**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey conducted 11/13/2023-11/20/2023, the facility did not ensure they provided the appropriate liability and appeal notices to Medicare beneficiaries for 1 of 3 residents (Resident #353) reviewed. Specifically, Resident #353 was discharged from the facility to home and did not receive a Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (Centers for Medicare and Medicaid Services) for Medicare Part A as required. Findings include: The CMS form instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 documents a Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as plans) must deliver a completed copy of the NOMNC to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), a comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care was not being provided daily. Resident # 353 was admitted to the facility with diagnoses including chronic respiratory failure, non-Hodgkin's lymphoma (type of lymphatic cancer), and heart failure. The 8/15/2023 Minimum Data Set (MDS) assessment documented it was a discharge assessment-return not anticipated, Skilled Nursing Facility Prospective Payment System (SNF PPS) Part A discharge (end of stay) assessment. The start of the most recent Medicare stay was 7/24/2023 and the end of the most recent Medicare stay was 8/15/2023. The discharge status was not documented. The resident's admission Record documented the resident's child was the responsible party and emergency contact. The resident was discharged to home with home care services. The form CMS-20052 SNF Beneficiary Protection Notification Review for Resident #353 documented Medicare Part A skilled services start date was 7/24/2023 and the last covered day of Part A services was 9/28/2023. The facility initiated a planned discharge on [DATE] from Medicare Part A services when benefit days were not exhausted. A NOMNC form CMS-10123 was not provided to the resident and there was no documented explanation as to why the form was not provided. During an interview on 11/20/2023 at 11:18 AM registered nurse (RN) MDS Director stated they provided NOMNC CMS-10123 letters two days prior to the Medicare discharge date s. It was important to receive the letters so the resident could decide if they wanted to appeal. The form was sent via certified mail and then would be uploaded into the electronic charting system. They stated they were unaware the form was needed for Resident #353 when they were discharged home, and the resident was not provided with the form. 10NYCRR 415.3(g)(2)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00326492) conducted 11/13/2023- 11/20/2023, the facility did not ensure the implementation and development of person-centered comprehensive care plans (CCP) to meet residents' medical, nursing, and mental and psychosocial needs for 4 of 5 residents reviewed (Residents #91, #116, #141, and #216). Specifically, Residents #91's and #216's CCP did not include isolation precautions; Resident #116 did not receive ordered treatments or consume meals in the dining room as care planned; and Resident #141's low air loss mattress (used for pressure reduction) settings were not implemented as planned. Findings include: The facility policy Baseline Care Plan revised 12/23/2021, documented the care plan included physician orders, dietary orders, and infections. Direct care staff were educated about care plan interventions, services, and treatments to be administered by the facility and personnel acting on behalf of the facility. The facility policy Comprehensive Care Plans revised 10/17/2022, documented the facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that were identified in a comprehensive assessment. The comprehensive care plan should be reviewed and revised based on changing goals, preferences, needs of the resident, in response to current interventions by the Interdisciplinary Team (IDT) after each assessment, and inclusive of the comprehensive and quarterly review assessments. The care plan should describe services that are furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being. 1) Resident # 91 was admitted to the facility with diagnoses including obstructive and reflux uropathy (urine obstruction and backflow). The 9/7/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance of 1 for bed mobility, extensive assistance of 2 for transfers and toileting, and had an indwelling catheter (a tube used to drain urine into a collection bag), and did not have any multidrug-resistant organisms (MDRO). The CCP initiated 2/10/2023 documented the resident had occasional bladder incontinence. The CCP did not include the presence of MRSA (methicillin-resistant Staphylococcus aureus, a bacteria resistant to many antibiotics) in the resident's urine. There was no documented evidence the resident was planned for contact precautions. The undated resident care instructions ([NAME]) did not include isolation precautions. The 7/20/2023 nurse practitioner (NP) #30 progress note documented the resident had MRSA in the urine. There were no documented physician orders for contact precautions from 7/20/2023-11/17/2023. During an observation interview on 11/13/2023 at 10:46 AM, Resident #91 had a contact precaution sign on the door frame of their room and a plastic cart containing personal protective equipment (PPE) outside the room. Certified nurse aide (CNA) # 27 stated the resident was on isolation for MRSA in their urine. The contact precaution sign on the door frame and a plastic cart with PPE remained outside the resident's from 11/13/2023-11/17/2023. During an interview 11/17/23 at 11:36 AM registered nurse (RN) Unit Manager #29 stated they were responsible for creating care plans. They stated that if a resident was on transmission based precautions it should be on the care plan. Precautions should be triggered to show on the [NAME] (care instructions), and CNAs were expected to review the [NAME] at the beginning of each shift. If precautions were not listed on the [NAME] the CNAs would not know the resident was on precautions. They stated it was important for staff to know about transmission based precautions to prevent the spread of infection. They stated Resident #91 was on precautions and they did not put it on their care plan. 2) Resident # 116 was admitted to the facility with diagnoses diabetes mellitus, peripheral vascular disease (PVD, poor circulation), and right below the knee amputation (BKA). The 8/14/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance of 1 for bed mobility, transfers, dressing, eating, and toileting, and received application of non-surgical dressings and application of ointments/medications. The comprehensive care plan (CCP) initiated 10/29/2020 and revised 11/7/2023 documented the resident was to have meals in the dining room for close observation and encouragement. Resident #116's care instructions ([NAME]) as of 10/1/2023 documented the resident would have meals in the dining room for close observation and encouragement. The 11/2023 treatment administration record (TAR) documented apply ACE wrap to left lower extremity (LLE) to above knee every morning for preventative skin care. Apply tubigrip (elastic covering) to LLE in the morning (9:00 AM) related to edema and remove per schedule (8:59 PM). There were no corresponding physician orders for ACE wraps or tubigrips. There was no documented evidence the application of ACE wraps or tubigrips was included in the resident's CCP. Resident #116 was observed: - on 11/14/2023 at 9:49 AM, in the hallway, wearing a hospital gown with their left leg exposed without an ACE wrap or tubigrip. - on 11/14/2023 at 10:49 AM wearing a hospital gown in their room with their left leg exposed without an ACE wrap or tubigrip. - on 11/14/2023 at 12:24 PM, sitting in a wheelchair in their room in front of a bedside table that had their lunch tray. - on 11/15/2023 at 9:15 AM, sitting in bed wearing a hospital gown with their left leg exposed without an ACE wrap or tubigrip. Their breakfast tray was on the bedside table. - on 11/15/2023 at 1:00 PM in their room sitting in a wheelchair with their lunch tray on their bedside table. - on 11/16/2023 at 8:34 AM, sitting in their wheelchair. Their left foot had a non-skid sock without an ACE wrap or tubigrip. At 9:04 AM eating breakfast in their room. The resident stated they always ate meals in their room. Their left leg did not have an ACE wrap or tubigrip in place. - on 11/16/2023 at 11:33 AM sitting in their wheelchair without an ACE wrap or tubigrip on. - on 11/16/2023 at 12:50 PM sitting in a wheelchair in their room eating lunch. Their left leg did not have an ACE wrap or tubigrip. - on 11/16/2023 at 2:18 PM and 3:06 PM sitting in their wheelchair without an ACE wrap or tubigrip on their left leg. The 11/2023 medication administration record (MAR) documented OOB (out of bed) to dining room for all meals, three times a day for monitoring/supervision. The MAR documented the task was completed: - on 11/14/2023 at 1:00 PM by LPN #48 - on 11/15/2023 at 8:00 AM and 1:00 PM by LPN #56 - on 11/16/2023 at 8:00 AM by LPN Staff Educator #28 and at 1:00 PM by LPN #21. The 11/2023 TAR documented ACE wraps and tubigrips were applied to the resident's LLE at 9:00 AM: - on 11/14/2023 at 9:00 AM by LPN #48. - on 11/15/2023 at 9:00 AM by LPN #56. - on 11/16/2023 at 9:00 AM by LPN Staff Educator #28. During an interview on 11/16/2023 at 2:24 PM, certified nurse aide (CNA) # 25 stated supervision with meals meant a resident was watched while they ate to help them or for choking precautions and that information would be on their [NAME]. They stated they reviewed the [NAME] at the beginning of the shift but did not see that the Resident # 116 was supposed to eat in the dining room. They stated if a resident was supposed to have meals in the dining room, they should not be eating in their room. During an interview on 11/16/2023 at 2:30 PM, LPN Staff Educator #28 stated if the resident was care planned for supervision while eating, they should eat in the dining area. CNAs were expected to check the [NAME] every shift and follow it. They stated they did not know what a tubigrip was but it, as well as an ACE wrap, would be documented on the TAR. They stated if they signed it off on the TAR it meant the ACE wrap and tubigrip were in place. They stated they completed and signed off this task at approximately 1:45 PM that day. During an interview on 11/17/23 at 11:21 AM, RN # 29 stated that Resident # 116 was supposed to be supervised with meals and they expected the resident to eat in the dining room. They stated they had not seen the resident eat in the dining room for any meals from 11/13/2023 to 11/17/2023. They expected staff to know what a tubigrip was and if it was signed off on the TAR as completed, the tubigrips should be in place. They expected staff to follow medical orders and sign orders for treatments at the time they were completed. 3)Resident #141 was admitted to the facility with diagnoses including peripheral vascular disease (PVD, poor circulation), dementia, and muscle weakness. The 10/20/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, was dependent for rolling from back to sides, was not transferred from bed to chair due to medical condition, was at risk for the development of pressure injury, did not have pressure injury, and had a pressure reducing device for the bed. The care instructions ([NAME]) initiated 12/11/2021 documented monitor bed, pressure relieving surface low air loss mattress set at 120-130 pounds every day. An 8/29/2023 nurse practitioner (NP) #32 progress note documented the resident was resistant to turning and positioning and insisted on lying flat in their bed. Nursing reported the resident's back had a red, inflamed rash. The resident's back from shoulder blades to lumbar area above the hips was deep red in color. The plan included the resident was placed on a turning and positioning schedule and they would order a low loss air mattress. An 8/29/2023 NP #32 medical order documented low air loss mattress (used to distribute body weight over a broad surface to prevent skin breakdown), set at [120-130] pounds every shift for pressure relief, check setting. The CCP initiated 9/24/2021 and revised 8/8/2023 documented the resident had potential impairment to skin integrity. Interventions did not include a low air loss mattress. The resident had an order for no weights. The resident was observed lying in bed with their alternating air mattress set at a static normal pressure of 200 pounds: - on 11/14/2023 at 10:47 AM; - on 11/15/2023 at 8:35 AM; - on 11/16/2023 at 9:34 AM and 11:21 AM; and - on 11/17/2023 at 9:33 AM. The 11/2023 treatment administration record (TAR) documented low air loss mattress, set at [120-130] pounds every shift for pressure relief, check setting on days, evenings, and nights. The TAR documented the mattress was checked: - on 11/14/2023 days and evenings by licensed practical nurse (LPN) #57 and nights by LPN #58 - on 11/15/2023 days and evenings by LPN #21 and nights by LPN #59 - on 11/16/2023 days by an unidentified nurse, evenings by LPN #59, and nights by LPN #58. - on 11/17/2023 days by LPN #21. During an interview on 11/16/23 10:46 AM certified nurse aide (CNA) #20 stated residents at risk for pressure could get skin breakdown and an intervention to prevent skin breakdown was an alternating air mattress. They stated CNAs did not check the mattress settings, they just checked to see if the mattress was turned on. They stated if the mattress was not on, they would report it to the LPN because if the mattress was not set correctly the resident could get pressure sores. During an interview on 11/17/2023 at 9:37 AM LPN #21 stated nurses checked the bed every shift and documented it on the TAR. They stated they checked the order this morning and thought the order was for the pressure to be set at 160-165. They stated they were sure the mattress was at the correct settings. If the mattress was set too low, there would not be enough air and could