up, a whole meatball sub sandwich was not a chopped diet item and should be cut lengthwise and crosswise. A whole grilled cheese sandwich should be cut up. They were unsure if Resident #111 had a chopped diet. They stated if a resident received the wrong food consistency they could choke or aspirate (inhale food into the lungs) the food. During an interview on 6/27/2024 at 2:11 PM Resident Assistant #29 stated they knew how to care for a resident by looking up their profile in the computer. They thought Resident #111 had a regular diet. A chopped consistency diet should be cut up. They had received diet consistency training during orientation. During an interview on 6/28/2024 at 8:24 AM Licensed Practical Nurse Unit Manager #3 stated they were responsible for overseeing staff on the unit and staff knew how to care for a resident by looking up their profile in the computer. If a resident's diet changed, the speech pathologist would send an email and they would communicate it to staff. Licensed Practical Nurse #3 stated Resident #111 was on a chopped consistency diet, their food should be cut up, and it could be a choking risk if they consumed whole sandwiches. During an interview on 6/28/2024 at 8:48 AM Registered Dietitian #11 stated if they saw a resident with the wrong consistency diet, they would remove it and alert nursing and speech therapy. They were familiar with Resident #111 who had a regular diet with chopped consistency, and they should not receive whole sandwiches. A whole meatball sub needed to be cut and if whole, could cause a choking hazard to the resident. They referred to the speech pathologist for any changes in diet consistencies. During an interview on 6/28/2024 at 9:18 AM Speech Language Pathologist #26 defined a dysphagia diagnoses as one that made it difficult for a resident to swallow food. Their duties included evaluating residents for swallowing deficits. They were familiar with Resident's #111, they were on a regular diet with a chopped consistency, had no teeth, required their foods to be chopped or cut and not doing so could put them at a higher risk for choking. During an interview on 6/28/2024 at 10:13 AM the Food Service Director stated they were responsible for checking meal tickets before the trays left the kitchen and were brought to the units on 6/24/2024. They stated they had just hired an employee for the M job position, which was a nutritional service aide position on the tray line. They had just started orientation and they were responsible for checking meal tickets before they were delivered. The Food Service Director stated nursing was also responsible for checking meal tickets once the trays were delivered to the unit. An X marked on a meal ticket meant the resident ordered the alternative meal and a whole sandwich was inappropriate for a chopped diet consistency. Employees were oriented upon hire regarding diet consistencies. During an interview on 6/28/2024 at 11:47 AM, the Director of Nursing stated nurses and aides should be checking meal tickets for the correct diet consistencies when they arrived on the units. Chopped diets were typically ordered if a resident had chewing problems. Resident #111 required a chopped diet and a whole grilled cheese sandwiches or meatball subs would not be appropriate as the resident could choke or aspirate (inhale food contents into the lungs). During an interview on 6/28/2024 at 12:17 PM Family Nurse Practitioner #25 stated that dysphagia diagnoses were for residents with neurologic disorders such as cerebral infarctions (strokes), Parkinson's Disease (a progressive disease involving the brain and spinal cord) and any other neuro-muscular disorder. They stated Resident #111 had no teeth, required a chopped diet, and should not be receiving whole meatballs or whole sandwiches. Staff should have cut them up. Having no teeth put the resident at a higher risk for choking or aspiration. 10NYCRR 415.14 (d-e)

Based on observation, interview, and record review during the recertification survey conducted 6/24/2024-6/28/2024, the facility did not ensure each resident received and the facility provided food that accommodated resident allergies, intolerances, and preferences for 1 of 1 resident (Resident #59) reviewed. Specifically, Resident #59 did not receive ordered fluids on their meal tray and was not offered a substitution when they requested a sandwich. Findings include: The facility's Always Available Menu documented lunch and dinner entree alternates included the following sandwiches; ham, egg salad, tuna salad, turkey, bologna, sliced cheese, peanut butter and jelly, and chicken salad. Resident #59 was had diagnoses including Alzheimer's Disease and chronic kidney disease. The 5/19/2024 Minimum Data Set assessment documented the resident was cognitively intact, had a poor appetite most days, required supervision or touching assistance for eating, did not have a swallowing disorder, had obvious or likely cavity or broken natural teeth, and did not require a mechanically altered diet (altered texture). The Comprehensive Care Plan initiated 10/7/2022 documented the resident had upper and lower dentures that they did not wear. Interventions did not include alterations in food consistency. A 5/26/2022 Comprehensive Care Plan focus documented the resident was at risk for malnutrition and fluid impairment related to disease process. Interventions included encourage meal intake and completion, identify and honor preferences, observe for chewing/swallowing problems, provide diet as ordered of regular, pureed textures, and thin liquids with exceptions of soft baked goods and soft sandwiches. Nourishments included diet pudding, cheese and crackers, and sandwich variety in the evening. The 5/20/2024 physician order documented the resident was to receive a regular diet, pureed texture, thin liquid consistency. A 6/3/2024 Speech Language Pathologist #26 progress note documented the resident was treated for oral phase dysphagia (difficulty using the mouth, lips, and tongue to control food or liquid). The resident presented with mild oral phase dysphagia however, during consumption of certain soft foods the resident displayed adequate oral phase. Certain soft solids were added to the pureed diet (soft baked goods, soft sandwiches, and pancakes). The 6/18/2024 Speech Language Pathologist #26 progress note documented the resident fluctuated in intake and tolerance of soft options indicating the need for pureed diet consistency as primary consistency for all meals. The 6/21/2024 Registered Dietitian #11 progress note documented the resident had variable intakes. The resident received pureed textures. Textures downgrade per speech language pathologist on 6/17/2024. This was a notable decline over one month. The resident's recommended daily fluid needs were 2400-2835 milliliters per day. The plan was to discontinue Magic Cup (supplement) and provide Ensure Clear per resident's preference. There was no documented evidence the resident's care plan was updated to exclude soft sandwiches and baked goods per the speech language pathologist's recommendations. The 6/21/2024 physician order documented the resident was to receive 240 milliliters of Ensure Clear (a nutritional supplement) three times a day. The following observations of Resident #59 were made: - on 6/24/2024 at 12:03 PM, the resident's lunch was placed in front of them, and staff assisted with opening containers. The meal ticket documented 8 ounces of Boost and 8 ounces of water, and neither were on the resident's tray. At 12:12 PM the resident began feeding themself and at 12:19 PM they asked for water. At 12:41 PM the resident asked for soda for a burning chest and ginger ale was provided. At 12:49 PM the resident asked Certified Nurse Aide #8 for a sandwich. Certified Nurse Aide #8 stated they would have to ask if the resident could have bread. Another unidentified certified nurse aide stated the resident could not have a sandwich because the resident was a pureed everything. No other substitution was offered including a pureed sandwich. Resident #59 ate only a few bites of the pureed meal. During an interview on 6/24/2024 at 1:18 PM, Resident #59 stated they were hungry a lot and they did not like the food they were served. The consistency of the food and their medicine left a bad taste in their mouth. During an interview on 6/28/2024 at 9:43 AM, Licensed Practical Nurse #5 stated if a resident was served food they did not like, staff should call the kitchen for an alternate. If the resident did not like the alternate, there were sandwiches the resident could have. They stated if the resident was on an altered consistency, they should be offered the same alternates. The resident's status had changed drastically and sometimes they were unable to feed themself, and they drank better than they ate. When the resident was eating normally, all they ate were sandwiches. The resident asked for a sandwich, and they asked the aide to call it in, but they were not sure if the sandwich was provided. They asked two different certified nurse aides to call in the request and they should have followed up with the certified nurse aide to confirm the resident received the sandwich as requested. Alternatives were important to ensure the resident gets the nourishments needed. If a resident was not nourished, their health could decline rapidly. They should have let the registered dietitian know the resident drank better than they ate so that fluids could be increased on the resident's tray. During an interview 6/28/2024 at 10:48 AM, Licensed Practical Nurse Unit Manager/Supervisor #6 stated they asked residents how the food served met their preferences, allergies and/or intolerances. If a resident did not eat, or disliked the food, dietary was alerted for alternatives. Alternatives included sandwiches, hamburgers, cold plates, and soups. If a resident was on an altered consistency diet, they would call down to the kitchen for alternatives and they believed everything could be pureed. If a resident's intake was consistently poor, they expected staff to notify them and they in turn would work with the dietitian on a solution. Resident # 59 was placed on comfort care some time ago due to renal failure and over the last four weeks they had more and more issues with intake. The resident would drink non-stop, and they would chew and chew. Staff should know there were alternatives for puree textured foods. If the resident asked for a sandwich, they expected staff to clarify what the resident wanted and call the kitchen to obtain it. Even if the resident did not eat it, they it should be offered to the resident. During an interview 6/28/2024 at 12:25 PM, Registered Dietitian #11 stated based on ordered consistencies and the diet they were on they made sure the resident's preferences aligned. If a resident did not like the consistency specified, the resident would be referred to the speech language pathologist for a determination of whether the consistency could be liberalized. For resident meals there was always a main alternative and sandwiches available, for every consistency. Sandwiches should be pureed. If a resident requested an alternative, it should be provided to the resident. Resident #59 rapidly declined, and the speech language pathologist re-evaluated the resident. There was no reason the resident could not have a pureed sandwich. 10NYCRR 415.14(c)

Based on observations, record review, and interviews during the recertification survey conducted 6/24/2024-6/28/2024, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable mental and psychosocial well-being of each resident. Specifically, the facility received a letter from Centers for Medicare and Medicaid Services dated 2/09/2024, prohibiting the provision of a Nurse Aide Training and Competency Evaluation Program, conducting onsite nurse aide competency exams, or utilizing onsite clinical training by an off-site nurse aide training program, effective through 10/2025, and the facility was observed conducting an off-site nurse aide training program. Findings include: The facility contract with a local community college effective for the period of March 1, 2023, through December 31, 2024, documented the parties proposed to collaborate to provide for the certified nurse aide students at the college the In-Agency learning experiences necessary for them to become responsible practitioners and to qualify them for certification as nursing assistants. The college would provide the nurse aide curriculum, qualified instructors, and be responsible for the supervision of the students. The facility would provide the facilities, opportunities and favorable conditions, and staff time and cooperation necessary to provide the nurse aide students at the college with the agency experience required. During an observation on 6/24/2024 at 12:07 PM on Unit 100, there were 7 nurse aide students (students #36, #37, #38, #39, #40, #41, and #42) and Nurse Aide Instructor #13 assisting with meals. Nurse Aide Instructor #13 stated the nurse aide students were from a college and were in the facility for training Monday through Thursday from 9:00 AM-2:00 PM. During an observation on 6/25/2024 on Unit 100 at 9:52 AM, there were 7 nurse aide students (students #36, #37, #38, #39, #40, #41, and #42) and Nurse Aide Instructor #13 from an area college conducting clinical assignments on the unit. During an interview on 6/25/2024 at 1:26 PM Nurse Aide Instructor #13 stated the students were nurse aide students who had been coming to the facility for training since 1/10/2024. They had instructed two nurse aide training groups Group A and Group B. They stated Group A had tested out the week prior and Group B was finished Thursday 6/27/2024. Group B would return the following Monday through Thursday from 9:00 AM- 2:00 PM. Nurse Aide Instructor #13 was unsure who approved the program to provide training at the facility. During an interview on 6/25/2024 at 1:49 PM, the Administrator stated the off-site nurse aides had entered the building two weeks ago on 6/10/2024. They could not recall receiving a letter from the Centers for Medicare and Medicaid, they did recall a ban, but thought it only applied to in-house resident assistants training to become certified nurse aides. After re-reading and reviewing the Centers for Medicare and Medicaid enforcement letter dated 2/9/2024, the Administrator stated they must have received the letter and it meant they could not have any nurse aide training programs in the building. The Administrator stated that the nurse aide training program in the building would stop immediately. During an interview on 6/25/2024 at 2:29 PM Corporate Nurse #43 stated the facility had not applied for an exemption on the existing Nurse Aide Training and Competency Program. They were not aware they needed one to have an off-site nurse aide training through the community college. They thought the ban only applied to in-house staff being trained. Corporate Nurse #43 stated the current off-site facility would not be allowed to return as of 6/25/2024. 10NYCRR 415.26

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 6/24/2024-6/28/2024, the facility did not ensure a safe, clean, comfortable, and home-like environment for 4 of 4 Units (Units 100, 200, 300, and 400) reviewed. Specifically, floors, walls, ceilings, and resident chairs were damaged or unclean on Units 100, 200, 300, and 400; drain flies were observed in the Unit 200 shower room; and there was no negative air pressure in Units 200, 300, and 400 soiled utility rooms (negative pressure rooms have a lower air pressure, created by ventilation, to reduce the flow of potentially contaminated air or odors from leaking into the surrounding areas). Findings include: The facility policy, Housekeeping Responsibilities, reviewed 1/2022, documented the facility would maintain a clean, safe, and sanitary environment for the residents. Routine cleaning included daily cleaning of all horizontal surfaces with an acceptable grade disinfectant/germicide. A schedule of cleaning tasks and the employees responsible was to be maintained by the Housekeeping Supervisor. The following observations were made on Unit 100: - on 6/24/2024 at 10:33 AM, the floors were sticky when walking on them. The left side of the hall outside of room [ROOM NUMBER] had paint scraped off on both sides of the doorframe. - on 6/24/2024 at 10:44 AM, resident room [ROOM NUMBER] had a call bell out of reach of the resident lying in bed. There was a very strong odor of urine in the room. - on 6/24/2024 at 11:26 AM, Resident #52's wheelchair was ripped on the inside back rest and both arm rests. - on 6/24/2024 at 12:07 PM, Resident #44's reclining wheelchair had a soiled footrest. - on 6/24/2024 at 3:00 PM, the Unit 100 shower room had a missing call bell cord. There were miscellaneous items in the room including two fall mats, a wheelchair, and pads on the floor by the toilet. The following observations were made on Unit 200: - on 6/24/2024 at 2:05 PM, the soiled utility room had no negative pressure. - on 6/24/2024 at 2:18 PM, the shower room had no call bell cord, and there were two drain flies in the room. The following observations were made on Unit 300: - on 6/24/2024 at 11:10 AM, the shower room toilet seat cover was in disrepair and was worn through. - on 6/24/2024 at 11:17 AM, the soiled utility room had no negative pressure. The following observation was made on Unit 400: - on 6/24/2024 at 12:32 PM, the soiled utility room had no negative pressure. There was a 2 inch x 2 inch hole cut into the solid ceiling of the room. There was no documented evidence of work orders for any of the environmental issues identified during the tour of the facility. During an interview on 6/27/2024 at 9:21 AM, Housekeeper #4 stated they were assigned to work on Unit 100. They swept and mopped resident room floors, cleaned the resident room bathrooms, dusted the blinds, and replaced curtains if they were dirty. They also swept and mopped the hallways. It had been difficult to clean the unit floors due to residents with urinary incontinence issues. They stated they were responsible for cleaning and disinfecting the floors as needed if they appeared dirty. They used bleach for the floors. Nursing staff was responsible for cleaning wheelchairs, and certified nurse aides were responsible for cleaning body fluids. They stated the floors in the facility should not be sticky and could be caused by urine. During an interview on 6/28/2024 at 9:48 AM, Licensed Practical Nurse Unit Manager #3 stated the Maintenance Department was responsible for painting walls. The walls could use a paint touch-up. Work order tickets could be placed via the unit computers, or through a separate phone application, and the work orders went directly to the Maintenance Department. Work order requests would be submitted for things like leaky air mattresses, beds that were not working, plugged toilets, leaky sinks, unclean and damaged walls, and unclean and damaged wheelchairs. They stated the 11:00 PM to 7:00 AM nursing staff were responsible for cleaning wheelchairs, but this was not always completed. They should have been overseeing that wheelchairs were cleaned, and they had check sheets for the cleaning. The wheelchair for resident #52 was in disrepair and they should contact the Therapy Department to get a new chair. Licensed Practical Nurse #3 stated repairs should be completed within 24 hours unless it was urgent, and it should be completed immediately. During an interview on 6/28/2024 at 11:24 AM, the Maintenance Director stated they were responsible for overseeing maintenance for the entire building. They oversaw two maintenance technicians, a floor technician, and the housekeeping supervisor. All staff could use the hallway computers to place a work order, and the work orders would be sent immediately to the Maintenance Director. Work orders could also be created though an application on the phone, and orders completed this way went directly to the maintenance staff. Work order categories included floor care; electrical repair; heating, ventilation, air conditioning; call system; paint touch-ups; floors needing buffing, stripping, and waxing; and housekeeping mopping and sweeping. Priority work order tickets should be completed immediately or within 24 hours, painting work orders would usually take a couple of days, and resident equipment work orders would take a day and sometimes less. Maintenance staff were constantly on the resident units, and if they observed something they could create their own work orders. Nursing staff was educated on using the computers to submit work orders. The goal of the facility staff was to make and maintain a homelike environment for the residents. 10 NYCRR 415.29(j)(1)

Based on observation, record review and interviews during the recertification and abbreviated (NY00340701, NY00330066, NY00333069, and NY00328237) surveys conducted 6/24/2024 - 6/28/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 11 residents (Residents #56, #80, #90, and #127) reviewed. Specifically, Resident #127 had untrimmed fingernails and was not wearing their glasses; and Residents #56, #80, and #90 had unclean and untrimmed fingernails. Findings include: The facility policy, Resident Care with Activities of Daily Living, reviewed 1/2022, documented the facility was to accurately assist with residents' needs to support basic activities of daily living function. The supervisor was to be notified if the resident refused care and to report other information in accordance with facility policy and professional standards of practice. The facility policy, Care of Fingernails/Toenails, reviewed 1/2024, documented nail care included daily cleaning and regular trimming. The supervisor was to be notified if the resident refused care. The facility policy, Care of the Visually Impaired Resident, reviewed 1/2024, documented assistive devices to maintain vision included glasses and any other device used by the resident to assist with visual impairment. Residents who had lost or damaged their devices would be assisted in obtaining services to replace the devices. The supervisor was to be notified if the resident refused care. 1) Resident #127 had diagnoses including cerebral infarction (stroke), dementia, and need for assistance with personal care. The 5/4/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent on staff for showering/bathing and personal hygiene and wore corrective lenses. The Comprehensive Care Plan documented: - on 11/24/2023 the resident required assistance with self-care and mobility related to limited mobility and deconditioning. Interventions included substantial/maximal assistance for showering/bathing, and supervision or touching assistance for personal hygiene. - on 11/24/2023 and revised 3/4/2024 the resident had impaired visual function. Interventions included glasses, ensure the resident wore their glasses which were to be clean, free from scratches, and in good repair, and report any damage to nurse/family. Remind the resident to wear glasses as needed. The care instructions as of 6/27/2024 documented the resident wore glasses, required substantial/maximal assistance for showering/bathing, and supervision or touching assistance for personal hygiene. There was no documentation the resident's glasses were kept in another location for safe keeping, or if the resident required nail care from licensed nurses. Resident #127 was observed: - on 6/24/2024 at 11:06 AM, in their room with long, unkept fingernails and was not wearing glasses. The resident stated staff did not trim their fingernails. - on 6/25/2024 at 11:14 AM, in their room with long, unkept fingernails and was not wearing glasses. - on 6/26/2024 at 10:14 AM, in their room with long, unkept fingernails and was not wearing glasses. At 11:17 AM staff brought the resident to the unit dining area and seated them in front of the nurse's station. They were not wearing glasses. - On 6/27/2024 at 9:52 AM, in their room not wearing glasses. The Activities of Daily Living documentation task for the resident wearing their glasses was signed off as yes: - On 6/24/2024 at 9:35 AM by Certified Nurse Aide #17. - On 6/25/2024 at 11:15 AM by Certified Nurse Aide #17. - On 6/26/2024 at 2:59 PM by Certified Nurse Aide #18. - On 6/27/2024 at 8:05 AM by Certified Nurse Aide #17. The Activities of Daily Living documentation task for showering/bathing and personal hygiene was signed off as being done on 6/25/24 by Certified Nurse Aide #17. During an interview on 6/26/2024 at 10:14 AM Certified Nurse Aide #18 stated they were not sure of the resident's shower day. There was a shower list at the nurse's station, and they would check. They stated the resident's shower day was Tuesdays during the 7:00 AM - 3:00 PM shift. Sometimes the resident refused care, would state no and then staff would reapproach them. During an interview on 6/27/2024 at 9:56 AM Licensed Practical Nurse #16 stated they were not sure if the resident wore glasses. They looked through the resident's dresser drawers and nightstand drawer and stated they thought the resident's daughter took the glasses home because they were broken. During an interview on 6/27/2024 at 10:23 AM Certified Nurse Aide #17 stated the resident's shower day was on Tuesdays. They usually did that task first thing in the morning because the resident was hard to get up once they went back to bed, as they spent most of their time in their room. The resident's fingernails were cleaned in the shower. They did not trim the resident's fingernails because they thought the resident was diabetic and they did not see why the nurses would not know that. They never saw the resident wear glasses. They stated they did not know why they signed the Activities of Daily Living tasks that the resident was wearing their glasses. The nurses would probably know if the resident wore glasses or not. During an interview on 6/27/2024 at 10:55 AM Licensed Practical Nurse Unit Manager #19 stated the licensed practical nurses did skin checks on residents and would also be looking at fingernails while doing so. The certified nurse aides were supposed to trim residents' fingernails and they should be notifying the nurse if they were unable to or if a resident refused. If a resident was supposed to be wearing glasses and they could not find the glasses or they were broken, they should notify the nurse. They were not sure if Resident #127 wore glasses, but they could be broken, or family could have taken them home. Certified nurse aides should not be signing for tasks they were not completing. During an interview on 6/28/2024 at 9:42 AM Licensed Practical Nurse Unit Manger/Supervisor #6 stated fingernails should be trimmed by the certified nurse aides during the residents' showers or with daily care. Certified nurse aides could trim diabetic residents' fingernails. They stated the resident was not diabetic and their nails should be getting trimmed. If a resident had adaptive equipment such as glasses, then it would be documented in the care instructions. If a resident had glasses and they were missing or broken the certified nurse aides should be notifying the nurse. They stated the unit secretary kept the glasses in a locked drawer for safe keeping at the nurse's station. Most routine staff would know the glasses were kept there but some staff would probably not know this. 2) Resident #80 had diagnoses including right hemiplegia (weakness of the right side of the body). The 6/21/2024 Minimum Data Set assessment documented the resident was cognitively intact, had functional limitations in both arms, and was dependent for personal hygiene. The 12/26/2023 updated Comprehensive Care Plan documented the resident required assistance with self-care and mobility due to right sided weakness. Interventions included dependence with personal hygiene. The 6/26/2024 Activities of Daily Living documentation report documented the resident was provided daily personal hygiene care and daily shower/bathing care most every day during the month of June 2024. The following observations of Resident #80 were made: - on 6/24/24 at 12:59 PM, their fingernails were long with brown debris underneath. - on 6/27/24 at 11:55 AM, their fingernails were long with brown debris underneath. - on 6/28/24 at 9:00AM, their fingernails were long with brown debris underneath. During an interview on 6/24/2024 at 12:59 PM, Resident #80 stated their nails were too long, they poked their palms, and they wanted them cut. During an interview on 06/28/24 at 9:23 AM, Certified Nurse Aide #7 stated fingernails should be cleaned and trimmed on shower days or whenever nails were long or soiled. If a resident refused nail care, they would report to a nurse. Nail care was important as long, soiled fingernails could cause scratches which could lead to infection. They noticed Resident #80's fingernails were long and soiled and planned to groom them that day. During an interview on 6/28/2024 at 9:37 AM, Licensed Practical Nurse #5 stated they were not sure what the nail care policy was but expected certified nurse aides to provide nail care daily, and if not done, it was reported to them for follow-up. Proper fingernail care was important for the prevention of infection that could occur through scratches or by a resident putting soiled fingernails in their mouth. They were not aware of the condition of Resident #80's fingernails, but the resident often refused, and those refusals should be documented by the certified nurse aide in the hygiene task. They had not received any recent report the resident refused fingernail care. During an interview on 6/28/2024 at 10:28 AM, Licensed Practical Unit Manager/Supervisor #6 stated fingernails should be trimmed and cleaned on shower day and whenever needed. They expected any refusals to be reported to the team leader so a second attempt could be made. If a resident continued to refuse it should be reported to them so it could be documented, and care planned. Proper nail care was important for dignity and to prevent skin injury and infection. They were aware that Resident #80's fingernails were long and that the resident had a history of giving them and other staff difficulty about personal care. They did not see any documented refusals for fingernail care or a behavioral care plan. 3). Resident #90 had diagnoses including dementia and need for assistance with personal care. The 1/4/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent on staff for personal hygiene, and did not reject care. The comprehensive care plan revised 6/26/2024 documented Resident #90 required assistance with self-care and mobility related to cognitive impairment. Interventions included dependence for personal hygiene. The June 2024 resident care instructions documented the resident was dependent for personal hygiene. Resident #90 was observed with long fingernails on both hands and brown debris underneath: - on 6/25/2024 at 9:18 AM, walking in the hallway. - on 6/26/2024 at 7:45 AM, eating breakfast. - on 6/27/2024 at 8:52 AM, walking in the hallway. The 6/27/2024 Unit 100 staff assignment sheet documented Resident #90's shower day was Thursday on the 7:00 AM - 3:00 PM shift and was marked as completed. During an interview on 6/27/2024 at 10:15 AM Certified Nurse Aide #14 stated the resident required total care and they cared for the resident that day. Certified nurse aides were responsible for nail care unless the residents were diabetic. Nail care should be done on day shift or any chance they get if they were soiled. They had showered the resident that day but did not do nail care. The resident's fingernails had a brown substance under them and should have been cleaned. During an interview on 6/27/2024 at 1:59 PM Licensed Practical Nurse Unit Manager #3 stated the certified nurse aides were responsible for cleaning Resident #90's fingernails and they were usually cleaned on shower days. The resident's fingernails had a brown substance under them, they should have been cleaned on their shower day, and it was undignified for them to be dirty. During an interview on 6/28/2024 at 11:47 AM the Director of Nursing stated personal hygiene should be completed every day per the residents' preferences. Fingernails should be cleaned and trimmed daily, and it was undignified if not completed. Certified nurse aides and nurses could clean and trim fingernails and it was not appropriate if Resident #90's fingernails were not clean. 10NYCRR 415.12(a)(3)

Based on observation, interview, and record review during the recertification and abbreviated (NY00340613, NY00328237, and NY0330066) surveys conducted 6/24/2024-6/28/2024, the facility did not ensure each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 meals (6/26/2024 breakfast meal and 6/26/2024 lunch meal) reviewed. Specifically, the breakfast and lunch meals were not served at safe and appetizing temperatures. Findings include: The facility policy, Policy and Procedure Food Temperatures, reviewed 01/2023, documented the temperatures of all food items would be taken and properly recorded prior to service of each meal. All hot food would be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees Fahrenheit. Hot food items would not fall below 135 degrees Fahrenheit after cooking, unless it was an item which would be rapidly cooled to below 41 degrees Fahrenheit and reheated to at least 165 degrees Fahrenheit (for a minimum of 15 seconds) prior to serving. Temperatures would be taken periodically to assure hot foods stay above 135 degrees Fahrenheit and cold foods stay below 41 degrees Fahrenheit during the holding and plating process and until food left the service area. The facility policy, Food Preparation and Service, reviewed 01/2024, documented the danger zone for food temperatures was between 41 degrees Fahrenheit and 135 degrees Fahrenheit and promoted the rapid growth of pathogenic microorganisms that could cause foodborne illness. During an interview on 6/24/2024 at 10:49 AM, Resident #111 stated the food was not good. During Resident Council Meeting on 6/25/2024 at 10:30 AM, two anonymous residents stated the facility served food that was bland with no taste, and the hot foods were often served cold. During an observation on 6/26/2024 at 7:17 AM, Resident #111's breakfast meal tray was tested. A replacement tray was provided to Resident #111. Food temperatures on the tray were measured. The cheesy scrambled eggs were measured at 134 degrees Fahrenheit, the Super cereal was measured at 136 degrees Fahrenheit, the first can of diet cola was measured at 64.7 degrees Fahrenheit, and the second can of diet cola was measured at 64.9 degrees Fahrenheit. During an interview on 6/26/2024 at 12:35 PM Resident #63 stated the food was bland and had no taste, the hot foods were not hot, and the cold foods and drinks were not always cold. During an observation on 6/26/2024 at 12:39 PM, Resident #63's lunch meal was tested. A replacement tray was provided to Resident #63. Food temperatures on the tray were measured. The pureed barbecue chicken was measured at 129 degrees Fahrenheit, the pureed macaroni and cheese was measured at 123 degrees Fahrenheit, the pureed seasoned spinach was measured at 124 degrees Fahrenheit, the pureed fruit cocktail was measured at 69 degrees Fahrenheit, the honey thickened water was measured at 63 degrees Fahrenheit, the first 8 ounce container of 2% honey thick milk measured at 60 degrees Fahrenheit, and the second 8 ounce container of 2% honey thick milk measured at 62 degrees Fahrenheit. During an interview on 6/28/2024 at 10:13 AM Food Service Director #15 stated they tested food palatability for two test trays per week. Milk that measured at either 62 degrees Fahrenheit or 63 degrees Fahrenheit would not be acceptable and should not be served to residents. Hot foods that measured at 123 degrees Fahrenheit and 129 degrees Fahrenheit would not be acceptable and should not be served to residents. If residents were served food that measured outside the acceptable temperature range, they could become sick with a foodborne illness. 10NYCRR 415.14(d)(2)

Based on observation, interview, and record review during the recertification and abbreviated (NY00330066 and NY00331744) surveys conducted 6/24/2024-6/28/2024, the facility did not provide one or more rooms designated for resident dining and activities that were adequately furnished and had sufficient space to accommodate all activities for 2 of 4 dining rooms (Units 100 and 400). Specifically, Units 100's and 400's dining rooms had tables that did not accommodate residents' social and physical needs with inadequate space for dining or activities, and residents were lined up in the hallways during meals. Findings include: The facility policy, Preparing the Resident for a Meal, reviewed 1/2024, documented residents should be encouraged, not forced, to eat in the dining room to provide each resident the opportunity to socialize and make friends. Be sure the room was comfortable (i.e., not too warm, or cold) and had a relaxing environment (free of odors, loud noises, and bright lights). The following observations were made on Unit 100. The unit census was 36 residents. - During the lunch meal on 6/24/2024 between 11:31 PM and 12:16 PM the dining area had 6 square tables measuring approximately 3 feet x 3 feet. Two tables were placed together at the back of the room and 2 tables were placed together in the front of the room near the hallway. One square table was against the right side of the wall towards the back of the room and one square table was against the wall in the front of the room near the hallway. There were approximately 10 residents seated in the dining room. One resident was observed sitting in a reclining chair that was positioned sideways next to the back table near the wall. Two residents were seated at the back table with 2 square tables pushed together. One resident had a walker, the other a wheelchair. There were no other residents seated at the table. The meals were served on food trays that were approximately 12 inches long and were not removed during the meal. Residents seated at the tables were in wheelchairs, reclining chairs, or had assistive devices such as walkers and there was no room for ambulatory residents to sit. At 11:31 AM in the Unit 100 common area, there were approximately 10 residents seated at the tables in the common area and all other residents were lined up in the hallway, seated with bedside tables, across from the nursing station. The residents appeared cramped and were approximately ½ inch apart from one another. There was no music playing and no conversations between residents. Staff did not engage the residents in conversations. The following observations were made on Unit 400. The unit census was 39 residents. - on 6/24/2024 between 11:57 AM-12:18 PM there was no dining area on the unit. Several residents were lined up in the hallway eating on bedside tables. No conversations were observed between the residents. Other residents were eating in their rooms. - on 6/26/2024 at 8:08 AM, several residents were observed sitting lined up in the hallway eating breakfast served on bedside tables. During an interview on 6/26/24 at 11:31 AM, Certified Nurse Aide #12 stated the main dining room was closed and had not been utilized in a couple of months due to staffing. They stated residents with wheelchairs were placed at the tables and the other residents that were feeders or needed supervision were lined up in the hallway. During an interview on 6/28/2024 at 10:00 AM, Licensed Practical Nurse Supervisor #6 stated the main dining room was not being utilized and they had not seen it used in the 2 years since they had been employed at the facility. They stated they thought the units would be less congested if the main dining room was opened to residents. During an interview on 6/28/2024 at 11:47 AM, the Director of Nursing stated the main dining room had been closed since the COVID-19 outbreak and there had been discussions amongst management to re-open it. They stated they thought residents were lined up in the hallways for lack of space and thought being lined up in the hallway was not a dignified dining experience for the residents. 415.29(e)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey conducted 8/8/22-8/15/22, the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality for 1 of 1 resident (Resident #55) reviewed. Specifically, the facility did not provide Resident #55, whose primary language was not English, with a plan for communication of needs and preferences. The findings are: The facility policy Translation and/or Interpretation of Facility Services reviewed 1/2022 documented the facility's language access program would ensure that individuals with limited English proficiency (LEP) would have meaningful access to information and services provided by the facility. Resident #55 had diagnoses including dizziness and anxiety. The 5/3/22 Minimum Data Set (MDS) assessment documented the resident needed or wanted an interpretor to communicate with health care staff, their preferred language was listed (not English), had severe cognitive impairment based on brief interview for mental status (BIMS), usually made self understood and had difficulty communicating some words or finishing thoughts, usually understood others and missed some part/intent of message but comprehended most conversation. The comprehensive care plan (CCP) initiated 4/29/22 documented the resident had difficulty communicating with others related to a language barrier. Interventions included anticipate needs, be conscious of resident position when in groups, activities, dining room to promote interaction with others, discuss with resident/family concerns or feelings regarding communication difficulty, and provide translator as necessary to communicate with the resident. Special communication needs included translator needed, computer/tablet, iPad available at nursing station for translator, communication board, dry erase board, pen/pencil, and paper. A progress note on 5/2/22 at 8:18 AM by social worker (SW) #63 documented the resident was admitted to the facility, spoke a foreign language, and needed a translator. The 8/15/22 care instructions ([NAME]) documented the resident needed special communication and to use a translator, computer/tablet, communication board, dry erase board, or a pen/pencil and paper. The resident was observed: - on 8/8/22 at 12:29 PM, walking to the nurse's station speaking a language other than English and directed registered nurse (RN) #52 toward their room. RN #52 used finger pointing and directed the resident toward the activity room. The resident became upset and yelled loudly. No communication devices were used. - on 8/8/22 at 1:33 PM, the resident was dragging a chair down the hall to the nurse's station speaking a language other than English. RN #52 had their back turned to the resident and no communication device was used. During an interview on 8/11/22 at 11:12 AM with certified nurse aide (CNA) #21, they stated the resident did not speak English, used an iPad tablet to communicate with them, and they were not trained on how to use the iPad. They stated they would just ask the resident to point to what they wanted. During an interview on 8/11/22 at 11:31 AM, Activities Director #28 stated the CNAs knew how to use the iPad tablet, the facility would lose the internet connection intermittently, and staff thought they had disabled the interpreter application. During an interview with the resident on 8/12/22 at 11:00 AM via the language line the resident stated that they were upset that they were promised a private room and were not being given one. They stated they did not have personal belongings and did not have any hobbies. The resident became tearful and upset when speaking about not getting a private room and the call was ended to prevent additional distress. During an interview on 8/15/22 at 12:06 PM with SW #61, they stated they did the resident's admission, the resident could not speak English and the resident's son was present as a translator, so they did not use an interpreting service at that time. They stated the resident did not have dementia but did have some confusion when they first arrived. When they completed the resident's care plan review and BIMS they had used an interpreter service and determined the resident had a BIMS score of 3 (severe cognitive impairment). 10NYCRR 415.3(c)(1)(i)h