cause skin breakdown. If the setting was too high, it would be too firm and could cause skin breakdown. LPN #21 reviewed the TAR and stated the order was for 120-130 and looked at the bed setting and stated it was set at 200 which was too high and not the ordered setting. During an interview on 11/17/23 at 2:46 PM LPN #24 stated the purpose of an air mattress was to prevent skin breakdown. Settings were ordered according to the residents' weight and if the setting was set below the ordered setting it would be too soft and the resident's body could hit the metal of the bed causing skin breakdown. They stated If the setting was set higher than ordered it could be too hard causing more pressure and could lead to skin breakdown. LPN #24 stated staff knew the settings because they were documented in the care plan, and both CNAs and LPNs checked the air mattresses. During an interview on 11/20/2023 at 11:01 AM NP #32 stated they ordered low air loss mattresses to prevent skin breakdown for residents that were immobile or spent time in bed. They determined the settings by the weight of the resident. If the setting was too low, it would not have enough inflation and would not benefit the resident. If the setting was set too high, it would be too much pressure and not provide pressure relief. They stated they would not expect the setting to be at 200 if it was ordered to be 120-130. During an interview on 11/20/23 at 2:15 PM the DON stated the purpose of a low air mattress was to alternate pressure for wound healing and wound prevention. If it was set too high or too low, it would not relieve the pressure and the resident could develop pressure ulcers. NY10CRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00312845, NY00317835, NY00321300, NY00321978, NY00326461, NY00326492, NY00326914, and NY00327307) conducted 11/13/2023-11/20/2023, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming, personal hygiene, and oral hygiene for 5 of 7 residents (Residents #36, #100, #120, #141, and #183) reviewed. Specifically, Residents # 36 and #100 were not assisted with oral hygiene; Resident #120 did not receive fingernail hygiene; Resident #141 was not provided with a shower, oral hygiene, and fingernail care; and Resident #183 was not assisted with removal of facial hair. Findings include: The facility policy Denture Management revised 5/22/2017, documented residents with dentures were assessed and dentures were cleaned and stored to maintain integrity of the dentures. There was no documented policy on the provision of oral hygiene. The facility policy Grooming Fingernails revised 8/12/2008, documented residents' nails were to be kept clean and neat to support self-esteem and dignity. Nails were to be assessed weekly on their shower day by certified nurse aides (CNAs) and refusal of care was to be reported to the Team Leader or Charge Nurse. The facility policy Meeting Resident Needs revised 3/13/2019, documented CNAs would identify any unmet resident needs and address them (positioning, toileting, personal care needs) and anticipate upcoming resident needs and address them proactively. 1) Resident #141 was admitted to the facility with diagnoses including benign neoplasm meninges (tumors in the brain and spinal cord), muscle weakness, and was receiving palliative care (optimizes quality of life with a serious illness). The 10/20/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required supervision and set up with eating, and extensive assistance of one for bathing, dressing, and personal hygiene. The comprehensive care plan (CCP) updated 10/20/2023 documented the resident had an ADL deficit related to rhabdomyolysis (a breakdown of muscle tissue). The resident was dependent for eating, hygiene, and oral hygiene. The undated care instructions ([NAME]) documented the resident required assistance of two for transferring and showering and was dependent for oral and personal hygiene. The resident was to receive a shower weekly on Monday evenings and as needed. The [NAME] documented showering was resolved/cancelled on 10/13/2023. During an observation and interview on 11/13/2023 at 10:17 AM, the resident had long fingernails on both hands. The resident stated they had not received a shower or had their teeth brushed in a long time. They stated they would like their teeth brushed, their nails clipped, and a shower. They had asked staff and a doctor had come to clip their toenails, but no one would clip their fingernails. During an observation and interview on 11/14/2023 at 10:47 AM, the resident had long fingernails on both hands. The resident stated they asked for their fingernails to be cut many times, but they were not cut. They stated they had asked for a shower and to have their teeth brushed for months. They stated they cleaned their teeth with straws. The resident stated they did not receive a shower on 11/13/23 (Monday) but would have taken one if it was offered. During an observation on 11/15/2023 at 8:35 AM, the resident had long fingernails on both hands. Several straws were observed on the floor next to their bed. During an interview on 11/15/2023 at 12:30 PM licensed practical nurse (LPN) #21, stated CNAs were responsible for completing residents' personal hygiene needs. They stated if a resident refused care the CNA should tell the LPN who would report it to the Unit Manager. LPN #21 stated they observed Resident #141 putting straws in their teeth. They stated hygiene needs could not be met because they were short staffed and having 1 or 2 CNAs to care for 20 residents was not acceptable. They stated getting a shower was important and it made residents feel better and not feel depressed. They stated showers also helped keep the resident's peri area clean and decreased the potential for a urinary tract infection. They stated clean and short fingernails would help to limit infection. They stated oral care was necessary to prevent cavities, tooth loss, and infection. During an observation and interview on 11/16/2023 at 9:34 AM, the resident had long fingernails on both hands. The resident stated they still had not had a shower, had their teeth brushed, or their fingernails clipped. At 11:21 AM, the resident was cleaning their teeth with a straw, had stubble on their face and stated they would shave if they could reach the razor. They stated their fingernails were long and jagged and they would like them clipped. During an interview on 11/16/2023 at 11:28 AM CNA #18, stated that CNAs were responsible for hygiene needs which included shaving, clipping, and cleaning fingernails, unless the resident was a diabetic, assisting with oral hygiene care, and showering. CNA #18 stated they were usually assigned to Resident #141 and had never given them a shower as they were scheduled for evening showers. They had not provided oral care to the resident because the resident refused when asked, and they asked the nurse to care for the resident's fingernails last Friday. They stated they were supposed to tell the nurse when a resident refused care and they did not. If a resident did not get personal hygiene care they could get an infection, cavities, and have issues with mouth pain. The CNA reviewed the shower schedule and there were two schedules listed for the resident. One schedule documented a Monday shower during the day shift, and the other documented Tuesday on the day shift. CNA #18 stated they thought the resident was an evening shower which was why they had not given them a shower on their shower day. During an interview on 11/16/2023 at 1:53 PM, LPN #24 stated CNAs could not always do care because of staffing issues. They stated sometimes there were only 3 scheduled CNAs on the day shift, and they could not always complete showers, nailcare, or oral care. They stated the last shower for Resident #141 was documented on 11/3/2023 and it was documented yesterday that the resident was independent with brushing their teeth. LPN #24 stated the resident was not independent and they expected the resident to be assisted and set up. They stated if oral care was not provided, they could get gingivitis (gum disease), tooth loss, infection, cavities, pain, and may even be unable to chew foods. During an interview on 11/17/2023 at 9:33 AM, the resident stated they had never refused oral care, fingernail care, or a shower. During an observation and interview on 11/20/2023 at 9:40 AM, the resident was in bed cleaning their teeth with a straw. They stated they were only given their toothbrush one day last week and had to clean their teeth with a straw because they could not reach their toothbrush and toothpaste. They stated they were happy that it was Monday and their shower day. 2) Resident #183 was admitted to the facility with diagnoses including muscle weakness with a history of falling, high blood pressure, and kidney disease. The 10/13/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, did not reject care, required extensive assistance of one for most ADLs, and had functional limitation in range of motion for both arms. The comprehensive care plan (CCP) updated 10/3/2023 documented the resident required assistance with ADLs related to impaired balance. Interventions included set up assistance for eating, oral care, and personal hygiene; and substantial assistance of one for showering and lower body dressing. The undated care instructions ([NAME]) documented the resident required set up for oral care and personal hygiene and substantial assistance of 1 for showering. Resident # 183 was observed: - on 11/13/2023 at 11:09 AM, sitting in a chair in their room with a significant amount of light-colored hair on their lip and chin. - on 11/14/2023 at 11:00 AM and 11:15 AM, sitting in a chair in their room with a significant amount of light-colored hair on their lip and chin. - on 11/15/2023 at 8:28 AM sitting in a chair in their room with a significant amount of light-colored hair on their lip and chin. During an interview on 11/16/2023 at 10:46 AM, certified nurse aide (CNA) #20 stated that Resident #183 should be shaved if they would like because it was not dignified to have facial hair. They were assigned to the resident on Monday and today and provided care, however, they did not shave the resident because the resident did not ask. They stated they should have asked the resident if they wanted to be shaved. During an interview on 11/16/2023 at 1:53 PM, licensed practical nurse (LPN) Unit Manager #24 stated CNAs were responsible for assisting residents with care including shaving female residents for dignity reasons. They stated Resident #183 should be shaved and had been shaved previously. LPN Unit Manager #24 stated they observed Resident #183 with a significant amount of facial hair on their lip and chin hair between 11/13/2023 and 11/16/2023, and they requested a CNA shave the resident earlier that morning. They stated that care was often missed because they were short-staffed. 3) Resident #36 was admitted to the facility with diagnoses including diabetes, and below knee amputations of both legs, and dementia. The 8/29/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, did not reject care, required extensive assistance of one for dressing and personal hygiene, and was totally dependent on transferring with a mechanical lift. The comprehensive care plan (CCP) updated 8/29/2023 documented the resident had a self-care deficit related to amputations of the left leg above the knee and the right leg below the knee. Interventions included set up for eating, extensive assistance of one for grooming, and total assistance of 2 for dressing lower extremities, and a mechanical lift for transferring. The undated care instructions ([NAME]) documented the resident required extensive assistance of 2 for mobility and personal hygiene was to be provided every day and evening shift and as needed on the night shift. The resident required 2 staff for care due to accusatory behaviors. The 8/14/2023 dental consult documented a periodic oral exam was completed. The resident's dental hygiene was fair, and the recommendation was to assist the resident with oral care twice a day. During an observation and interview on 11/14/2023 at 8:59 AM, the resident had significant plaque on their teeth. They stated they did not receive assistance with brushing their teeth. During an observation and interview on 11/15/2023 at 10:06 AM, the resident had food between their lower teeth. They stated they would like to have their teeth brushed. During an interview on 11/16/2023 at 1:53 PM, licensed practical nurse (LPN) #24 stated CNAs could not always complete resident care because of staffing issues. They stated sometimes there were only 3 CNAs scheduled on the day shift so residents could not always get showers, nailcare, or oral care completed. If oral care was not provided it could lead to gingivitis, tooth loss, infection, cavities, pain, and even being unable to chew foods. They stated they expected all residents to be offered oral care and if they refused the CNA should notify the LPN so the resident could be reapproached. During an observation and interview on 11/17/2023 at 12:33 PM, the resident was in their room with food particles in their lower teeth. The resident stated they had not had their teeth brushed for as long as they could remember and would like them brushed. During an interview on 11/17/2023 at 12:55 PM, CNA #20 stated they completed care for Resident #36 in the morning. They stated they did not complete oral care for Resident #36 because the resident refused oral care. They did not tell the nurse and should have. Oral care was important to prevent cavities and problems with the mouth. They stated to complete oral care they needed a toothbrush and toothpaste, or a swab and mouthwash and supplies were kept in the room or bathroom. They stated they were not able to locate a toothbrush, toothpaste, mouthwash, or mouth swabs in the bathroom or in any of the drawers in the resident's room. During an interview on 11/17/2023 at 2:46 PM, LPN #24 stated they wanted to know when anyone