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey conducted 8/8/22-8/15/22 the facility failed to determine the clinical appropriateness of self-administration of medications for 1 of 8 residents (Resident #124) reviewed. Specifically, Resident #124 had a physician order documenting the resident was not capable of self-administering medications and multiple creams and Melatonin (a hormone that promotes sleep) were observed in the resident's locked bedside table. Findings include: The facility policy Administering Medications reviewed 1/2022, documented residents may self-administer medications only if the attending physician, in conjunction with the Interdisciplinary Care Planning Team, determined they had the decision-making capacity to do so safely. Resident #124 had diagnoses of chronic kidney disease, schizoaffective disorder, and history of intentional self-harm poisoning by medications. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition, had no behaviors exhibited, and required supervision for most activities of daily living (ADL). The comprehensive care plan (CCP) initiated on 11/11/2020 documented the resident had impaired skin integrity related to psoriasis. Interventions included apply treatment per physician order. The CCP did not include the resident's ability to self-administer medications. Physician orders documented: - on 4/6/22 Melatonin 5 milligram tablet, give 2 tablets at bedtime for insomnia. The order was discontinued with no documented date. - on 6/20/22 psoriasis deep moisturizing ointment 2% (coal tar extract) apply to areas of irritation topically every 8 hours as needed for psoriasis. The order was discontinued with no documented date. - on 7/7/22 the physician certified the resident was not capable of self-administering medications. During an interview on 8/8/22 at 11:06 AM, the resident stated they had a diagnosis of psoriasis (skin condition) and had topical medication they applied themselves. They kept the medication in a locked drawer in their bedside stand. Observed in the drawer were Ketoconazole (antifungal, over the counter, OTC) shampoo, Minerin (OTC moisturizing) cream, MG 217 psoriasis 2% coal tar (for psoriasis, OTC), and Ultravate lotion (for psoriasis, requires a prescription) lotion. The resident stated they applied the MG 217 once daily and did not use the Minerin cream as it made their face turn black. Also observed in the locked drawer were 2 white round pills in a medication cup. The resident stated they were Melatonin which they took for trouble sleeping. The pills had been provided by a nurse, but the resident was unsure which one. They were unsure how long the pills had been in the drawer. The following observations of the resident's room were made: -on 8/9/22 at 9:14 PM the resident had psoriasis creams and 2 round white pills in a medication cup in their locked drawer, The resident stated they were the same Melatonin and creams that were there on 8/8/22; and -on 8/11/22 at 10:01 AM the resident had psoriasis creams and 2 round white pills in a medication cup in their locked drawer. The resident stated they continued to self-administer 2% coal tar ointment to psoriasis plaques. During an interview on 8/11/22 at 1:49 PM, licensed practical nurse (LPN) #11 stated they usually worked the evening shift on unit 2. The resident did not have an order for Melatonin and had not requested Melatonin from the LPN. The resident had no order to self-administer medications. The LPN believed the resident was able to put their own psoriasis ointment on and assumed the resident was able to keep psoriasis treatments in their room. They should not have pills in their bedside stand, and they had never given the resident pills to keep in their room. It could be unsafe for them to take medications unsupervised. During an interview on 8/11/22 at 2:13 PM, registered nurse (RN) Unit Manager #15 stated the resident did not have an order to self-administer medications, should not have medication at the bedside, and had no idea there were medications in the resident's drawer. The resident did not have an order for Melatonin. The unit had a treatment cart where topical medications, shampoos and dressings were stored. These items were not to be stored in resident rooms. The resident would need to be assessed to keep any medication at the bedside. The resident had Ketoconazole shampoo, Minerin cream, MG217 psoriasis 2% coal tar, and Ultravate lotion in their locked bedside drawer with no current orders for any of those items. During an interview on 8/15/22 at 2:01 PM, nurse practitioner (NP) stated they had not been asked for an order for the resident to self-administer medications. Based on the resident's history and hospitalization, the resident would not be appropriate to self-administer medications. The resident had recently stated if they had access to pills, they would take them all. The medications at bedside could present potential for harm to the resident if they were to gather enough. The psoriasis cream application should be supervised by nursing staff to make sure it was being applied appropriately. There could be a potential for skin breakdown. The resident had severe mood fluctuations and may not apply treatments on some days or overuse on others. 10NYCRR 415.3(e)(1)(vi)

Based on interview and record review during the recertification survey conducted 8/8/22 to 8/15/22, the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while an investigation was in process for 1 of 3 residents (Resident #99) reviewed. Specifically, certified nurse aide (CNA) #10 was not removed from having contact with residents immediately following an alleged incident of abuse, neglect, or mistreatment involving Resident #99. Findings include: The facility policy Abuse and Neglect - Clinical Protocol revised 1/2022 documented abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also included the deprivation by an individual including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Neglect was defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility policy Accident and Incident - Investigation and Reporting revised 1/2022 documented all accidents or incidents involving residents, employees, visitors, vendors, etc., that occur on facility premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or Supervisor shall promptly initiate and document an investigation of the accident or incident. Resident #99 had diagnoses including Parkinson's disease (progressive neurological disorder), dementia, and falls. The 7/10/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, did not reject care, and required extensive assistance from 2 staff for transfers. The comprehensive care plan (CCP), last revised 7/22/22, documented: - the resident was at risk to be a victim of abuse/neglect related to impaired cognition. Interventions included to assess the resident for signs and symptoms of abuse/neglect and investigate all allegations of abuse/ neglect promptly. - The resident required the assistance of 2 staff using a mechanical lift for transfers. The 8/7/22 facility investigation completed by the Director of Nursing (DON) documented: - at 7:30 PM, an incident occurred involving Resident #99. When staff were transferring the resident, the strap on the mechanical lift was not tight enough to hold the bar in place, and the bar tapped against the resident's forehead. No injury was noted. Statements included with the facility investigation documented: - Licensed practical nurse (LPN) #11 documented on 8/7/22 at 7:30 PM, they observed Resident #99 leaning forward in their wheelchair to the point of almost falling out. They asked certified nurse aides (CNA) #10 and 60 to assist the resident to bed. CNA #10 stood up from up from a chair at the nurse's station, began to curse, stated Resident #99 did not need to go to bed, reported the resident was not on their assignment, and the resident's assigned CNA was on break. CNA #10 went into Resident #99's room and LPN #11 heard a lot of noise, so much noise that they were afraid for Resident #99. Upon entering the resident's room, LPN #11 observed CNA #10 attempting to use the mechanical lift to transfer the resident alone. One of the lift pad straps was not connected properly causing the metal bar to be loose, hitting Resident #99's head. LPN #11 asked CNA #10 to stop transferring the resident. Resident #99 was grabbing towards their head and stated stop, it hurt. At that time, CNA #60 entered the room and LPN #11 asked CNA #10 to leave the room and take a break. LPN #11 and CNA #60 transferred the resident to the bed. LPN #11 contacted registered nurse Supervisor (RNS) #12 and told them what had occurred. RNS #12 told LPN #11 to tell CNA #10 to take a break and have them call the RNS once they were done with the break. - Resident #125 documented on 8/7/22 at 7:30 PM, they observed Resident #99 leaning forward in their wheelchair. LPN #11 asked CNAs #10 and #60 to put Resident #99 in bed. Resident #125 observed CNA #10 stand up from the nurse's station, cursed at LPN #11, and stated they would put Resident #99 to bed. CNA #10 roughly brought Resident #99 into their room and began to slam the mechanical lift around. At that time, LPN #11 entered Resident #99's room and Resident #99 stated CNA #10 hit them in the head with the mechanical lift. LPN #11 asked CNA #10 to leave and take a break. CNA #10 continued to scream and swear at LPN #11 in front of Resident #125 and other residents. Resident #125 noted (the CNA) was completely out of line and very rough with (Resident #99). I was there for the whole confirmation. The DON further documented on the 8/7/22 investigation: - action taken included a RN assessment and the CNA was suspended pending the outcome of the investigation. - The DON signed and dated the investigation was completed on 8/9/22 and documented there was no evidence to support an allegation of abuse, neglect, or mistreatment. The 8/7/22 Employee Counseling form written by the DON documented CNA #10 was suspended 8/7/22, 8/8/22, and 8/10/22 as a result of exhibiting anger at the LPN, swearing in front of residents, exhibiting anger in Resident #99's room, and attempting to Hoyer (mechanical) lift Resident #99 alone. On 8/9/22, the DON documented they reviewed the form with CNA #10 via telephone. CNA #10's 8/7/22 time sheet documented the worked from 10:07 AM to 9:21 PM. On 8/12/22 at 10:34 AM, the DON stated in an interview, incident and accident reports were initiated as soon as incidents were reported to the Supervisor and if staff were being investigated, they would be suspended immediately. In this case, the DON stated CNA #10 was suspended and was not retrained until Saturday (8/13/22). Re-education was provided to CNA #10. The DON stated they thought CNA #10 used inappropriate language and did not follow what was asked of them. The DON felt the incident required suspension and a look at CNA #10's behavior. During a telephone interview on 8/12/22 at 2:40 PM with RNS #12, they stated on 8/7/22, LPN #11 called them and reported the incident with the Hoyer lift. When RNS #12 arrived at the unit, CNA #10 was not there and had gone on break. RNS #12 started the investigation and left the incident report for the DON to review the next day. CNA #10 continued to work on the unit and then at around 9 PM, CNA #10 texted RNS #12 and reported their behavior with Resident #99 had been out of line. RNS #12 reached out to the DON at that time and the DON said it was okay to send CNA #10 home. RNS #12 stated if they thought abuse had occurred, they would have sent CNA #10 home immediately. They stated they thought CNA #10 was verbal with the LPN and did not know it was in front of or towards residents. During an interview with LPN #11 on 8/15/22 at 10:24 AM, they stated on 8/7/22 around 7:30 PM they asked CNAs #10 and #60 to assist Resident #99 to bed. CNA #10 stood up and cursed at them. CNA #10 was observed to bring the mechanical lift from the hallway into the resident's room. At that time, they heard loud noise and when they entered the room, CNA #10 was transferring Resident #99 by themselves. Resident #99 was holding their head and the metal bar from the mechanical lift was contacting Resident #99's head. LPN #11 asked CNA #10 to leave the room when CNA #60 entered, and LPN #11 and CNA #60 put the resident to bed. CNA #10 did not leave the room right away and continued to curse in the resident's room. Resident #99 said their head hurt. LPN #11 called RNS #12 to report the incident and let them know they sent CNA #10 on break. LPN #11 stated CNA #10 came back to the unit to work after their break and after speaking with RNS #12 and worked until 9 PM to 9:30 PM when they were sent home. LPN #11 stated it was their understating CNA #10 was sent home due to something occurring between CNA #10 and RNS #12. LPN #11 stated Resident #125 seemed upset after the incident with Resident #99 and the incident was loud and concerning and CNA #10's behavior was uncalled for. 10NYCRR 415.4(b)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification and abbreviated (NY00276204, NY00294053, NY00297551, NY00264591, NY00293364, NY00300052, and NY00290644) surveys conducted 8/8/22-8/15/22, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 of 10 residents (Residents #17, 37 and 48) reviewed. Specifically, Resident #17's hair was unclean, Resident #37 was not dressed daily, and Resident #48's nails were unclean, and their clothing was not changed daily. Findings include: The facility policy Brushing and Combing Hair dated 1/2022 documented the resident's hair should be brushed and combed every morning before breakfast and whenever necessary throughout the day. Staff were to comb and style the resident's hair according to their preferences. The facility policy Dressing and Undressing the Resident dated 1/2022 documented staff were to encourage the resident to choose the clothes that they would wear for that day and encourage the resident to dress self whenever possible. Residents that may need assistance with dressing and undressing may include a blind resident, resident with limited mobility, a disabled resident, or a confused resident. Staff were to document date and time the procedure was performed. If the resident refused the procedure, the reason why and intervention taken should be documented. If refused the staff should notify the supervisor. 1) Resident #48 had diagnoses including Parkinson's disease (a progressive neurological disorder), major depressive disorder, and legal blindness. The 5/27/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required limited assistance with dressing and hygiene, and did not reject of care. The comprehensive care plan (CCP) initiated 2/17/21 documented the resident required assistance with activities of daily living (ADLs) related to being legally blind. Interventions included limited assistance of 1 for personal hygiene. The resident was observed: - on 8/8/22 at 10:14 AM, 12:10 PM, 12:37 PM, and 1:08 PM with long fingernails that were unclean with dark brown debris underneath. The resident was wearing a striped polo shirt with black sweatpants. At 12:37 PM, the resident stated their hands were sticky. - on 8/9/22 at 11:05 AM and 4:28 PM, with long fingernails that were unclean with dark brown debris underneath. The resident was wearing the same striped polo shirt and black sweatpants. - on 8/10/22 10:33 AM wearing a red top with gray pants and on 8/12/22 at 2:10 PM, the resident was wearing the same red top and gray pants. The activities of daily living (ADL) task record documented the resident had been assisted with dressing and bathing from 8/8/22 through 8/11/22 on the day shift by certified nurse aide (CNA) #2. Personal hygiene was provided on 8/8/22 by CNA #5 and on 8/9-8/12/22 by CNA #2. There was no documentation the resident had declined ADL care. During an interview with CNA #2 on 8/11/22 at 2:16 PM, they stated the resident used to require set up assistance, but now required more help with their ADLs. The resident needed assistance of 1 and sometimes refused care. The resident had asked for a shower on 8/10/22, which they provided. They changed the resident's clothes after the shower. The resident sometimes thought the clothes in their closet were not theirs. CNA #21 provided the resident's shower on 8/8/22 and they did not know if CNA #21 changed the resident's clothes. CNA #2 stated the resident's nails were cut 8/10/22 by CNA #21. During an interview with CNA #21 on 8/12/22 at 4:07 PM, they stated they gave the resident a shower on 8/10/22 because the resident asked for it. When they gave the resident a shower, they trimmed their nails because they were long. The resident allowed nail care without issue. The CNA stated the resident could dress themselves. During an interview with CNA #5 on 8/12/22 at 4:32 PM, they stated the resident's level of assistance with care varied. There were times the resident required dressing assistance, and other times they did not. Staff should have tried to assist the resident in changing their clothes. They were assigned to the resident on 8/8/22 and the resident did not request bathing and the CNA stated they had not offered bathing. During an interview with licensed practical nurse (LPN) Unit Manager #4 on 8/15/22 at 10:58 AM, they stated staff should offer to change the resident's clothes every day. Their nails should have been clipped and cleaned last week. If the resident had declined care staff should note the refusal in the record and notify the Unit Manager. The LPN stated they would have approached the resident and if they continued to decline care, they would have written a progress note. 2) Resident #17 had diagnoses including dementia and arthritis. The 7/31/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance of 2 for hygiene, and extensive assistance of 1 for bathing. The comprehensive care plan (CCP) initiated 5/11/17 documented the resident required assistance with activities of daily living (ADLs) related to dementia. Interventions updated on 7/24/19 included the resident was totally dependent for personal hygiene and dressing. The resident was observed: - on 8/8/22 at 11:44 AM, sitting in a recliner chair in an alcove across from the Unit 4 nursing station wearing black yoga pants and a floral top. The resident's hair appeared wet/greasy and was brushed. - on 8/8/22 at 2:17 PM, sitting in a recliner in an alcove across from the nursing station with greasy appearing hair. - on 8/9/22 at 9:36 AM, 8/10/22 at 9:20 AM, 8/11/22 at 9:33 AM, 8/12/22 at 8:49 AM, and 8/15/22 at 8:51 AM, sitting in a chair in an alcove across from the nursing station. The resident's hair was brushed and appeared greasy. The 7/2022 and 8/2022 certified nurse aide (CNA) ADL task sheets documented the resident received personal hygiene and bathing at least daily from 7/1/22 through 8/12/22. When interviewed on 8/15/22 at 9:26 AM, CNA #19 stated they did not give the resident a shower. The resident was scheduled for a shower once a week. Resident specific care was documented on the care instructions/care plan and each CNA was to check the care instructions daily. The CNA stated the resident was already up and dressed when the CNA arrived for duty on 8/15/22. The CNA stated the resident's hair looked greasy and was not washed in at least a week. The CNA stated staff should wash the resident's hair without showering if it looked greasy. There was no dry shampoo available. When interviewed on 8/15/22 at 9:36 AM, CNA #20 stated the resident received a shower weekly on Sundays and thought the last time the resident received a shower was a week ago. The CNA stated they brushed the resident's hair that morning and there were a few flakes in their hair, and it appeared greasy. When interviewed on 8/15/22 at 10:46 AM, licensed practical nurse (LPN) Unit Manager #6 stated residents were bathed once a week and as needed or requested. Hair was to be washed during showers or baths. They rounded every day to ensure the baths were done. If a resident refused a bath/shower, the reason why was determined, and staff should reapproach the resident later. The LPN Manager stated the resident's hair appeared greasy. The resident's normal shower day was Monday during the day shift and staff should have tried to wash the resident's hair if it was greasy. When interviewed on 8/15/22 at 2:07 PM, the Director of Nursing (DON) stated it was expected that each resident's hair looked clean, combed and not greasy looking. The DON stated shampooing of hair was implied under the bathing/showering task and should be done if signed for. If a resident's hair appeared greasy, it was assumed the hair was not washed. 3) Resident #37 had diagnoses including dementia, traumatic brain injury, and major depressive disorder. The 5/23/22 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, inattention that was continuously present, and required extensive assistance of 1 for dressing. The comprehensive care plan (CCP) initiated 7/23/18 documented the resident required assistance with activities of daily living (ADLs) related to dementia. The CCP did not include interventions for bathing or hygiene. The care instructions ([NAME]), active on 8/8/22, documented the resident was totally dependent on staff for dressing. There was no documented evidence the resident had refused and/or declined dressing. The resident was observed in their room wearing a hospital gown on 8/8/22 at 10:35 AM and on 8/9/22 at 3:32 PM. The resident was unable to state their dressing preference. During an interview with CNA #3 on 8/11/22 at 1:46 PM, they stated staff were responsible for dressing the resident as the resident required assistance with everything. The resident could be combative and yelled out, but it had not deterred them from providing care. During an interview with licensed practical nurse (LPN) Unit Manager #4 on 8/15/22 at 11:06 AM, they stated the resident screamed during care, but would allow care. They should have been dressed daily. They stated if a resident refused care staff should document that in the medical record and notify the Unit Manager to go and assist and offer redirection. 10NYCRR 415.12(a)(3)