refused care. They stated they would expect oral hygiene supplies to be in every resident's room for ease of performing oral care. During an interview on 11/20/23 at 11:01 AM, nurse practitioner (NP) #32 stated if a resident did not have oral care completed, they could get dental caries (cavities), thrush (yeast infection of the mouth), and may not want to eat which could cause weight loss. 10NYCRR 415.12(a)(3)

Based on observation, record review, and interviews during the recertification survey conducted 11/13/2023-11/20/2023, the facility did not ensure residents were provided an ongoing program to support their choice of activities, designed to meet their interests and support their physical, mental, and psychosocial well-being for 2 of 2 residents (Residents #53 and #190) reviewed. Specifically, Resident #53 was not provided preferred activity when their television was non-functional; and Resident #190 was not provided meaningful activities that met their interests and preferences. Findings include: The facility policy, Resident Rights, reviewed and revised 10/18/2022, documented the nursing facility was committed to protecting and supporting the rights for each resident including freedom of choice to make their own, independent decisions through support of resident choice, such as to choose activities and schedules, participation in organizations and activities of their choice, and right to reasonable accommodations of needs. The facility policy, Assessment, Provision, and Documentation of Activity, reviewed and revised 10/20/2022, documented that every effort would be made to promote residents' participation in preferred, meaningful activities, which included care plans that are individualize and structured per the resident's interest, and reflect adequate level of stimulation. The facility would ensure residents' preferences for activities were identified and current, participation in those activities were maximized, and necessary accommodations were in place to enhance the resident's participation. The undated facility activity calendar for November documented the following activities: -11/13/2023 at 2:30 PM, Team Scattergories in the Chapel Garden. -11/14/2023 at 10:45 AM, Catholic mass in the Chapel Garden; 2:00 PM-4:00 PM, Woofs from the Dogs of [local dog rescue] on the 2nd and 3rd floor lounge, and room to room. -11/15/2023 at 2:30 PM, Bingo in the Chapel Garden. -11/16/2023 at 10:45 AM, Protestant services in the Chapel Garden; 2:00 PM, Let's Get Physical Exercise Group in the Chapel Garden. -11/17/2023 at 2:30 PM, Music in the Chapel Garden. -11/18/2023 and 11/19/2023, 1:1 visits - Lounge & Room to Room. The undated 2nd floor activity calendar for November 2023 documented the only activity added for the 2nd floor residents was on 11/17/2023 at 10:45 AM, morning exercise in the lounge. No additional activities were documented for the 2nd floor residents between 11/13/2023-11/19/2023. 1)Resident #53 was admitted to the facility with diagnoses including macular degeneration (vision loss), hearing loss, and muscle weakness. The 6/27/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact; required extensive assistance of one for most activities of daily living (ADLs); had moderate difficulty hearing; had impaired vision; felt it was very important to listen to music they liked, to keep up with the news, and go outside to get fresh air when the weather was good; and it was somewhat important to do their favorite activities. The 6/20/2023 recreation assessment documented that Resident #53 had poor/hard of hearing, poor vision, and was independent, but needed help with set up. It was very important they had music they liked, they kept up with the news, and got to go outside. The resident was a loner, and the TV was all the activity material the resident needed. The comprehensive care plan (CCP) revised on 6/26/2023 documented the resident was alert and able to make decisions regarding their preferences of care. Interventions included adapting programs as needed to promote success, introduce to peers with similar interest, offer and invite resident to preferred activities of interest, provide leisure materials for independent leisure time, and visit one on one as needed. The CCP revision on 7/27/2023 documented the resident was independently capable of pursuing their own leisure. Interventions included checking in for any needs or supplies such as large print reading materials and large print word puzzles. The resident's leisure interests were watching TV and listening to music. The 8/30/2023 activity participation documented Resident #53 was alert and oriented, they rarely wheeled their chair, they were a very private person and was hesitant to reveal their interests. The resident had refused all recreation groups to date. They stayed in their room and watched TV and used their phone to contact family. The 11/7/2023 health status note documented that resident was moved to an alternative room. The facility census documented the resident was returned to their original room on 11/9/2023. The undated resident activity log for November documented there were 38 activity categories for residents. The activity log categories included games, movie, nail care, sensory stimulation, social, strolls, and religion. The November 2023 activity log documented Resident #53 was offered 2 communication visits on 11/7/2023 and 11/14/2023. During an interview on 11/13/2023 at 11:40 AM, Resident #53's family member stated the resident sat in their room all day. The resident was moved to an alternative room and since then they did not have a working television. They stated they used the remote to turn on the television, without success. The resident had a hearing amplifier that was used for one-on-one situations but not in group settings. They stated the resident liked books on tape if someone could set it up for them as the resident could not see if the lights were on or use the buttons. During observations on 11/13/2023 at 11:40 AM, 11/14/2023 at 10:35 AM, 11/15/2023 at 11:31 AM, and 11/16/2023 at 9:06 AM, Resident #53 was seated in a wheelchair in the center of their room with no activity materials and the television was off. During an interview on 11/15/2023 at 11:07 AM, certified nurse aide (CNA) #8 stated there was a monthly activities calendar and the activities were the same for the whole facility and were held downstairs. They did not know if the activities were adapted to the needs of the resident as they had never seen an activity occur. They had seen the other unit CNAs facilitate drawing and coloring one time in the last month. Resident #53 preferred to stay in their room. They were not sure if any activities were available that met Resident #53's needs and abilities. During an interview on 11/15/2023 at 11:31 AM, Resident #53 stated that when they went to the temporary room on 11/7/23 they were not able to bring the television with them. Upon returning to their original room on 11/9/2023 the remote was no longer working for their television and they could not use it. They stated they were without their television from 11/7/2023 to 11/14/2023. During an interview on 11/16/2023 at 10:45 AM, licensed practical nurse (LPN) #9 stated that there was a calendar of events posted and activities were centrally located downstairs. Tuesdays and Thursdays were church services, Wednesdays was bingo, and Fridays there was musical entertainment. The recreation staff would come to the unit and asked the residents if anyone wanted to attend the posted activity. If residents were at different ability levels there would be two different activities, versus adapting one for all residents. LPN #9 had not seen activities staff go into Resident #53's room or provide them with activities to their ability level. LPN #9 stated there were not enough activities for the residents and it was important to have activities, because they had nothing to do. The resident became anxious doing nothing. If nursing did not provide activity, there would not be any. The residents just sat in front of the television in the dining room all day. During an interview on 11/16/2023 at 11:37 AM, registered nurse (RN) #2 stated sometimes recreation would come to the unit, but it would not be planned, and they would just show up and see if anyone was interested in an activity. They stated if a resident was deaf or blind, they would not have something for them specifically to do for activities. RN #2 stated recreation had books on tape, as they had seen them used before. The books on tape were set up and they could run by themselves. They stated activities were important as no one would want to just sit and stare at the wall all day and activities broke up the day and kept the residents socially engaged. During an interview on 11/16/2023 at 11:47 AM, RN #10 stated the calendar posted was for facility wide events. Recreation Leader #11 came up to the unit once or twice a week for unit specific events. They would show up to the unit with an activity, like horseshoes, balloon toss, or bowling. The recreation department had enough activities, however, the unit could add a few more activities. It would be nice to see the residents more involved. Activities were adapted to the resident abilities by residents helping each other. Resident #53 used their television as their preferred activity. The television was large and loud. During an interview on 11/16/2023 at 2:38 PM, licensed practical nurse (LPN) #9 stated that when Resident #53 was moved from their room to the alternate room they were given a smaller television without closed captioning. When the resident was moved back to their original room the TV remote did not work on the television. LPN #9 did not know when the television was fixed. The maintenance department was responsible for fixing televisions and a work order should be put in for assistance with the television. They stated Resident #53 was not provided other activities while their television was broken. During an interview on 11/16/2023 at 4:25 PM, recreation leader #11 stated that the director of recreation organized the facility events. Recreation leader #11 was responsible for units C and the second floor. Monday morning events were done briefly and done every other Monday between units C and the second floor. If a resident could not attend bingo, they would have no other activity for that day. CNAs on the unit sometimes did a mini movie with the lights down low during bingo for those that stayed on the unit. Recreation Leader #11 stated they were unaware of what the period was of Resident #53's television not working. Activities were important as the resident did not cook, clean, or work. Activities provided meaning for many residents. Some residents needed more support socially, and the recreation department tried to meet the needs for activity diversity and group size. Recreation Leader #11 stated there could always be more activities, and more could be provided if they had additional time to spend on one unit or another. During an interview on 11/17/23 at 11:50 AM, recreation leader #11 stated the facility had books on tape available, on CD and cassette in the gathering room. The residents tended to use them during independent time, but they had to be able to set up the devices themselves. 2)Resident #190 was admitted to the facility with diagnoses including spinal stenosis (narrowing of the spinal canal), epilepsy (seizure disorder), and hemiplegia affecting left dominant side (left side paralysis). The 8/15/2023 Minimum Data Set (MDS) assessment dated documented the resident was cognitively intact and required extensive assistance of two for most activities of daily living (ADLs). The 5/22/2023 MDS assessment documented it was very important to the resident to have books, newspapers, and magazines to read, listen to music they liked, be around animals such as pets, and to participate in religious services; it was somewhat important to do their favorite activities, to do things with groups of people, and to go outside to get fresh air when the weather was good. The comprehensive care plan (CCP) revised 6/24/2022 documented the resident was independently capable of pursuing own leisure activities. Interventions included independent leisure interests such as, TV (sports, news, history channel), music (country), outdoor activities, mass, dice, cards, current events, strolls, and socializing. Staff should periodically invite the resident to group activities they may enjoy, provide calendar of events, and provide conversation visits to maintain contact and rapport. The CCP was revised on 9/20/2022 and documented the resident was alert and able to make decisions regarding their preferences of care. Interventions included encouraging interactions socially with staff, peers, and visitors, offering and inviting the resident to preferred activities of interest, and providing weekly/monthly recreation calendars. The 6/24/2022 recreation leader #11 assessment documented Resident #190 required a wheelchair for mobility and was alert and oriented. It was very important they had their favorite activities to participate in. The activity preferences listed exercise/sports with additional clarifying comments of watching baseball, football, and college basketball. Resident #190 was a member of the American Legion and enjoyed playing cards. The 11/8/2023 recreation leader #11 activity participation note documented the resident was alert and oriented, they stayed in bed most of the day, they usually watched TV while in bed and followed major sports. They got up for Catholic mass on Tuesday mornings. When the resident was out of bed they participated in musical entertainment and unit activities, however, that did not happen often. The resident rarely read or worked on word puzzles. They participated in room-to-room activities, such as physical games and games of chance. Room activities, mass, and large group activities would be offered when they were out of bed. Transportation would be provided to