Based on observation, interview and record review during the recertification and abbreviated (NY00300052 and NY00264591) surveys conducted 8/8/22-8/15/22, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 1 resident (Resident #73) reviewed. Specifically, Resident #73 did not have Prevalon boots (a boot that floats the heels to reduce pressure) applied to their bilateral heels while in bed or in their wheelchair as planned. Findings include: The facility policy Care plans- Baseline revised 1/2022 documented a baseline care plan was to be developed for the resident within 48 hours to assure the resident's immediate care needs were met and maintained, including initial goals and physician's orders. The facility policy Pressure Ulcers/Skin Breakdown Clinical Protocol reviewed 4/2022 documented the physician would help the staff review and modify the care plan as appropriate, especially when wounds were not healing as anticipated or new wounds develop despite existing interventions. Resident # 73 was admitted to the facility with diagnoses including diabetes, obesity, and difficulty walking. The 6/22/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance with bed mobility and locomotion, did not walk, had one Stage 2 (partial thickness skin loss) pressure ulcer present on admission, used a pressure reducing device for chair and bed, received pressure ulcer care, application of nonsurgical dressings, and application of ointments/medications. The comprehensive care plan (CCP) initiated 6/17/22 documented the resident had impaired skin integrity of Stage 2 pressure ulcers to their bilateral heels. On 6/29/22 the CCP was updated and documented the resident had impaired skin integrity of the left lower leg, an open area to the right heel, and a deep tissue injury (purple/maroon area of discolored intact skin) to the left heel. Interventions included an air mattress, a cushion for their wheelchair and Prevalon boots while in bed or in the wheelchair. A 6/29/22 wound assessment evaluation by the Director of Nursing (DON) documented the resident had unspecified stage pressure ulcer of the right heel measuring 5.1 centimeters (cm) x 8.2 cm x 0.1 cm; and a suspected deep tissue injury on the left heel measuring 6.0 cm x 10.5 cm. Interventions included repositioning, heels raised while in bed, pressure relief in wheelchair, specialty mattress, and the care plan was updated. An 8/4/22 wound assessment by registered nurse (RN) #52 documented the right heel measured 4.8 cm x 4.2 cm x 0.8 cm and was a Stage 4 (full thickness tissue with exposed bone, tendon, or muscle); the left heel measured 1.0 cm x 1.5 cm x 0.1 cm and was a Stage 2. Interventions utilized included repositioning. The resident was observed: - on 8/8/22 at 2:49 PM sitting in their wheelchair with dressings to both heels and ACE bandage wraps. The resident's heels were resting directly on the wheelchair foot rests. - on 8/10/22 at 10:20 AM, the resident was lying in bed with their heels resting directly on the mattress. The Prevalon boots were in the wheelchair next to the bed. An 8/11/22 wound assessment by RN #52 documented the right heel measured 4 cm x 5 cm x 0.5 cm and was a Stage 4. The left heel measured 1.5 cm x 0 cm and was a Stage 2. Interventions included pressure relieving wheelchair seat cushion, specialty mattress, resident education, and care plan was updated. During an interview on 8/11/22 at 2:00 PM with certified nurse aide (CNA) #7, they stated the resident wore boots on their feet at night and they were unsure if the resident needed to wear them while in the wheelchair. The CNAs were responsible for putting them on the resident. The resident did not refuse to wear them. The resident was observed: - on 8/11/22 at 2:24 PM sitting in an electric wheelchair with bandaged heels resting directly on the footrests without Prevalon boots on. - on 8/12/22 at 10:35 AM sitting in their wheelchair with their heels resting directly on the footrests without Prevalon boots on. The resident stated they never refused to wear the Prevalon boots. The 8/2022 treatment administration record (TAR) documented offloading sponge boots to bilateral feet when in bed and as needed for comfort two times a day for wound care, with a start date of 8/12/22. On 8/12/22 the TAR documented the boots were off. During an interview on 8/15/22 at 10:26 AM with licensed practical nurse (LPN) #6, they stated the resident had blue (Prevalon) boots initiated on the care plan during the initial care plan development on 6/29/22. There was no physician order for the boots prior to 8/12/22. LPN #6 stated nurses and CNAs were responsible to make sure the resident had the boots on while in bed or in the wheelchair when they completed rounds every 2 hours. During an interview on 8/11/22 at 2:37 PM with RN #52, they stated the Prevalon boots were for relieving pressure on the heels. The nurses and aides were responsible for ensuring the resident had the booties on. They stated the resident did not refuse to wear the boots. During an interview on 8/15/22 at 8:12 AM with wound physician #53, they stated the resident had a pressure ulcer on the right heel that was not progressing as expected and it was infected. They stated the resident had laboratory work that showed an elevated ESR (erythrocyte sedimentation rate, a blood test that can reveal inflammatory activity). The resident was diabetic which could possibly delay wound healing. The wound deteriorated quickly and was likely due to an infectious process. They stated nursing was responsible for ensuring the care plan was followed. 10NYCRR 415.12 (c)(1)

Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00268090) conducted on 8/8/22-8/15/22, the facility failed to ensure the resident environment remained free of accident hazards as possible and residents received adequate supervision and assistance devices to prevent accidents for 1 of 9 residents (Resident #108) reviewed. Specifically, Resident #108 had smoking materials in their room which were not secured per facility policy and the resident's plan of care and other care planned interventions to promote smoking safety were to implemented as planned. Findings include: The facility policy Smoke Free Policy, revised 1/2022, documented it was the policy of the facility to maintain a smoke free facility. The facility was to possess all smoking and lighting materials at all times. The resident would be evaluated on admission, quarterly, and upon a significant change to determine if the resident was a smoker or non-smoker. If a smoker, the evaluation would include current level and frequency of tobacco consumption; ability to smoke safely with or without supervision; cognition; vision; dexterity/safety, and occupational therapy (OT) evaluation for safe smoking. Any resident with safety restrictions due to non-compliance would be re-educated, have their room searched, and smoking items confiscated. Resident #108 had diagnoses including end-stage renal (kidney) disease with dialysis and tobacco use. The 7/9/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, did not smoke, and received dialysis treatments. The 4/13/22 quarterly occupational therapy (OT) smoking evaluation documented the resident did not use assistive devices altering smoking ability, had no tremors, had multiple bilateral digit amputations, independently propelled in a wheelchair, and was alert and cognitively intact. The assessment did not document if the resident was a safe or unsafe smoker. The 5/11/22 physician's progress note documented the resident smoked previously and quit. The 7/13/22 OT smoking evaluation documented the resident did not use assistive devices altering smoking ability, had no tremors, independently propelled in a wheelchair, and was alert and cognitively intact. The assessment did not document if the resident was a safe or unsafe smoker. The comprehensive care plan (CCP), initiated 11/22/19, documented the resident was a problem smoker, smoked only when out on pass, understood the facility's non-smoking policy, did not smoke on/in facility property, was found non-compliant with keeping smoking materials on their person or in their room, was educated regarding the need to turn over smoking material on return to the facility, and could request them when going out on pass. Interventions included to assess the resident's physical ability and understanding, weekly room checks, provide smoking apron if indicated, refer to the physician to promote smoking cessation, remove smoking materials and keep them in a secure location, and instruct the resident to return materials when returning from out on pass and dialysis on Tuesdays, Thursdays, and Saturdays. When interviewed on 8/8/22 at 2:10 PM, the resident stated they smoked cigarettes when they were at dialysis and obtained the cigarettes and lighter from a family member. The resident stated they did not have any smoking materials with them presently. There were no visible smoking materials observed on the resident or in their room at that time. When interviewed on 8/11/22 at 9:37 AM, certified nurse aide (CNA) #20 stated the resident told them they smoked when they went out on pass. CNA #20 stated they never saw the resident smoke and was not sure if any staff checked if the resident had smoking materials in their room. CNA #20 stated 8/10/22, they were told the resident smoked and they were not sure who told them or why they were made aware. During an observation on 8/11/22 at 9:53 AM, licensed practical nurse (LPN) Unit Manager #6 and the surveyor received permission from the resident to look in their room for smoking materials. The resident stated at that time there were cigarettes and a lighter in their bag on the back of the wheelchair as they were going to dialysis shortly. The cigarettes and lighter were observed in the bag. The resident stated they also had cigarettes in their dresser and they placed their lighter and cigarettes in the locked nightstand drawer when they returned from out on pass. When interviewed on 8/11/22 at 9:55 AM, LPN Unit Manager #6 stated they were made aware the resident smoked within the past few weeks when questioning why it was in the resident's record about them being a smoker. LPN Unit Manager #6 stated they were made aware the resident smoked at dialysis only. When interviewed on 8/11/22 at 10:37 AM, CNA #58 stated they were not aware of any smokers on the unit or in the building. CNA #58 stated no resident should have lighters and was not aware of any who did. When interviewed on 8/11/22 at 10:45 AM, the Director of Therapy stated they completed smoking evaluations quarterly and on admission. The facility only had one smoker who was grandfathered in when the policy changed and the smoker was not Resident #108. There was no smoking allowed in the facility or on the grounds. The Director was not sure if Resident #108 smoked off facility grounds. Resident #108 would not be a safe smoker as they had dexterity issues due to loss of some fingers and could not safely use a lighter. When interviewed on 8/11/22 at 11:00 AM, CNA #7 stated Resident #108 smoked off facility property at dialysis, which was where they got their smoking materials. The CNA was unaware if room checks were done or if the resident kept their own smoking materials with them. When interviewed on 8/11/22 at 11:16 AM, LPN Unit Manager #6 stated no one was allowed to smoke on facility grounds. LPN #6 was made aware Resident #108 was a smoker on 7/13/22 when the smoking evaluation was done. LPN #6 was aware the resident smoked at dialysis only. LPN #6 stated only registered nurses (RN) were authorized to initiate or edit the CCPs. OT was responsible for completing smoking evaluations. LPN #6 read the resident's CCP and stated it documented the resident was a problem smoker, found to be non-compliant with keeping materials in their room, and LPN #6 stated they were not aware of what was on the CCP until this time. LPN #6 stated they were not aware the CCP documented weekly room checks were planned. They stated they were not familiar with the facility smoking materials policy as there were supposed to be no smokers in the facility. The LPN Manager was unsure of where the room checks would be documented if they were completed. 10NYCRR 415.12 (h)

Based on observation, interview, and record review during the recertification survey conducted 8/8/22-8/15/22, the facility failed to assist residents in obtaining routine dental care for 1 of 3 (Resident #96) residents reviewed. Specifically, the facility did not obtain the services of a dentist for Resident #96 when their lower dentures were missing and not recovered. Findings include: The facility policy Dental Services reviewed 1/2022 documented routine and emergency dental services were available to meet the residents' oral health services in accordance with the resident's assessment and plan of care. Social services representatives would assist residents with appointments and transportation arrangements. Direct care staff would assist residents with denture care, including removing, cleaning, and storing dentures. Dentures would be protected from loss or damage to the extent practicable, while being stored. If dentures were damaged or lost, residents would be referred for dental services within 3 days. If the referral was not made within 3 days, documentation would be provided regarding what was being done to ensure the resident was able to eat and drink adequately while awaiting dental services; and the reason for delay. Resident # 96 had diagnoses including diabetes and kidney cancer. The 5/29/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required supervision with set-up for eating, extensive assistance of 1 for personal hygiene, did not receive a mechanically altered diet, and did not have broken or loosely fitting dentures, or mouth pain. The comprehensive care plan (CCP) initiated 4/21/22 documented the resident had oral/dental health problems related to upper and lower dentures. Interventions included denture care, refer to dentist as needed, and coordinate arrangements for dental care and transportation. The 7/14/22 at 5:49 AM licensed practical nurse (LPN) Unit Manager #6's progress note documented the resident's dentures were missing, they looked in the resident's room and were unable to locate the dentures, a missing item form was filled out and would be turned in to social work at morning report. The 7/2022 facility Missing Items list did not include Resident #96's missing dentures. The 7/22/22 at 5:25 PM LPN #35's progress note documented the resident phoned the state police to report their missing dentures. The resident appeared frustrated. The resident was informed the Unit Manager was working on resolving the situation and getting the resident a new pair of dentures, and it would take time. The Unit Manager was made aware of the situation. There were no social work progress notes regarding Resident #96's missing dentures or arrangements for dental care. During an interview on 8/8/22 at 11:40 AM, Resident #96 stated their roommate took their denture cup from their bedside table approximately 5 weeks ago, staff found the denture cup on the roommate's bed, and only the top dentures were recovered. Resident #96 stated their bottom dentures were still missing and they had not seen a dentist for replacement. During an observation and interview on 8/10/22 at 11:40 AM, Resident #96 received a regular diet with regular consistency lunch. The resident's meal included a hot dog on a roll, baked beans, fresh melon, pasta salad, coffee, and milk. The resident consumed half of their hotdog and bites of the beans. The resident stated they had difficulty eating without lower dentures. During an interview on 8/11/22 at 2:01 PM, certified nurse aide (CNA) #7 stated the resident told them about a month ago on an evening shift that their dentures were missing. CNA #7 stated a search was done and the top dentures were found. The CNA notified the Unit Manager (no longer employed at the facility). The lower dentures were not found, and they reported it to the evening nurse. CNA #7 stated the resident did not eat well due to missing their lower dentures and often refused meals and alternatives. During an interview on 8/11/22 at 2:45 PM, LPN Unit Manager #6 stated that they were made aware of the resident's missing dentures on 7/22/22 by LPN #35. The LPN Manager stated an email was sent to social services about the missing dentures and to the unit clerk to set up a dental appointment. There was no documented evidence of a scheduled dental appointment in the resident's medical record. During an interview on 8/11/22 at 3:23 PM, social worker # 8 stated they were aware of the resident's missing dentures, and they would be replaced by the facility. The social worker was unsure how long it would take, and the unit clerk was responsible for setting up an appointment. The dentist came to the facility monthly. During an observation on 8/12/22 at 12:06 PM, Resident #96 had no lower teeth. The resident received a lunch tray with lemon fish, French fries, peas and carrots, cottage cheese and Jell-O. Resident #96 refused their lunch and stated they could not eat it because they needed their lower dentures. The resident stated their family was going to bring in dinner later. During an interview on 8/12/22 at 10:20 AM, unit clerk #67 stated the facility had an in-house dentist and a resident could be sent out for an emergency dental issue. The Unit Manager sent the clerk an email if a resident needed an appointment made. They had not received an email regarding the resident's need for a dental appointment and there was no dental appointment set up for the resident. 10NYCRR 415.17(b)