all groups. The undated resident activity log for November documented there were 38 activity categories for residents. The activity log categories included games, movie, nail care, sensory stimulation, social, strolls, and religion. The November 2023 activity log documented Resident #190 was offered 1 entertainment/party on 11/3/2023, 1 communication visit on 11/6/2023, 1 recognition event on 11/11/20231, mass service on 11/14/2023, and 1 pet visit on 11/14/2023. During an observation and interview on 11/14/2023 at 9:18 AM, Resident #190 stated they enjoyed activities when they were available, but there were not many activities on the unit. The resident stated they mostly looked forward to Tuesday morning mass. During an interview on 11/15/2023 at 11:07 AM, certified nurse aide (CNA) #8 stated there was a monthly activities calendar and the activities were the same for the whole facility and were held downstairs. They did not know if the activities were adapted to the needs of the resident as they had never seen an activity occur. They had seen the other unit CNAs facilitate drawing and coloring one time in the last month. They stated Resident #190 preferred to stay in their room, and they were unsure if activities could be brought to their room. During an interview on 11/16/2023 at 11:15 AM, Resident #190 stated that the facility did not come to ask them about activities unless it was to go to mass on Tuesdays. At 2:47 PM, Resident #190 stated that if the facility offered sports related activities they would attend. They wanted to have a football or baseball game activity, or sports related trivia. They stated they greatly enjoyed historical related activities and a Super Bowl or World Series activity would be fun. During an interview on 11/16/2023 at 11:47 AM, RN #10 stated the calendar posted was for facility wide events. Recreation Leader #11 came up to the unit once or twice a week for unit specific events. They would show up to the unit with an activity, like horseshoes, balloon toss, or bowling. The recreation department had enough activities, however, the unit could add a few more activities. It would be nice to see the residents more involved. Activities were adapted to the resident abilities by residents helping each other. Resident #190 went to mass and was very interested in sports. They had the full listing of sporting events. There was a group of men that would sometimes get together to watch the local university sporting events, but they requested the television be changed for them, and it was not a pre-planned activity. During an interview on 11/16/23 at 1:03 PM, the Director of Recreation stated they created a shell of activities that were all house activities, meaning the entire building was included in to the one event. Those events were held in the chapel garden. Recreation leaders were assigned to specific units. They created additional small group activities that were added to the shell for their particular units. Once completed those were the documents hung up on the units and in resident rooms. The 2nd floor calendar indicated the only event listed on 11/15/2023 was bingo. If a resident did not prefer bingo, they would not have any activity for the day. This was scheduled every Wednesday. If a resident preferred not to attend church service, there were no other activities for them until 2:30 pm, which was an exercise class. They stated If a resident was blind and deaf, they could match the resident with a volunteer to assist with an activity. The recreation department had sensory activities, could do more room-to-room activities, or independent activities with assistance to help with a blind and deaf resident. If a resident had interest in sporting events, they had exercise activities and Bocce ball available. During an interview on 11/17/2023 at 12:40 PM, the director of nursing (DON) stated that activities were important for the residents, especially for cognition and happiness. The lack of activities could negatively affect the residents' quality of life. If a resident needed closed captioning on their tv, which was a preferred activity, it was expected the closed caption to be fixed or available right away, or an alternative activity of choice provided. Activities should be available for all interests and level of cognition. 10 NYCRR 415.5(f)(1)

Based on observation, record review and interview during the recertification and abbreviated surveys (NY00317835, NY00312624, NY00321818, NY00312845, NY00321300, NY00321978, NY00326461, NY00326492, and NY00326914) conducted 11/13/2023-11/20/2023, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 1 resident (Resident #146) reviewed. Specifically, Resident #146 had an unstageable (full-thickness pressure injuries in which the base is obscured by dead tissue) right heel pressure wound, and an unstageable right buttock wound and there was no documented evidence treatments were completed as ordered. Findings include: The facility policy Accountability of Medication and Treatment Administration revised 11/25/2016 documented the treatment nurse would document the administration of the treatment in the resident record immediately following the treatment. If the treatment nurse was unable to provide the treatment the charge nurse should be notified in a timely manner that the treatment could not be completed and notify the next shift the treatment could not be completed. The charge nurse should notify the Nurse Manager or nursing Supervisor the treatment was not completed. Resident #146 was admitted to the facility with diagnoses including an unstageable pressure ulcer of the right buttock and a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer of the right heel. The 10/4/2023 Minimum Data Set (MDS) Assessment documented the resident had intact cognition, did not reject care, was frequently incontinent of bowel, was at risk for developing pressure ulcers, had 1 stage 4 pressure ulcer and 1 unstageable pressure ulcer on admission, received pressure ulcer care, and received applications of ointments/ medications to areas other than their feet. The 9/28/2023, Weekly Wound/ Impaired Skin Tracking form completed by nurse practitioner (NP) #14 documented the resident was admitted with an unstageable right heel pressure wound that was 5 centimeters (cm) x 5.5 cm. The treatment plan included to cleanse with wound cleanser, apply wound gel every other day and as needed. Additionally, the resident was admitted with an unstageable sacrum (lower back) pressure wound that was 6 cm x 7.5 cm. The resident was being treated for osteomyelitis (bone infection) to the right heel. The treatment plan included to cleanse with wound cleanser, apply wound gel every other day and as needed, assist with toileting and incontinence care, assist with repositioning and they recommended an air mattress for their bed. The 10/4/2023, comprehensive care plan (CCP) documented the resident had an actual impairment to their skin. Interventions included avoid scratching; keep hands and body parts from excessive moisture; encourage good nutrition and hydration to promote healthier skin; monitor/document location, size and treatment of skin injury; report abnormalities, failure to heal, any signs or symptoms of infection to medical; a low loss air mattress for their bed; weekly treatment documentation to include measurement of each area of skin breakdown including width, length, depth, type of tissue and exudate; and any other notable changes or observations. The 10/14/2023 physician orders documented: - Cleanse the unstageable right heel pressure ulcer with wound cleanser, apply calcium alginate dressing (an absorbent dressing) cutting it to fit the wound, apply zinc (mineral that helps with healing), and cover with gauze. Lightly pack the undermining (erosion of tissue around the wound border) at 11-1 O'clock (location of area based on a clock) with calcium alginate daily on the day shift and as needed for wound care. - Cleanse the unstageable sacrum pressure ulcer with wound cleaner, apply calcium alginate dressing, cutting it to fit the wound, lightly packing to depth, apply Triad (a coating used to protect skin), cover with gauze, and use to use a brief to secure the dressing daily on the day shift and as needed for wound care. The 10/19/2023 Weekly Wound/ Impaired Skin Tracking completed by NP #14 documented the right heel pressure wound was a stage 4, had improved and measured 6 cm x 5 cm. Their treatment plan included to continue to cleanse with wound cleanser and apply calcium alginate dressing and follow up with the wound consult physician as recommended. The 10/2023 Treatment Administration Record (TAR) documented; - to the unstageable right heel, cleanse with wound cleanser, apply calcium alginate cutting to fit wound, apply zinc to peri wound, cover with gauze, and rolled gauze; to undermining from 11-1 O'clock lightly pack with calcium alginate every day shift. - to the unstageable sacrum, cleanse with wound cleanser. apply calcium alginate cutting to fit wound, lightly packing depth; apply Triad to peri wound, cover with ABD pad (absorbent dressing), and use brief to secure the dressing. The was no documentation the treatments to the right heel or the sacrum were completed on 10/23/2023. Licensed practical nurse (LPN) #48 documented they had provided the resident their medications and signed for them on the medication administration record (MAR) on 10/23/2023. There were no nursing progress notes for 10/23/2023 documenting the reason the treatments were not done. The October 23, 2023, B unit Day Shift Unit Assignment sheet documented there was 1 registered nurse (RN) Unit Manager, 1 LPN, and 3 certified nurse aides (CNAs) on the day shift. On 10/23/2023, NP #14 documented they and the Unit Manger and called and spoke to the resident's family about the resident's wounds and why healing was delayed. They reviewed the treatment order and the family had concerns and social work and nursing were aware. The 10/2023 Treatment Administration Record (TAR) documented; - to the unstageable right heel, cleanse with wound cleanser, apply calcium alginate cutting to fit wound, apply zinc to peri wound, cover with gauze, and rolled gauze; to undermining from 11-1 O'clock lightly pack with calcium alginate every day shift. - to the unstageable sacrum, cleanse with wound cleanser. apply calcium alginate cutting to fit wound, lightly packing depth; apply Triad to peri wound, cover with ABD pad (absorbent dressing), and use brief to secure the dressing. The was no documentation the treatments to the right heel or the sacrum were completed on 10/24/2023. LPN #50 documented they had provided the resident their medications and signed for them on the medication administration record (MAR) on 10/24/2023. There were no nursing progress notes for 10/24/2023 documenting the reason the treatments were not done. The 10/24/2023, The B unit Day Shift Unit Assignment sheet documented there was 1 RN Unit Manager, 2 LPNs, and 4.5 CNAs. On 10/25/2023, NP #30 documented they spoke to the resident's family member as they felt the resident's sacrum wound had gotten worse. NP #14 spoke to the family about the wound upon admission and how it was currently doing. The resident continued to be followed by the wound care physician twice monthly. The family member discussed the resident's incontinence of stool and hygiene of the wound. NP #14 communicated the family members concerns to the wound care physician. The family member was explained that the resident's hospitalization, infection, and use of antibiotics all played a part in wound healing. The 10/2023 TAR did not document the resident's dressing changes to their right heel and sacrum were completed on 10/30/2023. LPN #48 documented they had provided the resident their medications and signed for them on the MAR on 10/30/2023. The 10/30/2023, Day Shift Unit Assignment Sheet documented there was 1 RN Unit Manager, 1 LPN, and 2.5 CNAs. During an interview on 11/13/2023 at 1:02 PM, Resident #146 stated their wounds were improving, but their treatments were not always done. They stated it was hard to keep the area on their sacrum clean because they had loose stools at times and felt like the facility did not have enough staff to do everything they needed to do. During an interview on 11/16/2023 at 4:28 PM, RN Unit Manager #29 stated treatments were documented on the TAR when they were completed. If a nurse did not sign for the treatment, it meant they either failed to document the treatment was completed or they did not complete the treatment as ordered. If another nurse or physician completed the dressing the nurse should document who completed the treatment in the medical record. They stated typically the unit was scheduled with 2 nurses, usually 2 LPNs on the medication and treatment carts. Sometimes there would only be 1 nurse on the unit due to the census of the unit. If the census was 25 residents or less than they would have only 1 nurse on the treatment and medication carts. If a nurse was unable to complete treatments per the physician order, they should let the RN Unit Manager or RN Supervisor know so they could provide help or notify the physician the treatment was not done. Usually, the treatments also had an as needed order so they could be done anytime if they were not completed as scheduled. They stated they were not made aware of any treatments not being completed as ordered. During a telephone interview on 11/16/23 at 5:00 PM, LPN #48 stated if a resident had a wound treatment order it was located on the TAR and whoever completed the treatment should sign the TAR or document that it was completed by someone else. They stated if they signed that they provided the resident their medications then they were usually the nurse assigned to that resident. They also stated if they were working with Resident #146 that meant they were the only nurse passing medications and doing treatments on the unit. They stated they might not have documented the treatment was completed because there was not enough staff on the unit, and they should document a progress note if someone else completed the dressing change. During a follow up interview on 11/20/2023 at 11:40 AM, LPN #48 reviewed the resident's electronic medical record including the MAR and TAR. They stated they were the nurse assigned to Resident #146 on 10/23/2023 and 10/30/2023. They stated if they were the only nurse, it all came down to time and if they did not document the treatment was completed it was not done or they did not have time to sign for it. They stated it was important for treatments to be completed as ordered to promote wound healing. They stated they would ask for help when they needed to. During a follow up interview on 11/20/2023 at 11:55 AM, RN Unit Manager #29 stated nursing staff should document on the TAR when a treatment was completed. They had not been made aware the resident's treatments were not completed and they would want to be made aware. It was important for treatments to be completed to aid with wound healing. During an interview with Director of Nursing (DON) on 11/20/2023 at 12:41 PM, they stated it was expected that nursing staff complete the treatments per the physician's orders and document it was completed on the TAR. If for some reason a treatment could not be completed as ordered the RN in charge should be made aware and the physician should be notified. They stated if the treatment had not been signed as completed it meant the treatment was not done. They had not been notified treatments were not being completed due to possible lack of staffing on the B unit. It was important to complete the treatments as ordered to promote wound healing. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey conducted 11/13/2023-11/20/2023, the facility did not ensure residents received special eating equipment as required for 2 of 2 residents (Residents #135 and #103) reviewed. Specifically, Resident #135 was not provided with a scoop plate as ordered and Resident #103 was not provided with a scoop plate or adaptive silverware. Findings include: The facility policy Management of Resident Dining revised 2/25/2020 documented dining service staff safely transported meals including meal tickets and required dishware to the appropriate units. Nursing staff double checked compliance with diet order including adaptive equipment and delivered the meal to the room and again verified all items on the tray were accurate including adaptive equipment (this constituted the third check). The facility policy Standards for Resident Dining revised 10/9/2018 documented that staff ensured that residents who required assistive devices/adaptive equipment at mealtime (per meal ticket) were provided with necessary items. 1)Resident #135 was admitted to the facility with diagnoses including cerebral vascular accident (CVA, stroke), protein-calorie malnutrition, and diabetes. The 10/27/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and was independent with eating set up assistance and had limitations in functional mobility on one side of body. The occupational therapy discharge summary completed by occupational therapist (OT) #60 on 10/4/2023 documented the resident required supervision or touching assistance with eating and had feeding equipment including built up silverware and a scoop plate. The comprehensive care plan (CCP) initiated 5/31/2023 and revised on 10/23/2023 documented a therapeutic diet with goal of tolerating diet through next review and interventions of consistent carbohydrate/ NAS (no added salt) diet with regular texture and thin liquids with a scoop plate. Meal tickets for Resident #135 observed from 11/13/2023-11/17/2023 documented adaptive equipment of a scoop plate. During meal observations on 11/15/2023 at 1:09 PM and 11/6/2023 at 12:55 PM the resident was not provided with a scoop plate as plate as planned. 2) Resident #103 was admitted to the facility with diagnoses including dementia, glaucoma (nerve damage in the eye), and diabetes. The 10/2/2023 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and required supervision/ touching assistance with eating. The undated care instructions ([NAME]) documented the resident required a scoop plate for feeding equipment. The 8/17/2023 OT #60 progress note documented that feeding equipment needed was built up silverware and scoop plate. Meal tickets for Resident #103 observed from 11/13/2023-11/17/2023 documented adaptive equipment of a scoop plate and red foam silverware grips. During meal observations on 11/13/2023 at 11:48 AM and on 11/14/2023 at 12:13 PM the resident was not provided a scoop plate or built up silverware. During an interview on 11/17/2023 at 11:43 AM, registered nurse (RN) Unit Manager #29 stated the meal ticket indicated if adaptive equipment was needed, and staff checked the presence of adaptive items if they were included on the meal ticket. If the resident was supposed to have adaptive equipment and did not, it could negatively affect their intake. They stated they expected if adaptive equipment was missing from resident meal trays, the certified nurse aide (CNA) should call the kitchen and request the missing equipment. During an interview on 11/17/2023 at 1:36 PM, OT #61 stated they emailed nutrition after they completed the resident assessment and nutrition added the appropriate adaptive equipment to the meal ticket. They stated occupational therapy added the specific adaptive equipment to the CCP which then transferred to the care instructions. They confirmed the scoop plate and build up silverware was present on the CCP and the care instructions for Resident #103. It would not be appropriate for Resident #103 to use a regular plate and they should have had a scoop plate. Resident #135 was care planned for a scoop plate to aide with self-feeding and should not have a regular plate. During an interview on 11/17/2023 at 2:28 PM, CNA #26 stated they checked meal tickets for adaptive equipment. Adaptive equipment was intended for increased independence with eating. If a resident had adaptive equipment ordered, they should never eat without it. They were unsure if Resident #135 was supposed to have adaptive equipment. 10NYCRR 415.14(g)

Based on observation and interview during the recertification survey conducted from 11/13/2023-11/20/2023, the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety in the main kitchen. Specifically, single service items were re-used, the hood filters were not maintained, and the clean ice scoop was not stored properly. Findings include: The following observations were made in the main kitchen: - on 11/13/2023 at 10:00 AM the ice scoop was sitting directly on top of the ice machine. The hood filter closer to the walk-in cooler had a damaged filter. The filter slats were damaged and spaced approximately 1-inch apart. - on 11/14/2023 at 12:20 PM, the ice scoop was sitting directly on top of the ice machine. Staff were actively using the ice scoop to pour ice in drinks for service on the units. At 12:25 PM, kitchen operations manager #64 was pouring drinks for service from re-used plastic gallon water jugs. The jugs were labeled with black marker not to discard. - on 11/20/2023 at 12:00 PM, with Chef Manager #62 present, the ice scoop was in the scoop holder and on top of the ice machine. The damaged hood filter had approximate 1-inch gaps between the slats of the grate. Staff were pouring water for meal service from re-used gallon jugs. During an interview on 11/20/2023 at 12:05 PM, Chef Manager #62 stated that they were not aware staff were re-using plastic gallon water jugs. They stated that was one thing that they had tried to change, and it would be addressed. They were aware that single service items could not be re-used. Chef Manager #62 stated the ice scoop should be properly stored in the holder and the holder adhered to the side of the machine, or the wall. They were not sure why the holder was on top of the machine, and the scoop should not be on the top of the machine because that was not a routinely cleaned surface. They were not aware of the damaged hood filter. 10NYCRR 415.14(h)

Based on observation, record review, and interview during the recertification and abbreviated (NY00317835 and NY00321978) surveys conducted 11/13/2023-11/20/2023, the facility did not ensure resident call systems were accessible to call for staff assistance for 1 of 3 residents (Resident #116) reviewed. Specifically, Resident #116 was observed on multiple occasions with their call bell out of reach. Findings include: The facility policy Meeting Resident Needs revised 3/13/2019, documented that the certified nurse aide (CNA) would strive to conduct hourly checks during their shift that included verifying the call bell was located within resident reach. Licensed staff were expected to verify that staff were conducting those hourly checks per policy. Resident #116 was admitted to the facility with diagnoses including diabetes mellitus, depression, and right below the knee amputation (BKA). The 8/14/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and required extensive assistance of 1 for bed mobility, transfers, dressing, toileting, and hygiene. The comprehensive care plan (CCP) initiated 10/29/2020 and revised 11/7/2023 documented the resident was at risk for falls due to deconditioning and poor safety awareness. Interventions included ensure the call light was within reach and encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance. The resident was observed with their call bell on the floor under the bed, and out of reach: - on 11/15/2023 at 9:17 AM, 10:45 AM, and 3:36 PM. - on 11/16/2023 at 8:34 AM, 11:33 AM, 12:50 PM, and 2:18 PM. During an interview on 11/16/2023 at 2:28 PM, CNA #25 stated if the call bell was out of reach, the resident would be unable to call for help and an adverse outcome could occur. They stated the resident could use their call bell and it should always be in reach. CNA #25 stated anytime a CNA left the resident's room they should check that the call bell was in reach. They stated they had not checked the location of the call bell since making the resident's bed in the morning when they placed it over the headboard. During an interview on 11/16/2023 at 2:57 PM, licensed practical nurse (LPN) #28 stated it was everyone's responsibility to make sure call bells were always accessible. LPN #28 stated it was not appropriate that the resident's call bell was on the floor under the bed. During an interview on 11/17/2023 at 11:21 AM, registered nurse (RN) Unit Manager #29 stated anytime staff was in a resident room they should check to ensure the call bell was within the resident's reach so their needs could be addressed. They stated the call bell should be placed in reach and checked during hourly rounds. They stated the resident would not be able to reach the call bell on the floor under the bed. 10NYCRR 415.5(e)(1)

Based on interviews during the recertification survey conducted 11/13/2023-11/20/2023, the facility did not ensure residents had the right to exercise their rights as a resident of the facility and as a citizen or resident of the United States for all 241 residents of the facility. Specifically, mail from the United States Postal Service (USPS) was not delivered to residents on Saturdays, thereby denying all residents the same rights provided to other citizens of the general community. Findings include: The facility policy, Resident Rights, reviewed and revised 10/18/2022, documented the nursing facility recognized and supported the residents' right to exercise their rights as a resident of the facility and of the United States. The policy summarized the rights of resident as stipulated under the Federal and State law. During a resident group interview on 11/13/2023 at 3:40 PM, ten anonymous residents stated personal mail was not delivered to them on Saturdays. During an interview on 11/15/2023 at 11:45 AM, unit secretary #1 stated they would go to the mailroom and get the mail for the unit. They delivered the mail to the residents when they worked Monday through Friday. They stated mail did not come to the unit on Saturdays and was held until Monday and passed out then. During an interview on 11/15/2023 at 11:48 AM, registered nurse (RN) #2 stated that packages or food delivery service would be delivered to the supervisor's office and brought to the unit for residents, but parcel mail was not delivered to residents on Saturdays. During an interview on 11/16/2023 at 2:27 PM, central supply staff #3 stated that mail came in the building through the glass windows by the front door. The business office would separate out their items. Central supply staff #3 stated they would get a phone call stating the mail was ready for pick up and they would get the mail from the bucket and sort out the parcels by unit. The sorted mail was placed in the appropriate unit mailbox. They stated the unit secretaries were responsible for getting the mail from the unit mailboxes every day. They stated If the mail was still in the mailbox at the end of the day at approximately 4:00 PM, they took the mail to the unit. Central supply staff #3 stated mail was delivered to the facility on Saturdays but neither members of the business office nor central supply worked on Saturday. Mail was not sorted on Saturdays and residents did not receive mail on Saturdays. They stated it was important for residents to receive mail on Saturdays, especially during the holidays and birthdays. During an interview on 11/17/2023 at 2:26 PM, the Administrator stated when mail arrived the business office took their items out and the remainder went to central supply. If mail was delivered on Saturday, it would be distributed Monday. They stated residents should get mail the day it was delivered. During a telephone interview on 11/17/23 at 2:28 PM, the Director of Central Supply and Purchasing stated mail was delivered to the facility Monday through Saturday and on Saturday the front desk would sort the mail for distribution. During an interview on 11/17/23 at 2:51 PM, operator/receptionist #5 stated they worked the front desk every Saturday. The process for mail on Saturday was USPS would deliver a white postal bin and the facility would provide a return white postal bin for outgoing mail. If the parcels appeared official in appearance, they went into a white filing cabinet with a lock and was locked until Monday. They stated mail, such as magazines, business-related post cards, or junk mail stayed in the bin on the counter until Monday. The business office came and got the mail from the locked cabinet on Mondays. 