Based on observation, record review and interview during the recertification survey conducted 8/8/22-8/15/22, the facility failed to ensure the menus reflect, based on a facility's reasonable efforts, the religious, cultural, and ethnic needs of the resident population for 1 of 1 resident reviewed (Resident #48). Specifically, Resident #48 had limited intake due to cultural and ethnic food preferences and there was no documented evidence the facility attempted to obtain foods that would meet the resident's preferences. Findings include: The facility Resident Food Preferences Policy and Procedure dated 1/2022 documented that upon the resident's admission the dietitian or nursing staff would identify a resident's food preferences. Nursing staff would document the resident's food and eating preferences in the care plan. If the resident refused or was not happy with their diet, the staff would create a care plan that the resident was satisfied with. The Food Service Department would offer a variety of foods at each scheduled meal. Resident #48 had diagnoses including Parkinson's disease (a progressive neurological disease), major depressive disorder, and legal blindness. The 5/27/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and required supervision with eating. A registered dietitian (RD) assessment dated 2/2021, documented the resident was oriented to person only with confused cognition. The assessment was completed with the resident and documented none under ethnic/religious/cultural food preferences. The 2/28/22 diet technician #29's progress note documented the resident's intake at meals varied. The resident's weight was stable for 3 months however, the resident was below their ideal body weight. There was no documentation that food preferences were discussed with the resident. The 4/19/22 diet technician #29's progress note documented the resident's appearance was very thin and that most likely they had some weight loss although they refused to be weighed. Intake at meals varied and they often left greater than 50% of food uneaten at meals. There was no documentation that the resident's meal preferences were discussed with the resident and/or their representative. A 5/26/22 diet technician #29's assessment documented the resident continued to be very thin. The resident was independent at meals and preferred to stay in their room. The resident was at nutritional risk related to intake and diagnoses. The care instructions and comprehensive care plan (CCP), active on 8/9/22, documented the resident: - was independent with meals after set-up. - Had reports of feeling down, depressed, or hopeless and staff were to provide support and reassurance. - Had a nutritional problem and was at risk for malnutrition with a history of significant weight loss in 5/2021 related to inadequate oral intake/poor appetite. The CCP and care instructions contained no documentation related to the resident's cultural/ethnic food preferences. The resident's meal profile active on 8/11/22 documented none under the area of religion/culture. The resident was observed on 8/8/22 at 12:20 PM, standing in their room with a bed side table in front of them and a meal tray on the bedside table. The resident was drinking Ensure (nutritional supplement). The resident received rice, a pork chop, and mixed vegetables and all were untouched. At 12:37 PM, the resident was asked about their meal and preferences, and they declined to answer. The resident was observed on 8/9/22 at 11:05 AM. The resident was seated in their room and talked about their relatives and where they resided oversees. They discussed their cultural food, naming various items and what they liked to eat. The resident stated where they would find them in the store prior to their admission to the facility. They stated they primarily ate their cultural food before coming to the facility and had not had any since admission. They stated no one at the facility had ever asked them about their specific cultural preferences related to food choices. The resident was observed on 8/9/22 at 12:11 PM, seated with their meal tray on a bed side table in their room. The resident was eating a roll. The resident received a half cup of cabbage casserole which was untouched. The resident did not answer when asked about the meal. During an interview with certified nurse aide (CNA) #2 on 8/11/22 at 2:16 PM, they stated the resident did not like American food. The resident would eat breakfast but picked at their lunch meals. They thought diet technician #29 had spoken to the resident about food preferences. During an interview with CNA #4 on 8/12/22 at 4:32 PM, they stated the resident would tell them they did not care for the food and the resident ate small amounts. They had not heard of any specific food requests from the resident but had not asked. During an interview with licensed practical nurse (LPN) Unit Manager #4 on 8/15/22 at 10:58 AM, they stated the resident was not from this country and their food preferences were different. The resident had never mentioned anything specific that they liked to eat, and they were not aware of any problems related to eating/food. They stated they thought diet technician #29 had spoken to the resident about food preferences. During an interview with diet technician #29 on 8/15/22 at 12:49 PM, they stated the resident received small portions because they did better with drinking than eating and drank Ensure well. They stated the resident was not always forthcoming with information when asked about what they liked to eat. Diet technician #29 stated no other staff had reported to them the resident requested a certain type of food. The resident's cultural food was not on the facility's regular menu. If they had known the resident preferred certain foods, they would have checked to see if it was available or if there was anything local they could have brought into the facility. During an interview with RD #30 on 8/15/22 at 1:03 PM, they stated they had not been asked the resident about cultural food preferences. If they had they would have asked the kitchen if the food was available. Food service could have looked locally for that type of food. During an interview with the Nutrition Service Director on 8/15/22 at 2:37 PM, they stated no one had ever mentioned or asked about alternative food items for the resident. They stated they were not familiar with the resident and if they were aware of a preference, they would have asked corporate if they could accommodate the preference. 10NYCRR 415.14(c)(1-3)

Based on observation, record review and interview during the recertification and abbreviated (NY00294053) surveys conducted 8/8/22-8/15/22, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 certified nurse aides (CNAs #20 and 45) and activity aide #51 observed for appropriate mask wearing. Specifically, CNAs #20 and 45 and activity aide #51 were observed not wearing face masks appropriately in resident care areas. Findings include: The facility policy Personal Protective Equipment - Using Face Masks reviewed 1/2022 documented an objective of using face masks was to prevent transmission of some infections that were spread by direct contact with mucous membranes. Be sure that face masks covered the nose and mouth while performing treatment or services for the patient. The facility policy Updated Guidance on COVID-19 revised 1/10/22 documented all staff and contractors must wear a face mask in the facility. This includes breakrooms, bathrooms and other spaces where they will encounter co-workers. During an observation on 8/9/22 at 8:55 AM on Unit 4, 7 residents (Residents #49, 113, 130, 107, 12, 108, and 93) were sitting in front of the nursing station. CNAs #20 and 45 were observed removing breakfast trays from the meal cart and serving residents with their face masks positioned on their chins, exposing their noses and mouths. During an observation on 8/9/22 at 11:46 AM, activities aide #51 walked by the Unit 4 nursing station carrying a coat and not wearing a face mask. They walked directly past 3 unidentified residents to the activities department. When interviewed on 8/10/22 at 9:21 AM CNA #20 stated staff were supposed to wear face masks around residents to prevent the risk of spreading any potential respiratory infections. If a resident had COVID-19 or if a resident was on droplet precautions staff should wear an N95 mask. They stated on 8/9/22 the Infection Preventionist (IP) had seen them with their face mask slipping down and told them to pinch the nosepiece. They did, but it still slipped down. Their glasses were heavy and sometimes pushed their face mask down. They were not aware of their face mask being worn below their mouth on 8/9/22 while passing out breakfast trays. The facility did not offer alternative face masks that fit better. When interviewed on 8/10/22 at 9:23 AM CNA #45 stated they were supposed to wear face masks around residents to prevent the spread of germs, was not aware their mask was down when observed passing breakfast trays on 8/9/22, and sometimes the mask slipped down. When interviewed on 8/10/22 at 12:58 PM, activities aide #51 stated face masks were worn to protect staff and residents from any possible diseases by keeping the germs from spreading from noses and mouths or vice versa. Staff were required to wear the face masks throughout the building and were to cover their noses and mouths. They were not aware they had to wear a face mask at all times throughout the facility. They received mask wear education during new employee orientation 3 - 4 weeks ago. They were unaware there was a box with face masks just inside the employee entrance and they usually donned a mask in the lobby during health screening and clocking in to work each day. When interviewed on 8/15/22 at 9:55 AM, licensed practical nurse (LPN) Unit Manager #6 stated they expected all staff to wear a face mask around residents. If they saw a staff member not wearing their face mask appropriately they would pull them aside and give them a verbal warning, and if they did it again they would get a written warning. The main exit doors for staff was off of Unit 4, and sometimes staff pulled their face masks down as they walked down the hall to go outside. They were trained a few weeks ago on infection control by the Staff Educator. When interviewed on 8/15/22 at 11:41 AM, the Staff Educator stated new employees received education on blood-borne pathogens and general handwashing. The Infection Preventionist (IP) did staff competencies throughout the year which included personal protective equipment (PPE). They did rounds on the units to make sure staff were wearing PPE appropriately. They would counsel staff immediately if PPE was worn inappropriately. They were constantly re-educating on PPE. They had different face masks available for staff, and if staff needed a better fitting face mask they would recommend an N95 or KN95 mask. When interviewed on 8/15/22 at 1:23 PM the IP stated all staff were expected to wear face masks properly in the facility. They have told staff if they needed to take a breather from their face masks they should be by themselves in the medication room or employee lounge. They had not conducted recent trainings on face mask usage. They did rounds on the units several times a day and if inappropriate face mask usage was observed they would immediately tell staff to pull the mask up. They had different styles of face masks so staff would have the best fit, and face masks were everywhere in the facility. 10NYCRR 415.19(a)(1-2)(b)(2)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00271335, NY00276204, NY00290644, NY00293364, and NY00297551) conducted 8/8/22-8/15/22, the facility failed to provide a safe, clean, comfortable, and homelike environment for 4 of 4 resident units (Units 1, 2, 3, and 4) reviewed. Specifically, there were sticky/unclean floors, scrapped/damaged walls, exposed electrical wires, water dripping from a ceiling vent, resident clothing left on the ground in a clean utility closet, a loose/unsecured toilet bowl, and a loose/unsecured resident room doorknob. Additionally, Resident #48's room was not personalized and/or homelike. Findings include: 1)Unclean Floors/Scraped Walls The Maintenance Schedule for Floors, revised 1/28/21, documented that two resident room floors would be stripped and waxed each day. The following observations of floors and walls were made: - on 8/8/22 at 10:18 AM, and 8/9/22 at 9:31 AM, the floor in resident room [ROOM NUMBER] was sticky and covered with black marks and a wall near the resident bed was scuffed/damaged - on 8/8/22 at 10:11 AM and 8/9/22 at 11:05 AM, the floor in room [ROOM NUMBER] was sticky/unclean, and there were grayish/black spots on the floor between the resident beds and in the center of the room. - on 8/8/22 at 10:26 AM, the wall in room [ROOM NUMBER] on the right side resident area was scuffed and the paint was peeling. - on 8/8/22 at 10:37 AM, the floor in room [ROOM NUMBER] was sticky/unclean. - on 8/8/22 at 10:47 AM, the floor in room [ROOM NUMBER] was greasy/unclean, and the wall behind the resident bed had several unpainted spackle patches and a 2 inch x 2 inch hole in a section of drywall beside an electrical outlet. - on 8/8/22 at 10:56 AM, the floor in room [ROOM NUMBER] was stained under the right side resident bed. - on 8/8/22 at 10:56 AM, the floor in room [ROOM NUMBER] was sticky/unclean. - on 8/8/22 at 11:01 AM, the wall next to the resident bed in room [ROOM NUMBER] was deeply gouged/damaged, and there was debris on the floor. - on 8/8/22 at 11:05 AM, the wall behind the left side resident bed in room [ROOM NUMBER] was scraped/damaged. - on 8/8/22 at 11:14 AM, the floor in room [ROOM NUMBER] was stained with gray blotches, and the lower sections of the walls in the room were scuffed and chipped. - on 8/8/22 at 11:20 AM, the floor in room [ROOM NUMBER] was sticky/unclean and had debris on it. - on 8/8/22 at 11:31 AM, the floor in room [ROOM NUMBER] was scuffed/stained. - on 8/8/22 at 11:32 AM, the floor in room [ROOM NUMBER] was sticky/unclean, and there were multiple walls that had spackle patches and had not been painted. - on 8/8/22 at 1:57 PM, the floor in room [ROOM NUMBER] was sticky and there was black/brown debris on sections of the floor. - on 8/8/22 at 2:30 PM, the floor in room [ROOM NUMBER] was unclean, there were missing sections of wax next to scraped waxed unclean floor sections, and there were multiple unpainted white spackle spots on the floor. - on 8/10/22 at 9:57 AM, the floor in room [ROOM NUMBER] was sticky/unclean. - on 8/12/22 at 3:10 PM, the floor in room [ROOM NUMBER] had a 2 foot x 2 foot section with no wax present and had black spots on it. The room walls were chipped/damaged. - on 8/12/22 at 3:20 PM, the wall in room [ROOM NUMBER] behind a resident bed was scrapped/damaged. - on 8/12/22 at 3:23 PM, the floor in room [ROOM NUMBER] was sticky/unclean. - on 8/15/22 at 9:20 AM, the floor in room [ROOM NUMBER] was sticky/unclean, and the walls near both resident beds were scrapped/damaged. - on 8/15/22 at 9:25 AM, the floor in room [ROOM NUMBER] was sticky/unclean, and the walls near both resident beds were scrapped/damaged. - on 8/15/22 at 9:28 AM, the walls near both resident beds in room [ROOM NUMBER] were scrapped/damaged. - on 8/15/22 at 9:35 AM, the floor in room [ROOM NUMBER] floor was sticky/unclean, and there were marks on the floor that matched the shape of the electric bed legs. - on 8/15/22 at 9:38 AM, in room [ROOM NUMBER] the wall near the right side resident bed and the wall under the window in were scratched/damaged. - on 8/15/22 at 9:41 AM, the floor in room [ROOM NUMBER] was sticky/unclean, and the walls near both resident beds were scrapped/damaged. - on 8/15/22 at 9:45 AM, the floor in room [ROOM NUMBER] was sticky/unclean, and the walls in this room were scratched/damaged. - on 8/15/22 at 9:47 AM, the floor in room [ROOM NUMBER] floor was sticky/unclean. The Maintenance Director was interviewed: - on 8/8/22 at 2:30 PM and stated that the floors were stripped and waxed as needed and should be completed twice a year for each resident room. Service tickets were completed when resident rooms were completed. They stated that the floor in room [ROOM NUMBER] had not been stripped and waxed by the maintenance staff since they were hired a year ago. They were not sure when it was last completed. They had requested that all resident room floors be buffed monthly, but this had not been maintained due to room changes during the COVID pandemic. - on 8/10/22 at 2:00 PM and stated that the floor stripping and waxing schedule could not be maintained due to staffing issues, COVID-19, and resident room changes. - on 8/12/22 at 1:26 PM, stated they could not find the last documented time that the floor in resident room [ROOM NUMBER] had been stripped and waxed. The previous maintenance director did not document stripping and waxing of resident room floors. They stated they could not find any work orders for the wall repairs in room [ROOM NUMBER]. - on 8/15/22 at 10:00 AM, they stated that there were no work orders for the damaged walls in resident room [ROOM NUMBER]. At 10:50 AM, they stated that resident floors were stripped and waxed in order of the most stained/unclean floors. They could not find any documentation of the last time resident room floors had been stripped and waxed. The resident room wall maintenance was not done, and facility staff had not been properly completing work order forms to inform maintenance staff to correct the wall issues. During an interview on 8/10/22 at 2:10 PM, the Director of Plant Operations stated that wall patch repairs, from patch to paint, should be completed in no more than 5 business days. During an interview on 8/15/22 at 12:00 PM, housekeeper #25 stated the Unit 4 floors had not been stripped and waxed for several months, and work orders would be filled out if a floor needed to be buffed, stripped, and waxed. They could not recall the last time the facility had a comprehensive plan to strip and wax the resident room floors, and usually worked on unit 4. When they noticed chipped/damaged walls they would place a work order using the computer kiosk. They stated that all staff had been in-service on how to use the computer kiosks to create work orders and the work orders would be used for damaged walls and unclean floors. During an interview on 8/15/22 at 2:35 PM, housekeeper #26 stated the last time the facility had a comprehensive plan to strip and wax all the resident room floors was several years ago, and that was not acceptable. They stated that they were aware of the work order kiosk system and would always document via a work order any floor or wall issues found on unit 1. Housekeeper #26 stated that maintenance staff would immediately complete the work orders after they were submitted. During an interview on 8/15/22 at 2:45 PM, housekeeper #27 stated that the usually covered Unit 3 and that 4 or 5 resident room floors had recently been stripped and waxed. They stated the floors on Unit 3 were unclean and not acceptable and had noticed this when they were hired. The maintenance department was trying to keep on track with stripping and waxing the resident room floors, and that some residents had not allowed this process to be completed. After a resident room was deep cleaned, any issues observed by the housekeepers would be reported via a work order. 2) Miscellaneous The following observations were made: - on 8/8/22 at 10:37 AM and 8/12/22 at 3:23 PM, a wall in resident room [ROOM NUMBER] had a loose/dangling phone jack. - on 8/8/22 at 11:43 AM, there was water dripping from a ceiling vent located above the Unit 4 nursing station. - on 8/8/22 at 11:50 AM, there was resident clothing on the ground in the Unit 4 clean linen closet. - on 8/8/22 at 12:50 PM, the toilet in room [ROOM NUMBER] was loose and not secured to the floor. - on 8/8/22 at 1:57 PM, the closet in room [ROOM NUMBER] had exposed electrical heater wires. - on 8/9/22 at 10:45 AM, room [ROOM NUMBER] had stained ceiling tiles including a black stained tile. - on 8/15/22 at 9:28 AM, the doorknob to the access door to room [ROOM NUMBER] was loose. - on 8/15/22 at 10:00 AM, a wall strip over the right side resident bed in room [ROOM NUMBER] was cracked with sharp edges. The Maintenance Director was interviewed: - on 8/9/22 at 10:45 AM and stated that a water leak in room [ROOM NUMBER] was caused by a dripping condensation pipe, and they were not aware of the stained ceiling in the room. The facility had not replaced ceiling tiles in that room before, as it looked like the pipe had recently shifted and became straight which allowed condensation to back-up and drip down. - on 8/12/22 at 1:40 PM and stated that housekeeping and laundry staff were responsible for ensuring that clean resident clothing was not on the unclean floor. They stated that housekeeper #25 was covering for Unit 4 and should have discovered and picked it up off the floor as checking the linen closet was part of daily cleaning. The flange for the toilet in resident room [ROOM NUMBER] was broken, could create water on the floor, should have been noticed by staff, and all staff were aware of how to create a work order. - on 8/12/22 at 3:00 PM, they stated that they were not aware of the heater wires not being covered and that was not acceptable as dirt/debris could build up. They were not aware of the loose phone jack in the wall, and that a work order should have been made so maintenance staff could correct this. - on 8/15/22 at 9:28 AM, they stated that the doorknob should have been secure to the resident room [ROOM NUMBER]. - on 8/15/22 at 10:50 AM, they stated that they were not aware of the cracked wall strip with sharp edges in resident room [ROOM NUMBER]. During an interview on 8/15/22 at 12:00 PM, housekeeper #25 stated the Unit 4 clean linen closet was not supposed to be used for resident clothing and this room was maintained by the nursing staff. They stated that housekeepers do not go into the clean linen closets. 3)Personalization of Resident Room Resident #48 had diagnoses including Parkinson's disease (progressive neurological disease), major depressive disorder, and personality disorder. The 5/27/22 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and required supervision to limited assistance with most activities of daily living (ADLs). The comprehensive care plan (CCP), revised 2/14/22, documented the resident was able to make activity preferences known, preferred independent activities, listened to oldies music, and played checkers. The resident felt down, depressed, hopeless, isolated, and had little interest or pleasure in doing things. Staff were to provide support and reassurance. A 5/26/22 social services progress note documented a family member lived overseas. The resident's room was observed on 8/8/22 at 10:08 AM, 12:10 PM, 1:08 PM and on 8/9/22 at 11:05 AM and 4:28 PM. with no personalized bedding, wall decorations or other personalized items. A plastic bag was tied up with the top of a cardboard shoe box showing at the top of the bag. There was a deflated bear balloon on the cork board in the room. The resident was observed in the room during these observations and did not engage in conversation when asked about the furnishings. On 8/10/22 at 9:57 AM, the room remained the same. The plastic bag was opened, and items wrapped up in a separate plastic bag were on the nightstand. The resident could not state what the items were and said there were 2 books in the plastic bag that they were not going to read. On 8/11/22 at 2:10 PM, the resident's room did not have personalization and the resident did not answer questions about their room. During an interview with certified nurse aide (CNA) #2 on 8/11/22 at 2:16 PM, they stated the resident was from another country and they were very private. The resident stayed mostly in their room and came out occasionally. The plastic bag on the nightstand were personal items from a family member in the resident's native country. They did not touch the resident's items or know what was in the bags. During an interview with CNA #5 on 8/12/22 at 4:32 PM, they stated there was a bag on the resident's nightstand that had shopper service items in it. They had not done anything with the bag. They had not heard any requests for personalization and that was usually something the activities department would handle. Sometimes they would notify the licensed practical nurse (LPN) Unit Manager #4, but they had not let them know about the resident's room. During an interview with LPN Unit Manager #4 on 8/15/22 at 10:58 AM, they stated the activities department was able to assist with decorating rooms. No one had mentioned the resident's room to them, and they had not asked anyone to assist with decorating. During an interview with the Director of Activities on 8/15/22 at 12:22 PM, they stated the resident was more secluded. They kept to themselves, and staff had to go to the resident for all interactions. When their department played music from the resident's native country the resident would sit quietly and listen. Neither the resident nor staff had asked them for anything for the resident's room. They stated the family sent books in a package, it had taken a couple of attempts to open the package and books as the resident did not want anything from their family as they were estranged from them. 10 NYCRR 415.29(j)(1)