10NYCRR 415.3(c)(l)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification and abbreviated (NY00321818 and NY00317835 and NY00321978) surveys conducted 11/13/2023-11/20/2023, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 5 of 6 resident units (Units B, C, D, 2, and 3). Specifically, Unit 3 had mattresses and furniture in disrepair; Units B, C, D, 2, and 3 served resident meals directly on trays; and the medication room and the kitchenette were unclean on Unit 3. Finding include: The facility policy Resident Rights dated 10/18/2022, documented the residents had the right to a dignified existence that included a safe, clean, comfortable, and homelike living environment. The facility policy Standards for Resident Dining, dated 10/9/2018 documented the dining area tables should be properly set with placemats on the units, condiments, etc. Residents served in their rooms should have meals taken to the rooms covered and assist with set up within reach of resident. Unit 3 Mattresses/Furniture The following observations were made on Unit 3: - on 11/13/2023 at 10:30 AM and 11/14/2023 at 8:15 AM in room [ROOM NUMBER] there were broken dresser drawers placed on top of the dresser. - on 11/13/2023 at 10:57 AM, 11/14/2023 at 8:30 AM, and 11/15/2023 at 1:04 PM in room [ROOM NUMBER] there was a mattress with a large rip over half of its side. - on 11/13/2023 at 3:33 PM and 11/14/2023 at 8:48 AM in room [ROOM NUMBER] there was a mattress on the floor with a rip down half of the side. - on 11/14/2023 at 8:47 AM a chair between rooms [ROOM NUMBERS] had dark brown drips down the back. - on 11/15/2023 at 9:28 AM, 11/16/2023 at 10:46 AM, and 11/17/2023 at 12:53 PM a chair to the right of the kitchenette had a square rip in the seat with protruding foam. During an interview on 11/15/2023 at 12:50 PM licensed practical nurse (LPN) #21 stated the dresser in room [ROOM NUMBER] had been broken for nearly one year. They had reported it to the secretary but could not recall when. They stated when items were in disrepair it could take months to get them fixed. They stated they observed many mattresses with large tears that did not get replaced. They stated torn mattresses could be an infection control issue. During an interview on 11/16/2023 at 12:44 PM LPN #19 stated they notified the secretary when there was broken equipment. They stated they never filled out work orders but called maintenance when items were broken. They stated it normally took several days for a repair but not usually more than one week. If a mattress was ripped it could be an infection control issue. During an interview on 11/16/2023 at 1:53 PM, LPN Assistant Unit Manager #24 stated when equipment was broken a work order was completed by the secretary and they have also completed work orders. They stated they were not aware of the ripped mattresses and that work orders were normally addressed within a day or two. They stated the dresser had been broken for a month or two, but it took longer to get a dresser replaced because the facility does not provide dressers. Resident Meal Service The following observations were made on Unit 2: - on 11/13/2023 at 1:24 PM lunches arrived on the Unit 2 cart for hallway tray service. Residents were served their lunch meals directly on the trays without staff removing the food items. - on 11/15/2023 at 1:21 PM, Resident #38 was eating their meal with all food items remaining on the tray. Resident #38 stated they always ate on the tray, and it was how their meals were served to them. The following observation were made on Units C and D: - on 11/13/2023 at 1:16 PM, all residents in the dining room on D Unit had their lunches served directly on trays. - on 11/15/2023 at 8:50 AM, Resident #60 on C Unit was eating breakfast in their room with all food items served directly on a meal tray. - on 11/15/2023 at 1:36 PM, all residents in the dining room on D unit had their lunches served directly on trays. - on 11/16/2023 at 1:01 PM, all residents in the dining room on D unit had their lunches served directly on trays. The following observations were made on Unit 3: - on 11/13/2023 at 1:16 PM, multiple residents in the dining room were being served their lunch meal directly on a tray. - on 11/13/2023 at 1:57 PM, Resident #100 was being fed their meal directly from a tray. - on 11/14/2023 at 9:15 AM, multiple residents were in the dining room eating breakfast served directly on a meal tray. - on 11/15/2023 at 10:57 AM, Resident #36 was eating their breakfast meal served directly on a tray. Multiple residents were eating their meals directly from trays. The following observations Unit B observations included meals served on trays on the following dates: - on 11/13/2023 at 12:28 PM, all residents were eating from meal trays in the B unit dining room. - on 11/14/2023 at 8:55 AM, Resident #223 was served breakfast on a meal tray. - on 11/14/2023 at 12:23 PM, Resident #223 was served lunch on a meal tray. - on 11/14/2023 at 12:24 PM, Resident # 116 was served lunch that was set up on their beside table on a meal tray in their room. - on 11/14/2023 at 12:27 PM, Resident #135 was served lunch on a meal tray in their room. - on 11/15/2023 9:05 AM, Resident #223 was served breakfast on a meal tray in their room. - on 11/15/2023 at 9:15 AM, Resident #116 was served breakfast on their bedside table on a meal tray in their room. - on 11/15/2023 at 9:21 AM, Resident #135 was served breakfast on a meal tray. - on 11/15/2023 at 12:52 PM, Resident #223 was served lunch on a meal tray in their room. - on 11/15/2023 at 1:00 PM, Resident #116 was served lunch on a meal tray in their room. - on 11/15/2023 at 12:50 PM, Resident #135 was served lunch on a meal tray that was set up on the bedside table while they were up in their wheelchair. - on 11/16/2023 at 9:00 AM, Resident #135 was served breakfast on a meal tray while in bed. - on 11/16/2023 at 9:04 AM, Resident #116 was served breakfast on a meal tray in their room. - on 11/16/2023 at 9:06 AM, Resident #223 was served breakfast on a meal tray in their room. - on 11/16/2023 at 12:50 PM, Resident #116 was served lunch on a meal tray which was on the bedside table while they were up in their wheelchair. - on 11/16/2023 at 12:52 PM, Resident #223 was served lunch on a meal tray in their room. - on 11/16/2023 at 12:55 PM, Resident #135 was served lunch on meal tray. During an interview on 11/16/2023 at 9:31 AM, certified nurse assistant (CNA) #34 stated all meals were always served on trays. This was not homelike. Before COVID they had placemats and served out of the kitchenette with steam tables. That was much better because if items were missing, they could just go to the kitchenette to get the items. They stated there had been talk of using the kitchenettes again, but no actual plans had been disclosed to the unit staff. During an interview on 11/16/2023 at 9:38 AM, licensed practical nurse (LPN) #9 stated meal service was always served on the tray, and was not homelike. They used to service out of the kitchenette, but switched to trays after COVID. There were better ways to serve that were more homelike. During an interview on 11/16/2023 at 11:28 AM, CNA #18 stated meal service was always served on the tray and was not homelike. During an interview on 11/16/2023 at 11:37 AM, registered nurse (RN) #2 stated serving meals on the tray was not 100% homelike. The brain injury unit was always served on trays. 2nd floor was done on the hot trays in the kitchenette, but that was before COVID. During an interview on 11/16/2023 at 11:47 AM, RN #10 stated the food was always served on trays. It used to be served from hot plates. Hopefully, we go back to that and only use a plate. Tray service was not homelike, typically people would not eat on a tray at home. They said the steam tables were coming back but did not know when given all the other construction that was occurring. During an interview on 11/16/2023 at 1:53 PM, LPN #24 stated meal service was always served on the tray and was not homelike. They stated in the past meals were served from the kitchenette and were not served on trays. They stated they did not eat on a tray at home. Since changing to serving off carts, meals were served on trays. During an interview on 11/17/2023 at 11:43 AM, Registered Nurse (RN) Manager #29 stated it was important for residents to have a homelike environment because this was their home, and they should be given that same comfort level. Meals on trays are not homelike and it would be more homelike if the plates were taken off the trays before placed in front of the resident. During an interview on 11/17/2023 at 2:00 PM, the Director of Nursing (DON) stated that all meals were served on trays and did not think it was homelike to be served like that. They were working on alternate ways like using the steam tables in the future to make it more homelike. During an interview on 11/17/2023 at 2:28 PM, certified nurse aide (CNA) #26 stated it was important for residents to have a home like environment because it was their home and quality of life is important. It was homelike to place the plates and the drinks in front of the residents rather than on a tray. Medication rooms and the Unit 3 kitchenette The signed email from Chief Information Officer #54 dated 11/16/2023 documented the cameras were installed in the medication rooms for the B Unit on 11/2/2023 and Units 2 and 3 on 11/4/2023. During an observation on 11/13/2023 at 11:29 AM, the Unit 3 medication room had a white powder coating the floor beneath a camera mounted in the ceiling. During an observation on 11/13/2023 at 11:35 AM, the Unit 2 medication room had a white powder coating the floor beneath a camera mounted in the ceiling. Other debris was present and the floor throughout the medication room was visibly soiled. During an observation on 11/14/2023 at 10:08 AM, the B (Baker) Unit medication room floor had white debris under the camera mounted in the ceiling. A work order dated 10/6/2023 at 10:42 AM documented the sink on the 3rd floor dining area was clogged. During an observation on 11/13/2023 at 11:09 AM, the right door was ajar under the sink beside the ice dispenser in the 3rd floor dining room. The interior of the cabinet was stained and soiled by a black substance, and flies were present. During an interview on 11/13/2023 at 11:09 AM, the Director of Maintenance stated there was a leak in the cabinet beneath the sink of the 3rd floor dining room and they must not have finished cleaning it up. During an interview on 11/20/2023 at 10:41 AM, CNA #18 stated that housekeeping was responsible for cleaning the medication rooms. During an interview on 11/20/2023 at 11:09 AM, housekeeper #55 stated they tried to clean the medication rooms daily, but because the rooms were normally locked, they may not get to those every day. They stated when cleaning those rooms they would sweep, mop, wipe down the counters, remove the garbage, and the cleaning was not documented. Housekeeper #55 stated the water leaking under the sink in the 3rd floor dining room had been an ongoing issue for about 3 years and it was due to something not draining properly because it was not level. They stated they often put down paper towels, but they did not clean under the cabinet because they thought it was screwed shut. They stated they did not have any problems with pests within the facility, but if they saw something they would report it to the unit secretary. During an interview on 11/20/2023 at 2:59 PM, the Director of Environmental Services #43 stated the medication rooms were supposed to be cleaned daily, and depended on if they could get nursing staff to unlock the room. They stated they thought the cabinet below the sink in the 3rd floor dining room was locked and that would prevent that area from being cleaned. They stated the facility did not have any pest issues, and an outside company came every other week to treat any areas of concern. The Director of Environmental Services #43 stated it was important for the medication rooms to be cleaned for the health of the residents and it was not timely if the room had not been cleaned for two weeks. They stated this was the resident's home, and it was not dignified if it was not clean. During an interview on 11/20/2023 at 3:32 PM, the Director of Maintenance stated they had no idea how long the leak had been present beneath the sink of the 3rd floor dining room and they did not believe anything regarding that was documented. They stated they were not aware of any pest issues in the facility, but those were taken care of by environmental services. 10 NYCRR 415.29(j)(1)