Based on observation, record review, and interview during the recertification survey conducted 8/8/22-8/15/22, the facility failed to ensure services provided or arranged by the facility met professional standards of quality for 23 of 39 residents (Residents #2, 4, 13, 19, 32, 34, 36, 37, 39, 43, 44, 57, 66, 81, 82, 87, 89, 100, 102, 104, 111, 146, and 155) reviewed. Specifically, during a medication storage review of the Unit 1 medication cart, 23 residents had pre-poured medications in cups, stored in the top drawer of the Unit 1 medication cart. Findings include: The facility policy Administering Medications reviewed 1/2022 documented medications must be administered within 1 hour of their prescribed time, unless otherwise specified. The individual administering the medication must initial the resident's medication administration record (MAR) after giving each medication and before administering the next ones. Medications ordered for a particular resident may not be administered to another resident. The facility policy Storage of Medications reviewed 1/2022 documented drugs shall be stored to prevent the possibility of mixing medications of several residents. Drugs shall be stored in the packaging, containers, or other dispensing systems in which they were received. Only the issuing pharmacy was authorized to transfer medications between containers. The nursing staff would be responsible for maintaining medication storage and preparation areas in a clean and safe manner. Drug containers that have missing, incomplete, improper, or incorrect labels should be returned to the pharmacy for proper labeling before storing. The undated facility Medication Passes listing documented the medication administration times were 12:00 AM, 6:00 AM, 7:00 AM, 11:00 AM, 1:00 PM, 4:00 PM, and 7:00 PM. During a medication storage observation of the Unit 1 medication cart on 8/9/22 at 4:11 PM with licensed practical nurse (LPN) #32, the following medication cups were observed in the second from the right divided area of the medication cart's top drawer. Each individual cup was labeled with a resident name and contained the following observed pills: - Resident #2 - 2 large round white and 2 white with 216 in blue writing; - Resident #4 - 3 large round white and 1 oval white; - Resident #13 - 1 green, 1 white, 1 tan square, 1 tan round; - Resident #19 - 2 oval yellow and 2 round white; - Resident #32 - 3 blue/white, 1 large oval, 1 oval; - Resident #34 - 3 round white (1 labeled AN755 in black); - Resident #36 - 1 oval pink, 1 round orange, 1 oval white, 1 oval yellow; - Resident #37 - 6 blue/white, 1 rust, 1 small round white, 1 small oval white; - Resident #39 - 5 blue/white, 1 oval white, 1 white round; - Resident #43 - 1 round pink, 1 round blue, 1 oval white, 1 round white; - Resident #44 - 2 large round white, 2 round small white, 1 oval white, 1 large oval pink; - Resident #57 - 3 round white, 1 small round tan, 1 triangle brown, 1 oval white; - Resident #66 - 1 rust, 3 white round, 3 1/2 white, 1 rust triangle, 1/2 small rust, 1 tan round, 1 white oval; - Resident #81 - 1 green/tan, 2 round brown, 1 oval pink, 1 round white; - Resident #82 - 2 large oval pink, 1 round blue, 1 round white, 2 oval white; - Resident #87 - 1 large round white and 2 smaller round white; - Resident #89 - 2 large white round, 1 blue round; - Resident #100 - 2 round yellow, 2 large round white, 2 oval white, 1 oval tan; - Resident #102 - 2 large round white, 1 oval blue, 1 smaller round white. - Resident #104 - 3 white oval, 2 yellow oval, 1 round green, 1 round yellow, 1 white half; - Resident #111 - 1 large oval pink, 1 tan oval, 2 large round white, 1 small round white; - Resident #146 - 1 round pink, 1 oval orange, 3 round white, 1 white oval; and - Resident #155 - 7 white of various sizes. When interviewed on 8/9/22 at 4:11 PM, licensed practical nurse (LPN) #32 stated all the medications in the medicine cups in the top drawer of the medication cart were for those residents that were scheduled to receive medications after dinner until 9:00 PM. There were multiple residents who received medications during that time frame. The LPN stated the Director of Nursing (DON) had told the Unit 1 LPN Unit Manager that if the medication cups were labeled and the LPN preparing the medication cups was the same one that administered the medications, pre-pouring all the medications due for a medication pass was allowed. The LPN stated that if there were 2 residents with the same first name, then they wrote the residents last name on the cup in lieu of the first name. When interviewed on 8/9/22 at 4:58 PM, LPN Unit Manager #4 stated they had told staff it was ok to pre-pour medications if they were properly labeled and the nurse preparing them was the same one that administered them. It was their understanding that the nurse could set up the entire shift's medications for residents at the beginning of the shift. When interviewed on 8/15/22 at 2:07 PM, the Director of Nursing (DON) stated it was not a good standard of practice to pre-pour an entire med pass. The DON stated there was a chance of giving the medications to the wrong person, and a pre-poured medication could be discontinued from the time the medication was prepared to the time it was delivered and be given by mistake. There was also a chance the nurse that pre-poured the medication would have to leave the facility, and the nurse taking over would not know what the medications were or who they were for. The medications could be given to the wrong resident if the medications were not discarded. 10NYCRR 415.1 (b)(4) and 415.12 (m)

Based on observation, interview, and record review during the recertification survey conducted 8/8/22-8/15/22, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and include the expiration date when applicable for 2 of 7 medication carts (Units 1and 4) and 3 of 4 medication storage rooms (Units 1, 3, and 4) observed. Specifically, Units 1 and 4 had expired stock medications in the medication rooms and medication carts and the Unit 3 medication storage room refrigerator had an expired biological multi-dose vial. Findings include: The facility policy Storage of Medications reviewed 1/2022 documented the facility should not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs should be returned to the dispensing pharmacy or destroyed. Only persons authorized to prepare and administer medications should have access to the medication room. During an observation on 8/9/22 at 4:11 PM, the Unit 1 medication storage was observed with licensed practical nurse (LPN) #32. The following expired medications were observed in the medication cart: - Zinc (mineral supplement) 50 milligrams (mg) opened bottle with a manufacturer's expiration date of 5/22 and a handwritten open date of 7/15/22 on the bottle; -Docusate Sodium (stool softener) 100 mg open bottle with a manufacturer's expiration date of 7/22 and a handwritten open date of 7/10/22 on the bottle; - Vitamin B complex (supplement) opened bottle with a manufacturer's expiration date of 3/22 and a handwritten open date of 7/15/22 on the bottle; and - Calcium 600 mg + Vitamin D 200 (supplements) units with a manufacturer's expiration date of 5/22 and a handwritten open date of 8/5/22 on the bottle. During an observation on 8/9/22 at 4:11 PM, the following expired medications were observed in the Unit 1 medication room: - Enteric coated aspirin 325 mg (unopened) with a manufacturer's expiration date of 6/22; - Poly-iron (supplement) 150 mg (unopened) with a manufacturer's expiration date of 4/22; - Docusate sodium 100 mg (opened) with a manufacturer's expiration date of 7/22 and a handwritten date of 2/28 with 2 initials next to it on the bottle; - Folic Acid (supplement) 400 micrograms (mcg) (unopened) with a manufacturer's expiration date of 5/22: - Zinc 50 mg (unopened) 4 bottles with a manufacturer's expiration date of 5/22; and - Bisacodyl (laxative) 10 mg (unopened) suppositories with a manufacturer's expiration date of 3/22. When interviewed on 8/9/22 at 4:20 PM, LPN #32 stated the date handwritten on each bottle was the date the bottle was opened, and all the above mentioned bottles were all expired. Some of the bottles were opened past the manufacturer's expiration date. All nurses were to check the expiration dates on each bottle prior to administering them. They were not sure who was assigned to check the medication rooms and carts for expired medications, but they should have been discarded prior to the date of expiration. When interviewed on 8/9/22 at 4:58 PM, LPN Unit Manager #4 stated all nurses should be checking the medication room and carts on a weekly basis for expired medications. Those checks were not being documented and there was no specific shift assigned to perform those checks. They had no way to know if the checks were completed and they were unaware if residents had received expired medications. During an observation of the Unit 4 back medication cart on 8/9/22 at 5:07 PM, with LPN #33, the following expired medications were in the top drawer: - Zinc 50 mg bottle with a manufacturer's expiration date of 5/22 and a handwritten opened date of 5/15/22; and - Famotidine (antihistamine) 20 mg bottle with a manufacturer's expiration date of 7/22 and a handwritten opened date of 7/22/22. During an observation on 8/9/22 at 5:07 PM, the following expired medications were observed in the Unit 4 medication room: - Health eyes supplement with Lutein (unopened bottle) with a manufacturer's expiration date of 6/22; and - Enteric coated aspirin 325 mg (unopened) with a manufacturer's expiration date of 6/22. When interviewed on 8/9/22 at 5:23 PM, LPN #33 stated all the observed medications were expired. The nurse administering the medications was responsible to check each medication before giving it to ensure it was not past the expiration date. The LPN did not know who was assigned to routinely check for expired stock medication in the medication carts and rooms. The LPN did not think any residents had received the expired medications. On 8/9/22 at 5:42 PM, the Unit 3 medication room refrigerator was observed with LPN #34 and there was an opened vial of tuberculin Aplisol 5 TU/0.1 ml with no opened date on the vial or box. The vial had a manufacturer's expiration date of 10/22. LPN #34 stated the vial and box did not contain an expiration date and was considered expired since they did not know when the vial was opened. The LPN stated that the staff member opening the vial was to date the vial and that the vial was only good for 30 days after the opened date. When interviewed on 8/9/22 at 5:49 PM, LPN Manager #6 stated medication room checks for expiration house stock was the responsibility of the unit clerk and there currently were no assigned unit clerks for units 3 and 4. The medication nurses were to check the medication room refrigerators. The medication nurse assigned to the medication cart should have been checking daily for expired stock medications. The LPN Manager stated the tuberculin vial was considered expired as it had no opened date written on it and was only good for 30 days past the opened date. The LPN Manager stated the expired medications should have been discarded a couple of days prior to the expiration date. When interviewed on 8/15/22 at 2:07 PM, the Director of Nursing (DON) stated stock medications should be checked for expiration dates every night shift and the facility did not document those checks. The night shift nurse should check the medication rooms, medication carts, and medication refrigerator on their assigned unit. A stock medication vial was good for 30 days once opened unless indicated. The tuberculin vial should have been thrown away if undated. There should not have been any medications opened past the manufacturer's expiration date as it may not be effective or could have adverse effects. 10 NYCRR 483.45 (g)(h)

Based on observation, record review, and interview during the recertification and abbreviated (NY00271335) surveys conducted 8/8/22-8/15/22, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's main kitchen and emergency food supply room. Specifically in the main kitchen: - the hand-washing sink, near the dishwasher area, had a faucet that was leaking water. - The metal vent system, over the dishwasher, was rusty and soiled. - The metal support pieces for the ceiling tiles in the dishwasher area were unclean/rusty. - The wall behind the dishwasher was soiled with food and unclean. - The floor behind the 3 bay sink area was unclean with debris on it. - A section of floor between the 3 bay sink and a food heating oven had standing water and was unclean. - The walk-in milk cooler contained undated sliced cheese. - The dishwasher clean storage rack had two 8 quart measuring cups with orange colored debris on them. - The storage room contained two dented 62 ounce (oz.) mushroom cans and three dented 106 oz. crushed pineapple cans. Additionally, the emergency food supply room had water dripping from a ceiling overhead pipe into a plastic bin. Findings include: A policy or procedure for the frequency of cleaning kitchen walls, ceilings or floors was requested and non was received. During an observation on 8/8/22 at 10:20 AM and 8/9/22 at 12:40 PM, the main kitchen hand-washing sink near the dishwasher area had a faucet that was leaking water into a plastic container that was on the floor under the sink. This container disabled the hot and cold foot pedals from working. During an interview on 8/8/22 at 10:20 AM, the Maintenance Director stated they were not aware the main kitchen hand-washing sink near the dishwasher was leaking water into a plastic container under the sink, or of the broken wall tile, and no work orders had been entered for these issues. During an observation on 8/8/22 at 10:35 AM and 8/9/22 at 12:30 PM, the main kitchen metal vent system over the dishwasher was rusty and soiled. During an observation on 8/8/22 at 10:45 AM and 8/9/22 at 12:30 PM, the main kitchen metal support pieces for the ceiling tiles in the dishwasher area were unclean/rusty. During an observation on 8/8/22 at 10:51 AM and 8/9/22 at 12:29 PM, the main kitchen floor behind the three bay sink area was unclean with debris on it, and a section of floor between the three bay sink area and a food heating oven had standing water and was unclean. During an observation on 8/8/22 at 11:15 AM, the emergency food supply room had water dripping from a ceiling overhead pipe into a plastic bin and this bin was located on top of a wet plywood shelf. Water had migrated under and around a cardboard container of emergency tomato soup cans. During an interview on 8/8/22 at 11:15 AM, the Maintenance Director stated that they were not aware of the dripping water within the emergency food supply room and did not know who placed the plastic bin there to collect the water. During an observation on 8/9/22 at 12:32 PM, the main kitchen walk-in milk cooler contained undated sliced yellow cheese. During an observation on 8/9/22 at 12:42 PM, the main kitchen dishwasher clean storage rack had two 8 quart measuring cups with orange colored debris on them. During an observation on 8/9/22 at 12:57 PM, the main kitchen storage room contained two dented 62 ounce (oz.) mushroom cans dented and three dented 106 oz. crushed pineapple cans. During an interview on 8/9/22 at 3:33 PM, the Assistant Food Service Director stated: - they were aware of the plastic container collecting water under the main kitchen hand-washing sink near the dishwasher area and that a work order had been submitted for this. - In the last 6 months, they had not seen anyone cleaning the vent over the dishwasher area, and the ceiling tiles in the dishwasher area were replaced as needed and last painted over the winter of 2021. - The wall behind the dishwasher had been cleaned and had not been documented, and they were not aware of any policy for the frequency for cleaning walls, ceiling, or floors. - The main kitchen floor should have been mopped and swept by both the morning staff and night staff, that this was not documented, and that there were currently no task sheets for any kitchen staff. - They were not aware of the puddle found behind the food heating oven and a shop vacuum should have been used be used at least once a day by the night shift. - Open food items in coolers should be discarded after 3 days, there was no opened sliced cheese when the walk-in cooler was checked at 5:30 AM, and all kitchen staff had been trained to label and discard food after 3 days. - They routinely checked the clean rack to ensure all items were clean. The two 8 quart plastic containers were used specifically for Jello which was made every two days, and they were not sure when Jello was last made in the kitchen. - A dedicated stocking Supervisor was responsible for ensuring dented cans were removed and placed into the dented can bin and food supplies were last stocked last Thursday. They checked the storage room throughout the day and did not see the 5 dented cans. - They were aware of a history of condensation in that specific area of the emergency food supply room and was not aware of the current condensation dripping onto the plywood shelving. They were not sure who put the container in the storage room to collect the dripping, that it was not acceptable for emergency supply items to get wet or be in standing water, and that the specific soup cans should have been moved to a dry section of the emergency food supply room immediately when it was found. 10NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not ensure each resident had the right to a dignified existence and each resident was cared for in a manner and environment that promoted maintenance or enhancement of his or her quality of life for 4 of 7 residents (Residents #26, 66, 93 and 94) reviewed for dignity. Specifically, Resident #66 was not provided privacy during a wound treatment; Resident #94 had a receptacle of dirty linens placed in their room; Resident #26 was not fed their meal in a dignified manner; and Resident #93 was ambulated in the hallway by staff holding on to the resident's pants and incontinence brief. Findings include: The 8/2009 Quality of Life-Dignity facility policy documented that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures and that each resident's space and property shall be respected at all times. The facility policy Dressings, Dry/Clean revised 3/2019 documented to explain procedure to the resident and provide privacy. 1) Resident #66 was admitted to the facility with diagnoses including diabetes, anxiety and cerebral infarction (stroke). The 11/16/19 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required extensive assistance with activities of daily living (ADL) and had one or more unhealed pressure ulcers. The 1/17/20 physician order documented to cleanse the 4th right toe with normal saline, apply skin prep (a protective film) and 2 x 2 gauze every day. The 1/20 treatment administration record (TAR) documented to cleanse the 4th toe on right foot with normal saline, apply skin prep, and 2 x 2 gauze every day shift. Resident #66's wound care treatment was observed on 1/23/20 at 9:40 AM with licensed practical nurse (LPN) #11. LPN #11 entered the room, did not close the door, and provided the ordered wound care to the foot. During the treatment there were visitors, residents and staff members in the hallway with direct view of the resident. During an interview on 1/23/20 at 9:51 AM with LPN #11, she stated when treatments were performed staff should provide privacy to the resident by closing the door. She stated that she forgot to close the door during the observed wound treatment. During an interview on 1/23/20 at 1:57 PM with registered nurse (RN) Unit Manager #13, she stated the expectation during treatments was that resident privacy should always be maintained by closing doors. 2) Resident #94 was admitted to the facility with diagnoses including cerebral palsy (a congenital disorder of muscle tone) and dementia. The 12/13/19 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and required extensive assistance with most activities of daily living (ADLs). The resident [NAME] (care instructions) active on 1/24/20 documented the resident ambulated in their room and corridor with limited assistance of one staff and a rolling walker. During an observation on 1/22/20 at 9:08 AM three dirty linen carts were observed stored inside the door of the resident's room. The carts were half-full of dirty linens, obstructed the path to the resident and smelled of urine. The resident was observed in bed with the privacy curtain pulled. On 1/22/20 at 4:46 PM, the dirty linen carts were observed in the hall outside of the resident's room against the wall. When interviewed on 1/24/20 at 9:59 AM, certified nurse aide (CNA) #25 stated she was assigned to care for Resident #94 on 1/22/20. She stated she saw the linen carts stored in resident's room, they did not belong in the room and she removed them. She stated she assumed another CNA put the carts in there to get them out of the hall. She stated the other CNA should have taken care of the dirty linen instead of putting the carts in the resident's room. She stated it was a dignity issue and a tripping hazard for the resident. She stated the linen carts contained multiple resident's soiled linens. When interviewed by telephone on 1/24/20 at 3:28 PM, CNA #26 stated dirty linen carts were kept in the dirty utility room and there was never a reason to put dirty linen carts in a resident's room. She stated they should not be kept in the hall and were kept in the dirty utility room. During an interview on 1/24/19 at 12:42 PM, the Quality Assurance (QA) registered nurse (RN), who was covering for the Infection Control RN, stated that dirty linen carts should not be in resident rooms and staff should never bring dirty linen carts into a room. It was an infection control issue and a dignity issue. 3) Resident #26 had diagnoses including Huntington's disease (a progressive neurological disease) and adult failure to thrive. The 10/17/19 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and was totally dependent for activities of daily living (ADLs). The undated resident [NAME] (care instructions) documented the resident was totally dependent for eating. Staff were to use communication techniques which enhanced interaction, allow adequate time to respond, repeat as necessary, face the resident when speaking, make eye contact and use simple, brief, consistent words/cues. During a meal observation on 1/21/20 from 12:23 PM until 12:47 PM, Resident #26's meal was served, and the resident was fed by certified nurse aide (CNA) #18. CNA #18 began feeding the resident without telling the resident what food was being fed or speaking to the resident. The resident was removed from the dining table at 12:47 PM. CNA #18 had not spoken to Resident #26 during the entire meal and was observed speaking to other residents and staff nearby. When interviewed on 1/24/20 at 10:11 AM, CNA #18 stated she knew how to provide resident specific care by looking at the resident's care instructions or asking unit staff. CNA #18 stated she would tell a non-verbal resident what she was feeding them and could tell by their facial expressions if the resident liked it or not. She did not remember talking to Resident #26 during the meal on 1/21/20. She stated it was important to tell the resident what she was doing so the resident was not scared and knew what they were being fed. She stated she should have talked to the resident and did not know why she did not. When interviewed on 1/24/20 at 1:04 PM, LPN Unit Manager #1 stated she expected staff to interact with the residents when feeding them and tell them what food was being fed. 10NYCRR 415.5 (a)

Based on observation, record review and interview during the recertification survey, the facility did not determine self-administration of medications was clinically appropriate for 1 of 2 residents (Resident #87) reviewed for self-administration of medications. Specifically, nursing left medications for Resident #87 to self-administer without documentation the resident was assessed as safe to self-administer medications. Findings include: The facility policy Administering Oral Medications revised 3/2019 documented the procedure was to prepare the correct dose of medication, allow the resident to swallow the medications at a comfortable pace, and remain with the resident until all medications have been taken. The policy did not address self-administration of medications. Resident #87 had diagnoses including cerebral infarction (stroke) and anxiety. The 12/7/19 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required extensive assistance with personal hygiene and had functional impairment of one arm. The 11/21/19 physician order documented Tylenol 500 milligrams (mg) 2 tablets every 8 hours as needed for pain. The 1/2020 monthly physician orders did not document the resident could self-administer medications. The 1/22/20 at 8:20 PM nursing progress note documented the resident refused all medications after 3 attempts, told the nurse to get out of the room and to leave the resident alone. The 1/22/20 MAR documented the resident refused all evening medications and did not receive Tylenol that night. During an observation on 1/23/20 at 8:55 AM, Resident #87 was sitting on the bed and there were 2 round white pills in a medicine cup on the nightstand. The resident stated the pills were Tylenol and was not sure why they were left there. When interviewed on 1/23/20 at 9:00 AM, licensed practical nurse (LPN) #10 stated she had not been in the resident's room that morning. She stated the pills may have been Tylenol, as the resident would ask for Tylenol and Benadryl at night to help with sleep. She stated the resident should not have pills left in the room as the resident had behavioral issues. The nurse administering the medications should ensure the resident took them prior to leaving the room. When interviewed on 1/23/20 at 9:47 AM, certified nurse aide (CNA) #19 stated the Tylenol was in the resident's room when she took the breakfast meal tray in that morning. When interviewed on 1/23/20 at 1:57 PM, LPN #20 stated the resident asked for and did not got Tylenol around 3:30 AM that morning, as LPN #20 became busy and forgot to bring it to the resident. He stated the resident would ask for Tylenol and Benadryl at times to help with sleep. He stated he relieved registered nurse (RN) Supervisor #21 at 11:00 PM that night. On 1/24/20 at 12:20 PM, RN Unit Manager #22 stated the resident did not have an order to self-administer medications, and there should not be any medication left in a room unattended. Staff should sign for medication once the resident took the medication. She stated there were residents on the unit that wandered into other's rooms and there was potential another resident could take the pills if they were left unattended in a room. 10NYCRR 415.3(e)(1)(vi)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, the facility did not ensure that based on the comprehensive assessment residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 3 residents (Residents #26 and 113) reviewed for positioning and mobility. Specifically, Residents #26 and 113 were not assessed for positioning devices, did not have a plan of care to address positioning and the residents were observed poorly positioned without interventions in place. Findings include: The 3/2019 facility policy Care Plans-Comprehensive, Person Centered documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The 3/2019 facility policy Repositioning documented residents will be evaluated for the ability to reposition independently on admission, quarterly, after a change in condition and as indicated by resident's presentation. The interdisciplinary team will evaluate to determine if a positioning device is needed to maintain independent positioning. Residents who sit or recline in a chair with the back of the chair (or the back of the bed) elevated to or above a 30-degree angle should be evaluated for more frequent position schedule needs and the need for positioning devices/aides to maintain postural alignment. 1) Resident #26 was admitted with diagnoses including Huntington's disease (progressive neurological disease), adult failure to thrive and stroke. The 10/17/19 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, was totally dependent on one or two staff for activities of daily living (ADLs) and had impairments to both upper and lower extremities. The updated comprehensive care plan (CCP) initiated 7/19/13 documented the resident had Huntington's disease and was at risk for involuntary movement. Interventions included to monitor environment for possible padding of side rails and special chair if involuntary movements place resident at risk for injury, and notify physician if movements increase. The care plan did not document any specific interventions related to positioning or positioning devices. The 7/6/17 occupational therapy (OT) progress note documented the resident was to wear a left palm protector, or a rolled up washcloth until the ordered palm protector arrived, 24 hours per day 7 days a week excluding morning (AM) and evening (PM) care, was recommended heel protectors excluding AM/PM care depending on the resident's tolerance, and a pillow behind her knees at night time. There was no documentation of the resident's requirements for positioning and body alignment. The undated [NAME] (care instructions) documented the resident did not ambulate and used a geri-lounger (a mobile reclining positional chair) with one assist for mobility on the unit. There were no instructions for positioning or devices to maintain the resident's positioning. The 1/8/20 ADL Block Sheet (care instructions) documented the resident used a geri-lounger, was non-ambulatory, and used a left-hand palm splint at all times. During an observation on 1/21/20 at 12:37 PM, the resident was served lunch seated in a geri-lounger in the dining area. There was a gray pad on the foot rest under the resident's feet that covered the chair straps. The pad fell off the foot rest onto the floor from the involuntary movements of the resident's feet. The resident's hands were contracted. There were no palm guards or rolled washcloths in either hand. On 1/21/20 at 2:07 PM, the resident was observed in bed sleeping without palm guards or rolled washcloths in either hand. On 1/22/20 at 3:58 PM, the resident was observed in a geri-lounger in the common area with a gray pad on the foot rests. The resident's head rested on a small pillow placed on the right side of the upper part of the chair. There were no palm guards or rolled washcloths in the resident's hands. At 4:09 PM, the resident's significant other was observed placing a rolled wash cloth in the palm of the resident's left hand. On 1/23/20 at 12:13 PM, the resident was observed in a geri-lounger in the common area as meal trays were being delivered. The resident slumped to the right and there was no gray pad on the foot support. The resident's right foot hung off the foot support, and the toes of the left foot were in between the foot support straps. When interviewed on 1/23/20 at 2:04 PM, CNA #27 stated Resident #26 was hard to position and did not think there was anything in the care plan. The resident had a blue pad in the geri-lounger, she did not think it was for positioning but for pressure, and the block sheet just said the resident was to be in a geri-lounger. She had never discussed the resident's positioning with her nurse manager or therapy. On 1/24/20 at 7:43 AM, the resident was observed in a geri-lounger in the common area with no rolled washcloths in the palms, and no gray pad on the foot rest area. The top of the resident's left foot and toes were in between two of the spaces in the foot rest straps. When interviewed on 1/24/20 at 10:11 AM, CNA #26 stated if she did not know the resident, the care required was documented on the block sheet, or she asked the staff on that floor. She believed the resident was in the geri-lounger because of trouble sitting up. Therapy could evaluate the resident, but she had not mentioned anything to therapy. She stated the resident had a green neck pillow for positioning, but she did not know about anything else. The resident had a pad on the chair foot rest that either went on the footrest or by the ankles to prevent the resident's skin from breaking down. When interviewed on 1/24/20 at 11:36 AM, OT #29 stated both OT and physical therapy (PT) worked as a team to evaluate positioning for residents. She was not familiar with Resident #26 and she stated every resident was screened at least quarterly. She reviewed the resident's therapy and stated the resident was last seen in 2017. At that time a left palm protector was ordered, and a rolled wash cloth was to be used until the palm guard came in. If the resident was not wearing the device staff should have let therapy know. When interviewed on 1/24/20 at 12:00 PM, the Director of Therapy stated Resident #26 was on therapy's list to have a quarterly evaluation completed. No one had come to her for positioning advice for the resident. She accompanied the surveyor to Unit 1 where Resident #26 was sitting in the geri-lounger with both feet between the straps on the footrest of the chair. There was no gray pad in place. The gray pad was observed in the resident's room tucked beside the nightstand. The label on the pad documented the pad was a side rail pad. The Director stated there were different pads for footrests, but they were not used unless a resident's feet were getting caught in between the foot rest straps. When interviewed on 1/24/20 at 1:04 PM, LPN Unit Manager #1 stated Resident #26 had no specific positioning devices at that time. Staff referred to the CNA tasks in the electronic health record to determine if a resident needed a positioning device. If a resident required anything new, therapy notified her, and she tried to keep the documentation current. She was not aware that Resident #26 was to use a palm guard or any positioning devices. She expected staff would come to her with any positioning concerns so the resident could be evaluated by therapy. 2) Resident #113 was admitted to the facility with diagnoses including stroke with hemiplegia (inability to move one side of the body) and dementia. The 12/23/19 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition and was totally dependent on staff for most activities of daily living (ADLs). The 3/13/19 comprehensive care plan (CCP) documented the resident required assistance with ADLs. There were no documented interventions for the resident's positioning. The 3/14/19 physical therapy (PT) evaluation and plan of treatment note documented the resident had deficits in strength, balance, functional activity tolerance, safety, and range of motion which limited the ability to maximally participate in repositioning skills and functional mobility. The 4/5/19 occupational therapy (OT) discharge summary documented the resident was hesitant to allow for passive range of motion and left palm protector application. There was no other recent documentation the resident was assessed for positioning or further evaluation of the left palm protector. The 4/13/19 PT progress report and updated therapy plan documented the resident required maximum assistance for any repositioning in the geri-lounger (a mobile reclining positional chair). There was no documentation the resident was assessed for positioning. The 1/8/20 ADL block sheet documented the resident used a geri-lounger, was non-ambulatory and used a Hoyer (mechanical) lift for transfers. There were no documented positioning interventions. The [NAME] (care instructions) active on 1/24/20 documented the resident was totally dependent for most ADLs and utilized a geri-lounger chair. There were no documented positioning interventions. On 1/21/20 at 10:34 AM, the resident was observed in the hall seated in a geri-lounger. There was no support for the resident's neck, the left hand was contracted, and the resident held it on the abdomen with the right hand. The rest of the left arm dangled to the side with no support under it. When interviewed, the resident stated they had a stroke, and the left hand and arm were painful. Staff were supposed to roll up sheets and put them under the arm, but they had not done so. It helped the arm not hurt as much. On 1/22/20 at 8:54 AM and 1/23/20 at 8:18 AM and 12:00 PM, the resident was observed in the common area in the hall. The resident's geri-lounger was in a reclined position. There were no rolled sheets or supports under the left arm or behind the resident's head. When interviewed on 1/23/20 at 2:04 PM, CNA #27 stated staff used pillows to position the resident in the geri-lounger; usually one behind the head, one on each side, and one under the legs. CNA #25 started using the pillows because the resident always looked so uncomfortable. She stated if staff had any positioning concerns, they would have to tell therapy to look at someone or tell the nurse manager and then it would be on the resident's care plan if therapy ordered anything. When interviewed on 1/24/20 at 11:36 AM, OT #29 stated both OT and PT worked as a team to determine positioning for residents in wheelchairs. She was not aware anyone had reached out to therapy for positioning needs for Resident #113. She reviewed the therapy documentation and stated Resident #113 had never had any positioning recommendations. When interviewed on 1/24/20 at 12:00 PM, Director of Therapy #28 stated no one had come to her for positioning advice for the resident. She accompanied the surveyor to Unit 1. Resident #113 was observed in bed. The resident stated the pillows made a big difference in the pain in the left arm. At 12:18 PM, CNA #25 spoke with the surveyor and the Director of Therapy and stated she bought the pillows for the resident to use but the pillows had come up missing that week. A flimsy blanket was all they had to position the resident. She never said anything to therapy about the resident because they were related, but if she had positioning concerns for other residents, she told the nurse. When interviewed on 1/24/20 at 1:04 PM, LPN Unit Manager #1 stated no one had come to her regarding Resident #113. She was unaware the resident had pain and needed support for the left arm. She knew the extra pillows were missing and Social Services was supposed to replace them. It probably should have prompted her to get therapy involved but it did not. 10NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey the facility did not ensure a resident who displays or is diagnosed with dementia, receives the appropriate services to maintain their highest practicable mental and psychosocial well-being for 1 of 3 residents (Resident #93) reviewed for dementia care. Specifically, Resident #93 did not have individualized interventions in place to guide direct care staff in managing behavioral symptoms. Findings include: The 3/19 Care Plans, Comprehensive Person-Centered facility policy documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional need is developed and implemented for each resident. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. Care plan interventions are chosen after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Resident #93 had a diagnosis including dementia without behavioral disturbance. The 1/8/20 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, did not exhibit behavioral symptoms; required extensive assistance to total dependence on staff for most activities of daily living (ADLs); and received anti-psychotic(s) and anti-depressant(s) daily. The 10/18/19 comprehensive care plan (CCP) documented the resident was unable to choose her activity of interests and benefited from staff assistance. Staff were to provide appropriate cognitive sensory activities related to known interests provided by the family including music, outdoors, and being read to. Staff were to provide personal 1:1 bed side visits. Nursing progress notes documented on 10/22/19 the resident screamed most of the shift. There was no documentation of interventions attempted. A 10/24/19 nurse practitioner (NP) progress note documented the resident was being seen related to ongoing issues with anxiety and agitation as it related to her dementia. Nursing and certified nurse aide (CNA) notes were reviewed. The resident was already on medications to treat her anxiety and agitation and he recommended to continue with plan of care. He noted to his understanding that the resident had fluctuating behavior with no apparent underlying metabolic cause. A 10/30/19 physician progress note documented the resident was intermittently yelling out and that was baseline. A 12/10/19 NP progress note documented that the resident often screamed at staff during care, such as toileting, with the nurse reporting the resident was difficult to redirect at times. It was not recommended to change medications at that time. A 1/6/20 NP progress note documented the resident had some frequent periods of yelling out however, there was no source or reason. Staff were to continue supportive services. The CCP was revised on 1/7/20 and documented the resident's family member notified the facility the resident exhibited behavioral symptoms prior to being admitted to the facility including climbing out of bed and scooting on their buttocks. Staff were to assess for changes from baseline if the resident scooted on buttocks, report abnormalities to provider, distract with activities of interest, and document all behavioral symptoms. The CNA care instructions, active on 1/24/20, had no documentation the resident exhibited behavioral symptoms or what interventions to attempt if they did. During an observation on 1/23/20 at 8:17 AM, the resident was observed sitting at the dining room table moaning and clutching the edge of the table. Staff did not attempt to soothe or quiet the resident and continued to deliver meal trays to the other residents around the table. During an observation on 1/23/20 at 10:26 AM, the resident sat at the dining table calmly and was dozing. The resident was observed in the chair since the breakfast meal. -At 10:47 AM, the resident began calling out, moaning, and calling Mommy, Mommy. There were multiple residents in the area. Staff did not approach the resident, an activities aide sat behind facing another resident, and licensed practical nurse (LPN) #1 walked by. -At 10:49 AM, an unidentified CNA approached the resident and asked what they were doing. The CNA stood by the resident briefly then left and stood by the desk. The resident continued to moan and cry out. -At 10:50 AM, a female resident who sat at the end of the table yelled at the resident to Stop it! The resident continued to moan and cry. -At 10:51 AM, the unidentified CNA sat next to the resident and patted them on the back. The female resident at the end of the table yelled That's enough I said! The CNA said nothing, continued to sit next to the resident, and the moaning escalated. - At 10:54 AM, the female at the end of the table yelled Shut up! again. The CNA got up and walked toward that resident saying No then went behind the desk and drank out of her drink while standing in the doorway of the employee coat area. -At 10:57 AM, the resident was quiet and remained at the table with their head on the table. -At 11:00 AM, the resident began moaning again; there were no staff in the area. The moaning escalated. -At 11:01 AM, the female resident at the end of the table yelled, Oh shut up! at the resident. CNA #27 approached the resident and sat next to them. -At 11:03 AM, CNA #27 offered and fed the resident pudding. The resident ate bites. -At 11:11 AM, the resident finished the snack and began moaning and crying again. Three staff stood at the desk and did not approach the resident. -At 11:13 AM, CNA #27 sat by the resident and talked with them. -At 11:14 AM, The female resident at the end of the table told Resident #93 to shut up again. CNA #27 offered Resident #93 more bites of food. -At 11:21 AM, Resident #93 continued yelling and the female resident at the end of the table repeatedly told the resident to shut up. -At 11:27 AM, CNA #27 assisted the resident to stand and walk in the hall. They returned to the dining area, the resident's head rested against the CNA and then returned to the chair. -At 11:59 AM, the resident was quiet, made several attempts to stand from the chair but was unable. Staff were delivering lunch trays and did not intervene. When interviewed on 1/23/20 at 1:43 PM, CNA #25 stated she received training for dementia from the Assistant Director of Nursing (ADON). She stated the training covered what to do if a resident resisted care. She stated she just tried to re-approach the resident later if they resisted and if moaning was not a resident's usual behavior, she would tell the nurse. She stated she took care of Resident #93 at times, and the resident liked to holler. The resident liked to walk, she would try to walk the resident, and sometimes that helped. The resident would tire when walked, then napped and woke up calmer. She stated there was nothing written for interventions if the resident was yelling. The resident's spouse told the staff the resident yelled when needing to go to the bathroom and if that did not work, to walk or feed the resident. When interviewed on 1/23/20 at 2:04 PM, CNA #27 stated she had received an in-service a while ago for dementia care. The training explained what dementia was, not the care. She stated the [NAME] (care instructions) or the block sheets (care instructions) told what care the residents needed. She stated she knew which residents were going to disturb the other residents, so she sat with them, offered them something to eat, or took them for a walk. She stated Resident #93 yelled a lot and might quiet if laid in bed. She preferred to not put the resident in bed, so the resident did not end up on the floor. She stated she gave the resident pudding, walked the resident, and the resident calmed down after that. She stated she sat with the resident for a while at times holding the resident's hands but that did not work most of the time. When interviewed on 1/24/20 at 1:25 PM, LPN Unit Manager #1 stated the registered nurse who admitted a resident created the care plan and she could update it. She did not know if the resident had any interventions in their care plan for the dementia or the behaviors. She stated the resident's spouse said the resident moaned and yelled when having to go to the bathroom. Sometimes she gave the resident Tylenol which helped. She stated staff could not ask the resident what the resident preferred, so she would reach out to the resident's spouse to determine what might work. She stated the resident's care plan need more personalization. When interviewed on 1/24/20 at 2:14 PM, social worker #23 stated nursing was responsible for creating a dementia type plan of care, but any staff could update the care plan. Interventions were developed when the resident or their family told them things the resident liked. Staff also observed tried interventions and those could be added to the care plans. She was familiar with Resident #93 and stated walking or giving the resident a snack helped the yelling, but she did not think the resident could follow instructions. She noticed the resident did better if kept occupied. 10NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey, 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 for 2 of 2 residents (Residents #66 and 92) reviewed for infection control. Specifically, Resident #92's intravenous (IV) access did not have a cap placed on the port (end where IV tubing is connected) and staff were observed touching the end with bare hands. During a treatment Resident #66 did not have a barrier placed between bare feet and the floor and clean supplies and a soiled dressing were placed on the resident's bed. Findings include: The 3/2019 Administration Set/Tubing Changes facility policy documented all intravenous equipment shall be managed using aseptic technique and observing standard precautions. All equipment should be of needleless design, when connecting new tubing, and attach primed tubing to catheter access cap. The 3/19 Infection Control Professional policy documented it was the Infection Control Professional's responsibility to monitor infection control practices and employee compliance. 1) Resident #92 was admitted with diagnoses including dementia, chronic obstructive pulmonary disease (COPD, lung inflammation) and acute pneumonia. The 12/3/19 Minimum Data Set (MDS) assessment documented the resident was severely impaired cognitively and required extensive assistance of two staff for most activities of daily living (ADLs). The 12/5/19 updated comprehensive care plan (CCP) documented the resident had recent pneumonia and was receiving antibiotic therapy for an upper respiratory infection. The 1/21/20 physician order documented to give Levaquin (antibiotic) 500 milligrams (mg) daily for 7 days, and IV normal saline 100 milliliters per hour (ml/hr) for 24 hours for hydration. The 1/21/20 nursing progress note documented an IV was started on the resident's right forearm and normal saline was infused at 100 ml/hr. The 1/22/20 provider order documented to put IV fluids on hold and keep Heplock (portion of IV catheter in the vein unattached to tubing) in at this time. On 1/21/20 at 2:00 PM, the resident was observed napping in a wheelchair by the desk. The IV had been disconnected from the normal saline and tubing. The j-loop extension tubing (attached to the IV catheter that entered the resident's vein) was observed without an end cap. The end was open and unprotected. On 1/21/20 at 2:23 PM, licensed practical nurse (LPN) Unit Manager #1 was observed approaching the resident. She touched the uncapped end of the IV catheter with her bare hand and attempted to place it next to the resident's forearm. She asked LPN #2 to wrap it, stated she did not want to discontinue it, and it was being held in case they wanted the resident to get more fluids. LPN #2 took the resident to the resident's room. The resident returned and the right forearm was wrapped with gauze. When interviewed on 1/23/20 at 9:37 AM, LPN #2 stated she had wrapped the resident's IV in gauze but did not notice the end had no cap on it. She stated she thought LPN #1 discontinued the IV before she left yesterday, and she only wrapped the IV. She stated LPNs were not allowed to do any care concerning IVs, so she was not very familiar with them. She stated the resident would be at risk for infection with nothing on the end of the tubing and germs could possibly enter directly into the resident's vein. When interviewed on 1/24/20 at 12:55 PM, LPN Unit Manager #1 stated she had LPN #2 wrap the resident's forearm as they were not sure the IV was going to be discontinued. She did not remember touching the end of the IV, and she did not see that the access end cap was off. She stated she probably noticed the access cap was gone when she removed the resident's IV but did not think anything of it as it was being discontinued. She stated the IV was open into the resident's vein and the resident could have gotten an infection. During an interview on 1/24/20 at 12:42 PM, the Infection Control RN stated Resident #92's IV hub should be cleansed with alcohol prep and a new transparent film should be used to cover the hub. Resident #92's hub should not have been touched with bare hands and covered without being cleaned first. It was against infection control and best practice standards, and there were several potential issues for the resident and staff involved. 2.) Resident #66 was admitted to the facility with diagnoses including diabetes and stroke. The 11/16/19 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required extensive assistance with activities of daily living (ADLs), had one or more unhealed pressure ulcers and did not receive application of dressings to feet. The revised 3/2019 Dressing, Dry/ Clean Policy documented that clean equipment should be placed on a clean field. Tape a biohazard or plastic bag on the bedside stand or use a waste basket below the clean field. A 1/17/2020 specialty physician wound evaluation and management summary documented the resident had a fluid filled blister on the right toe and the plan was to apply skin prep daily. The 1/17/2020 physician order documented to cleanse the resident's 4th toe on the right foot with normal saline, apply skin prep (a protective film) and 2 x 2' s every day shift. The 1/2020 treatment administration record (TAR) documented to cleanse the resident's 4th toe on the right foot with normal saline, apply skin prep, and cover with a 2 x 2 every shift. During an observation of wound care to the right foot on 1/23/20 at 9:40 AM, licensed practical nurse (LPN) #13, walked into the resident's room with clean supplies and placed the supplies on the resident's bed with no barrier. The resident did not have a dressing on the right foot and the resident's bare feet were directly touching the floor with no barrier. After cleansing the wound, she placed the soiled dressings on top of the resident's bed linens with no barrier, trash bag or trash can present. During an interview on 1/23/20 at 9:51 AM with LPN #11, she stated that she forgotten to place a clean barrier under the supplies and under the resident's foot to keep the area clean and to prevent cross contamination. She stated that the expectation was to place clean barriers down to place supplies on and to place one under any extremity wound care was to be performed on. She stated that she should have placed soiled bandages in a biohazard bag or on a barrier to prevent any cross contamination. During an interview on 1/23/19 at 1:57 PM, registered nurse (RN) Unit Manager #13 stated that it was the facility policy that clean supplies were placed on a barrier. She stated the purpose of doing so was to prevent any cross contamination and to keep supplies and wounds clean. During an interview on 1/24/20 at 12:42 PM, the Infection Control RN stated the nurses had been educated and had undergone competencies for wound treatments. There should be a barrier between the resident and the environment, and the environment and the equipment. A receptacle for waste should be nearby to dispose of soiled items. If a barrier was not used it was against infection control and best practice standards, and there were several potential issues for the resident and staff involved. 10NYCRR 415.19(a)(1-3) Surveyor: Minnoe, [NAME]

Based on observation, record review and interview, the facility did not store drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 4 medication carts (Unit 2 front and Unit 4 back) and 2 of 2 medication rooms (Units 1 and 3) reviewed for medication storage and labeling. Specifically, multiple expired medications were observed stored in 2 medication carts and 2 medication rooms. Findings include: The 3/2019 Storage of Medications facility policy documented the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. During a medication storage observation of the Unit 2 front medication cart on 1/22/2020 at 1:48 PM with licensed practical nurse (LPN) #11 there was a bottle of Geri Lanta (antacid) that was open, had a handwritten open date of 12/3, and had a manufacturer's expiration date of 12/2019. The LPN stated it was expired and she usually checked expiration dates at the end of each shift. She stated the 11-7 shift nurse was responsible to check for expiration dates every night, and it was every nurse's responsibility to check expiration dates when administering a medication. She was not aware of any resident receiving the medication. On 1/22/20 at 2:03 PM, the Unit 3 medication room was inspected with licensed practical nurse (LPN) #6. In the refrigerator, three bottles of outdated pharmacy mixed liquid medications were identified: - One bottle containing lidocaine mouthwash suspension had a pharmacy use by date on the front label of 12/28/2019. A bright yellow sticker on the back of the bottle documented individual components and their manufacturer expiration dates of: lidocaine (local anesthetic) exp. 7/22; gerilante (antacid) exp. 0/20; and siladiol exp. 6/22. -One bottle containing liquid pantoprazole (treat acid reflux) 2 milligrams per milliliter (mg/ml). The pharmacy use by date on the front of the bottle read 1/17/20. The yellow sticker on the back documented individual components and their manufacturer expiration dates of: pantoprazole exp. 6/22; sodium bicarbonate exp. 8/21; and sterile water exp. 12/21. -One bottle of omeprazole 2 mg/ml suspension. The pharmacy use by date on the front of the bottle was 1/21/20. The yellow sticker on the back documented individual components and their manufacturer expirations dates of: omeprazole exp. 12/21; sodium bicarbonate exp. 10/22; Ora Sweet (sweetener) exp. 5/23; and sterile water exp. 12/6/21. LPN #6 stated she did not know which expiration date on the bottles was used, she had not given any of that medication and she was on this unit for the first time in 9 months. Registered nurse (RN) Unit Manager #7 entered the medication room and stated she used the dates on the yellow sticker on the back of the bottle, not the use by date on the front label to determine if a medication was expired. She stated she was the one who checked the refrigerator for expired medications. She stated she went by the sticker on the back of the bottle because it was bright and stood out. During a Unit 1 medication room refrigerator observation on 1/22/20 at 2:05 PM with LPN #2, the refrigerator contained 11 Tylenol 650 milligrams (mg) rectal suppositories with a manufacturer expiration date of 9/2019, 2 Tylenol 650 mg rectal suppositories with a manufacturer expiration date of 2/2019, and 5 Compro (to treat nausea and vomiting, anxiety, and schizophrenia) 25 mg rectal suppositories with a manufacturer expiration date of 9/2018. The LPN stated the Compro suppositories were expired for over a year, and the Tylenol suppositories were also expired. She stated the purpose of checking the expiration dates was to make sure a resident did not receive an expired medication as the medication would not have the desired effect or could have a negative effect on the resident. The LPN was not sure who was responsible to check the medication room refrigerator for expiration dates. When interviewed on 1/22/20 at 2:27 PM, LPN Unit Manager #1 stated every shift nurse should be checking the expiration dates of all the stock medications in the medication carts. The day shift medication nurse was to check the overstock medication dates in the medication room and the medication room refrigerator on a weekly basis. She stated there was no documentation of those checks, and there should not be expired medications in the medication carts, medication rooms, or medication refrigerators. She stated the expired medications should have been discarded, and she was not aware of any residents on the unit that received any of the suppositories. On 1/22/20 at 02:37 PM, the Unit 4 back hall medication cart was inspected with LPN #10. A half empty glass bottle of magnesium citrate (laxative) liquid was stored in the drawer with the floor stock liquid medications. The bottle's label did not have a manufacturer's expiration date, nor a date written on the bottle when the medication was opened. A second surveyor inspected the bottle and confirmed there were no expirations dates on the bottle. LPN #10 stated they check for expired meds once a week. The magnesium citrate was given to residents as needed and there were no residents with a current order to receive it. She stated normally the overnight staff checked the medication cart. She did not know where this was documented. Every nurse was supposed to check the medications before they were given and if there was no expiration date or the date was unreadable it was considered expired. When interviewed by telephone on 1/22/20 at 3:23 PM, pharmacist #8 stated the use by date written on the front of the bottle was the date the liquid medications expired. The expiration dates of the individual components of the mixtures were put on the bottle for compounding reasons, so they could trace back an individual ingredient if needed. Once opened and mixed, the medication ingredients were no longer sterile prompting a need for the use by date. When interviewed on 1/24/20 at 1:06 PM, the Director of Nursing (DON) stated each nurse assigned to a medication cart was to check the cart daily, the nurse managers and the nurses on each unit were to routinely check the medication room and refrigerator weekly for expired medications. There was no documentation of those checks. She expected each nurse manager to delegate which specific unit shift they were assigning to check the medication room and refrigerator. The RN Manager was ultimately responsible to make sure this was done. 10NYCRR 415.18(e)(1-4)