Based on observation, record review, and interviews during the recertification and abbreviated (NY00327307, NY00321978, NY00321818 and NY00317835) surveys conducted 11/13/2023-11/20/2023 the facility did not ensure sufficient nursing staff to provide nursing care to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 10 of 10 residents who expressed concerns regarding lack of sufficient staffing and not receiving care in a timely manner. Specifically, during a confidential group meeting (resident council) residents stated their call bells could sometimes take an hour to an hour-and-a half to be answered, and that there were not enough certified nurse aides (CNAs) to assist dependent residents with personal hygiene and toileting tasks. Additionally, deficiencies related to staffing levels were identified in the areas of ADL Care Provided for Dependent Residents (Residents #36, #100, #120, #141, and #183) and the area of Quality of Care (Resident #146); and one discharged resident (Resident #304) that was not provided incontinence care timely due to lack of sufficient staffing. Findings include: The facility policy Staffing, effective date 10/20/2022, documented the facility would provide sufficient nursing staff (on a 24-hour basis) with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain/maintain the highest practical physical, mental, and psychosocial well-being of each resident. The Facility Assessment, last updated 5/2023, documented the facility was licensed for a total of 284 skilled nursing beds. Within the total beds, two units (KB and B) were sub-acute, and there was a 20-bed certified brain injury unit. The remaining 182 beds accommodated long term care residents as well as a small sub-group of longer-stay rehabilitation residents. Most of the long-term care residents required assistance with mobility, bathing, dressing, and grooming. Sufficient staff were available to meet residents' needs, and staffing was evaluated routinely and was adjusted as needed. The certified nurse aide (CNA)/licensed practical nurse (LPN) staffing was supplemented with agency nursing staff and overtime to help achieve and maintain desired staffing patterns. Recruitment and retention strategies remained ongoing. The facility identified resources needed to provide competent care to its residents, and one of the areas included staff stability, where the facility would continue the Nurse Aide Training Program (NATP), agency diversification, and enhanced recruitment and retention strategies. During the entrance conference on 11/13/2023 the Administrator stated the facility census was 241 residents. Refer to citation F 684 Quality of Care Wound treatments not completed 10/23/2023 and 10/24/2023, Resident #146: Resident #146 had an unstageable (full-thickness pressure injuries in which the base is obscured by dead tissue) right heel pressure wound, and an unstageable right buttock wound and there was no documented evidence treatments were completed as ordered. During an interview on 11/13/2023 at 1:02 PM, Resident #146 stated their wounds were improving, but their treatments were not always done. They stated it was hard to keep the area on their sacrum clean because they had loose stools at times and felt like the facility did not have enough staff to do everything they needed to do. During a telephone interview on 11/16/23 at 5:00 PM, LPN #48 stated if a resident had a wound treatment order it was located on the TAR and whoever completed the treatment should sign the TAR or document that it was completed by someone else. They stated if they were working with Resident #146 that meant they were the only nurse passing medications and doing treatments on the unit. They stated they might not have documented the treatment was completed because there was not enough staff on the unit. Refer to Citation F 677 ADL Care Provided for Dependent Residents Resident #141 was not provided with a shower, oral hygiene, and fingernail care. Resident #183 was assisted with shaving. Resident #36 was not assisted with oral hygiene. During an interview on 11/16/2023 at 1:53 PM, LPN #24 stated CNAs could not always do care because of staffing issues. They stated sometimes there were only 3 scheduled CNAs on the day shift, and they could not always complete showers, nailcare, or oral care. During an interview on 11/16/2023 at 1:53 PM, licensed practical nurse (LPN) Unit Manager #24 stated CNAs were responsible for assisting residents with care including shaving female residents for dignity reasons. They stated Resident #183 should be shaved and had been shaved previously. LPN Unit Manager #24 stated they observed Resident #183 with a significant amount of facial hair on their lip and chin hair between 11/13/2023 and 11/16/2023, and they requested a CNA shave the resident earlier that morning. They stated that care was often missed because they were short-staffed. CNAs could not always complete resident care because of staffing issues. They stated sometimes there were only 3 CNAs scheduled on the day shift so residents could not always get showers, nailcare, or oral care completed. If oral care was not provided it could lead to gingivitis, tooth loss, infection, cavities, pain, and even being unable to chew foods. Incontinence care not provided timely 10/31/2023, Resident #304: Resident #304 was admitted to the facility with diagnoses including encephalopathy, unspecified and morbid obesity. The 10/31/2023 Minimum Data Set (MDS) assessment documented the resident had intact cognition, was dependent of two or more for toileting hygiene and toilet transfer, was always incontinent of bowels and used a wheelchair. The comprehensive care plan (CCP), initiated 10/26/2023, documented Resident #304 had a self-care deficit in toileting hygiene and was dependent of 2 requiring substantial or maximal assistance. The evening staffing for the KB unit on 10/31/2023 documented: - 1 LPN (LPN #37). - 4 CNAs: CNA #40 (float, 3PM - 11PM), CNA #36 (4PM - 7PM), CNA #35 (float from unit B, 7PM - 11PM), and CNA #65 (float, 7PM - 11PM). During an interview with licensed practical nurse (LPN) #37 on 11/16/2023 at 4:16 PM, who was the medication nurse for the KB unit, they stated they recalled an incident with Resident #304 on 10/31/2023. The resident's family was visiting on the evening shift when they heard shouting down the hall. The family was telling certified nurse aide (CNA) #40 the resident needed incontinence care. CNA #40 was telling the family member they needed a second staff to assist. The family member had stated they had been waiting for an hour for CNA #40 to find a second staff person for the resident to be changed. They (LPN #37) called the nursing supervisor because they were assisting another resident who had vomited. During an interview with registered nurse (RN) supervisor #38 on 11/16/2023 at 4:46 PM, stated LPN #37 had called them on 10/31/2023 to let them know a family member had interacted with CNA #40 about Resident #304 needing incontinence care, they were upset that incontinence care had not been provided for an hour, and that the family member had left the facility before the resident's care could be provided. CNA #40 had stated to them per the resident's care plan, the resident was a two person assist with incontinence care. The family member called the facility after they got home to inform them Resident #304 needed incontinence care. They (RN supervisor #38) stated CNA #40 was a float staff and they had been very short staffed that shift, so they assisted with incontinence care to Resident #304. During an interview with RN unit manager #41 on 11/17/2023 at 9:50 AM they stated if a family member ever expressed a care concern or had a confrontation with a CNA, the CNA should notify the nurse on the unit. If a second CNA was not available to assist with incontinence care per a residents' care plan, there was always the RN supervisor available to assist as the second staff person. Resident Group Meeting 11/13/2023: During a confidential resident group interview on 11/13/23 at 3:37 PM, ten anonymous residents stated that their call bell would sometimes take anywhere from 1- 1 1/2 hours before it was answered due to short staffing. They reported the following examples because of call bells not being answered timely due to inadequate staffing: - Residents had to stay on bedpans for a long period of time due to staff forgetting about them. - A resident had to help their roommate to the bathroom, because staff did not answer their call bell. - Residents did not receive showers on their scheduled shower days. - Residents had to ask for snacks, and when they did, staff never returned to their rooms. - Meal trays were not being served timely by unit staff once they arrived on the units. Facility staffing during day observations 11/13/2023 - 11/17/2023: Facility staffing documented the following nursing schedule for 11/13/2023-11/17/2023: Monday 11/13/2023, day shift (7 AM - 3 PM) staffing was scheduled for the following: - KB unit had 1 Nurse Manager (NM), 3 LPNs, and 5 CNAs (3 worked, 7:30 AM - 7 PM, 6 AM-2 PM, and 7 AM - 2PM, respectively) for 30 residents. - B unit had 1 NM, 2 LPNs, and 5 CNAs (1 worked 7 AM-12:30 PM) for 32 residents. - C unit had 3 LPNs, and 5 CNAs (2 worked 6 AM - 2 PM, and 7 AM - 7:30 PM, respectively) for 44 residents. - D unit had 1 NM, 3 LPNs, and 5 CNAs (3 worked, 7:30 AM - 3 PM, 10 AM-11 PM, and 8 AM - 2PM, respectively) for 42 residents. - 2nd floor had 1 NM, 2 LPNs, and 3 CNAs for 29 residents. - Brain Injury had 1 NM, 1 LPN, and 2 CNAs for 10 residents. - 3rd floor had 2 NMs, 3 LPNs, and 3 CNAs (2 worked 7 AM - 7 PM, and 11 AM-3 PM, respectively) for 55 residents. Tuesday 11/14/2023, day shift (7 AM - 3 PM) staffing was scheduled for the following: - KB unit had 2 NMs, 1 ANM, 3 LPNs, and 4 CNAs (2 worked 7 AM-3 PM, and 11 AM-3 PM, respectively) for 35 residents. - B unit had 1 NM, 2 LPNs, and 5 CNAs for 33 residents. - C unit had 1 NM, 2 LPNs, and 5 CNAs (1 worked 7 AM - 7:30 PM) for 43 residents. - D unit had 1 NM, 1 ANM (Assistant Nurse Manager), 2 LPNs, and 4 CNAs (1 worked 7:30 AM - 3 PM) for 42 residents. - 2nd floor had 1 NM, 2 LPNs, and 3 CNAs (2 worked 6 AM - 2 PM, and 7 AM - 2 PM, respectively) for 28 residents. - Brain Injury had 1 NM, 1 LPN, and 2 CNAs for 10 residents. - 3rd floor had 1 NM, 1 ANM, 3 LPNs, and 4 CNAs (1 worked 6 AM - 2 PM) for 54 residents. Wednesday 11/15/2023, day shift (7 AM - 3 PM) staffing was scheduled for the following: - KB unit had 1 NMs, 1 ANM, 2 LPNs, and 3 CNAs for 36 residents. - B unit had 1 NM, 2 LPNs, and 3 CNAs for 32 residents. - C unit had 1 NM, 3 LPNs (1 worked 11 AM-11:30 PM), and 1 CNA that worked 6 AM-2 PM for 42 residents. - D unit had 1 NM, 1 ANM, 3 LPNs, and 4 CNAs for 41 residents. - 2nd floor had 1 NM, 2 LPNs, and 3 CNAs (1 worked 6 AM - 2 PM) for 29 residents. - Brain Injury had 1 NM, 1 LPN, and 2 CNAs for 10 residents. - 3rd floor had 1 NM, 1 ANM, 2 LPNs, and 4 CNAs (1 worked 11 AM - 3 PM) for 54 residents. The facility did not provide staffing for Thursday 11/16/2023, day shift. Friday 11/17/2023, day shift (7 AM - 3 PM) staffing was scheduled for the following: - KB unit had 1 NMs, 1 ANM, 2 LPNs, and 1 CNAs for 36 residents. - B unit had 1 NM, 1 LPN, and 3 CNAs (1 worked 11 AM-3 PM) for 26 residents. - C unit had 1 NM, 2 LPNs (1 worked 7 AM-2 PM), and 1 CNA for 44 residents. - D unit had 1 NM, 1 ANM, 1 LPN, and 5 CNAs (1 worked 7:30 AM-3 PM) for 42 residents. - 2nd floor had 1 NM, 2 LPNs, and 3 CNAs (2 worked 6 AM - 2 PM and 11 AM-3 PM, respectively) for 33 residents. - Brain Injury had 1 NM, 1 LPN, and 2 CNAs for 16 residents. - 3rd floor had 1 NM, 1 ANM, 2 LPNs, and 3 CNAs (1 worked 6 AM - 2 PM) for 54 residents. During an observation and interview on 11/15/2023 at 12:28 PM, CNA #23 on Unit 3 stated they completed Resident #120's care and did not have time to do nail care. They stated the resident should have had nail care completed, however there was not enough staff to complete all the resident tasks. Resident #120's nails were long with brown debris underneath the nails. During an interview on 11/15/2023 at 12:30 PM, LPN #21 on Unit 3 stated they felt the facility was short staffed every day. There were three wings and they split a cart for one wing. Sometimes one nurse covered all three wings. They could not pass medications timely. Sometimes when the unit was short staffed, residents were not turned and repositioned. During an interview on 11/16/2023 at 11:28 AM, CNA #18 on Unit 3 stated good staffing for the day shift was 5 or 6 CNAs. Usually, they only had 3 or 4 staff on day shift, which was not enough. There were times they were not able to complete care, because of insufficient staffing. The facility used agency staff. They had been asked to work overtime even when they worked 6 to 7 days a week. Evenings was the worst shift to staff, and staff were offered a larger shift differential for evenings. During an interview on 11/16/2023 at 1:53 PM, LPN #24 on Unit 3 stated CNAs could not always do care because of insufficient staffing issues. The unit prioritized residents with skin issues. There were sometimes 3 CNAs on the day shift, and they could not always give residents their showers, oral care, or nail care. During an interview on 11/20/2023 11:01 AM, nurse practitioner (NP) #32 stated in the past, residents had told them they sat in urine for long periods of time and their call bells had been unanswered for long periods of time. NP#32 stated they had seen difficulties with staff trying to feed all the dependent residents timely. There seemed to be more resident falls on the weekends and evenings due to less staff. If CNAs did not give showers, do oral care, or nail care there could be the potential for open wounds, missed skin checks, dental caries, thrush, and residents not wanting to eat. If treatments were not done, residents could get wounds, or worsening wounds. Sitting in urine could cause urinary tract infections and excoriations. During an interview with the staffing coordinator/scheduler on 11/20/2023 at 12:00 PM they stated they had staff ratios for each unit, and it changed daily, based on call-outs. If a staff person was going to call out for their shift, they needed to do it 2 hours before their shift started. They made a list of CNAs who called out more to see if they needed to be spoken to or suspended. The facility offered money incentives (bonuses) for staff to pick up extra shifts. Mondays were difficult days to fill staffing because they typically had more call-outs, and if staff had just worked the weekend they did not want to work on Mondays. Evening shift was harder to staff because they had less staff. They had an active agency staff list they used to fill staffing vacancies. They tried to get any staff they could to fill shifts. Float staff had certain units they liked better, and they tried to put them on their preferred units, but that was not always the case. During an interview on 11/20/23 at 2:15 PM, the Director of Nursing (DON) stated staffing was addressed daily and needs were determined based on a combination of census and acuity. The facility had 2 full-time staffing coordinators. Call-outs tended to average 6-8 staff per day. Staff were tracked and held accountable for their call-outs and discipline notices were sent. They tried to make deals with staff and offer shift switches to cover shifts, but call-outs were the biggest problem. Some staff had told the DON that they were short staffed at times. Sometimes meal trays were not delivered on time because of kitchen staffing. During an interview with the Administrator on 11/20/2023 at 2:43 PM they stated staffing started out manageable but the call-outs were the problem. Mondays were tough days and the RN Unit Managers sometimes had to work as an LPN passing medications. LPNs had to work as aides. Some families had concerns that CNAs did not do something or did not provide care timely for residents. Float CNAs on the evening shifts were anxious at times because of family complaints about resident care. Continuity of care was important, and the more float CNAs, the less continuity of care. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, record review, and interview during the recertification and abbreviated (NY00326461, NY00326492, and NY00317835) surveys conducted 11/13/2023-11/20/2023, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, accurate, and at an appetizing temperature for 3 of 3 meals reviewed (11/14/2023 and 11/15/2023 lunch meals, 11/16/2023 breakfast). Specifically, food was not palatable or served at appetizing temperatures and meal trays were missing items, Findings include: The facility's policy Management of Resident Dining dated 2/25/2020 documented that it was the responsibility of the cook staff to verify that all food sent to the units for meal service was palatable and at a proper holding temperature. Resident interviews and observations included the following: - on 11/13/2023 at 10:48 AM, Resident #135 stated the food was not good and was mushy. The sandwiches did not taste good, and the chicken salad was not good. - on 11/13/2023 at 11:09 AM, Resident #183 stated the food was always cold. - on 11/13/2023 at 11:38 AM, Resident # 223 stated the food was not hot, was not delivered on time, and did not taste good. - on 11/13/2023 at 12:04 PM, Resident #38 stated they frequently received food that was unappetizing. The sandwiches were soggy due to watery vegetables being plated with the bread. - on 11/13/2023 1:07 PM, Resident #146 stated the food was not good and gave them gastrointestinal distress. They stated they wanted more protein meals, they ate the broth from bean soup and wax beans, and the food had a lot of gravy/sauce, and they would like more sandwich options. The resident stated they did not feel the meal met their needs. - on 11/13/2023 at 2:01 PM, Resident #223 stated their lunch was cold, and items were different than the menu, but this was the norm. - on 11/14/2023 at 9:49 AM, Resident #116 was eating their breakfast meal and stated their eggs were rock hard. During an observation on 11/14/2023 at 1:29 PM, the last tray from the lunch cart on the Unit 3 was selected as a test tray and a replacement was ordered for the resident. Certified nurse aide (CNA) #66 stated the meal did not look good. The top portion of the lasagna was blackened and burned. The meal ticket documented a supplemental dessert that was not included on the tray. During an observation on 11/15/2023 at 8:55 AM, breakfast carts arrived on Unit 3 and were missing all liquids and lids for coffee. Staff was observed looking for lids in the kitchenette. During an observation and interview on 11/15/2023 at 9:21 AM, Resident #135 stated dinner the previous evening was Salisbury steak and tasted like soapy water. Resident #135 stated they were afraid they would get sick if they ate it. They requested a prepackaged peanut butter and jelly sandwich. During an interview on 11/15/2023 at 11:03 AM, LPN #24 stated that orange juice did not come with the breakfast tray delivery today and was substituted with apple, cranberry, or beverage of choice. During an observation and interview on 11/15/2023 at 11:09 AM, Resident #179 was eating breakfast from a tray in their room. They stated they were missing their brown sugar for their oatmeal and their orange juice. CNA #53 answered the call bell and returned with brown sugar. He had been asking for orange juice since 9:30 AM. The CNA stated there was no orange juice in the facility and offered apple or cranberry juice which the resident declined. During an observation on 11/15/2023 at 12:55 PM, Resident #223 was missing chocolate ice from their lunch tray. During an observation on 11/15/2023 at 1:09 PM, Resident #135 was eating lunch in their room and stated they would eat the prepackaged peanut butter and jelly sandwich. They stated they were not going to eat anything else because the food was not good. They stated they loved squash, but it did not taste like squash and did not seem cooked. During an interview and observation on 11/15/2023 at 1:21 PM, Resident #38 stated the squash was served on the plate with the sandwich and the bread was soggy. Resident #38 lifted the sandwich to show the watery runoff from the squash under the sandwich, which had absorbed into the bottom slice of bread. During an observation on 11/15/2023 at 1:27 PM, the following temperatures were measured in the main kitchen on the meal service line: squash 140 degrees Fahrenheit (F), soup 159 F, and ham sandwich 52 F. At 1:36 PM the last cart left the kitchen for Unit 3. At 2:04 PM the last tray to be served on Unit 3 was selected as a test tray and a replacement tray was ordered for the resident. The meal ticket documented double portions of soup, ham salad, squash, mandarin oranges, 2 supplemental shakes, 1 supplemental dessert, 1 apple juice (nectar thick), 1 water (nectar thick), margarine, salt, and pepper. The tray included 1 serving of soup, 2 ham salad sandwiches,1 portion of squash, 2 applesauce, 1 supplemental shake, thickened cranberry juice, thickened lemon-flavored water, buttery spread, salt, and pepper. The tray did not include the supplemental dessert or double soup portions. At 2:08 PM the following temperatures were measured with licensed practical nurse (LPN) Assistant Unit Manager #24 present, the squash was 91 F, the ham sandwich was 70 F, the soup was 141 F, and the supplemental shake was 45 F. During an observation and interview on 11/15/2023 at 1:28 PM, Resident #179 stated they did not like ham salad on wheat bread and were not offered a substitute. They only ate salad, Mighty Shake (supplement), and pears. The resident's meal ticket documented the fruit as mandarin oranges. During an observation on 11/16/2023 at 8:39 AM the following temperatures were measured from the main kitchen steam table: oatmeal 165 F, scrambled eggs 162 F, and pancakes 142 F. At 9:07 AM the cart left the kitchen and at 9:09 it was delivered to the second floor. At 9:20 AM, CNA #34 was delivering the last tray from the cart which was selected as a test tray. The following temperatures were measured with unit secretary #1 present: eggs 116 F, milk 48 F, and coffee 132 F. The meal ticket documented crispy rice cereal and apple cinnamon oat cereal was provided. During an interview on 11/16/23 at 9:31 AM, CNA #34 stated they used to serve meals out of the kitchenette from steam tables which was much better because if items were missing, they could just go to the kitchenette to get the items. They stated if there were missing items they called down to the kitchen. They stated the food sometimes looked appealing but not always. During an interview on 11/16/23 at 9:38 AM, LPN #9 stated hot foods were served with cold foods, or warmed plates with cold sandwiches. Hot foods were not always served hot, and cold foods were not always served cold. They stated items were frequently missing. During an observation on 11/16/2023 at 12:50 PM, Resident #116 was missing cottage cheese and Resident #135 was missing yogurt from their lunch trays. During an interview on 11/16/2023 at 12:44 PM, LPN #19 stated many times residents said the food was cold. They stated food was often cold and even burnt. During an interview on 11/17/2023 at 10:43 AM, registered dietitian (RD) #86 stated substitutions were approved by the RD. The kitchen should let the RD know that an item needed to be substituted, and they would review what items were on hand and pick an appropriate substitution. Pears were a substitution for mandarin oranges, and they were served two days in a row for lunch. Approved substitutions were sent via email to the units by the general manager of the kitchen. The units were to relay the information to the residents. During an interview on 11/17/23 at 2:00 PM, the Director of Nursing (DON) stated they expected the food be appealing and for the residents to want to eat the food. Hot foods should be served hot and cold foods should be served cold. The food should be enjoyable for the residents to eat. During an interview on 11/20/2023 at 11:33 AM, diet technician #69 stated that when serving and checking trays they did look at the quality of the meal and they thought the lasagna was okay for service and was not burned. They stated they only checked the temperature of the meal when they did meal audit test trays which they tried to do about once a week. During an interview on 11/20/2023 at 12:05 PM, Chef Manager #62 stated each position on the tray line checked the tray to the point they were at, the checker at the end of the line checked the complete tray when loading the trays onto the cart for delivery to the units. Nursing staff should check when they passed trays, and they were the final check. They stated when trays were checked they looked at the following: the right diet, if it was up to temperature, appearance, taste, correct portion, and correct items on the tray. Chef Manager #62 stated it was important for the residents to get a quality meal that looked appetizing, was served at the appropriate temperature, and matched the menu because this was the resident's home. During an interview on 11/20/2023 at 12:59 PM, cook #68 stated they checked the temperature of the food as it was placed on the line, and again at the end of the meal service. They stated the hot food needed to be 165 F or over, and cold items needed to be 47 F and below. They stated the squash that was served at 91 F was not acceptable. [NAME] #68 stated the lasagna that was served was burned, but they tried to take the burned layer off before it was served. 10NYCRR 415.14(d)(2)

Based on observation, interview, and record review during the recertification survey conducted from 7/26/21-7/30/21, the facility did not provide each resident an ongoing program to support residents in their choice of activities designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident for 2 of 3 (Residents #2 and 31) reviewed. Specifically, Resident #2 was not offered meaningful activities and was not provided with activities of their choosing. Resident #31 was not provided with music of their choosing as care planned. The 10/27/20 updated Assessment and Documentation of Activity Participation policy documents every effort will be made to promote resident participation in preferred, meaningful activities which includes that care plans are individualized and reflect an adequate level of stimulation. Recreation Services will conduct an initial assessment to gather preferred interests; participation in these activities; strengths, needs, and any changes that impact their participation. Recreation Staff are to conduct a baseline care plan and initial recreation assessment within a timely manner; The initial recreation assessment is to be completed within 7 days of admission. Recreation staff document resident's preferred meaningful resident-centered activities. A new assessment is completed if a resident is re-admitted . Residents who prefer to do their own leisure, these pursuits will be documented how the resident is spending their time. 1) Resident #2 had diagnoses including right sided hemiplegia (paralysis), stroke, and high blood pressure. The 7/1/21 admission Minimum Data Set (MDS) assessment documented the resident had intact cognition, considered music, news, fresh air, and religion important, and required extensive assistance for bed mobility, transfers, dressing, and toileting and locomotion. The 6/24/21 unit recreation assessment documented the resident spoke English, hearing and vision were average, and was alert and oriented. Music was very important, news was somewhat important, favorite activities were very important, going outside was very important, religion was somewhat important; interest activities were games, cards, puzzles, pop, and R&B music, reading various genres, baseball, TV/movies, and talking. The comments section documented the resident had no requests at that time. The 6/28/21 comprehensive care plan (CCP) documented the resident had decreased level of leisure participation. Interventions included: games, cards, puzzles, music, outdoor activity, reading, sports, TV, and socializing, to provide activities, provide calendar of activities, and staff and peer conversation. The 7/2021 activity attendance form documented the resident refused a room to room social on 6/30/21, there was nothing documented from 7/1-7/21, refused a social on 7/8/21, refused a game activity on 7/9/21, went to a courtyard outing on 7/12/21, refused a social on 7/14/21, participated in a social on 7/21/21, refused a social on 7/23/21, and went outside on 7/26/21 and 7/28/21. During observations on 7/26/21 at 11:18 AM and 2:35 PM, the resident was sitting in a wheelchair in the hallway outside their room. The resident was looking out the exit door window. There were no books, magazines, puzzles, word puzzles, cell phone, or radio/CD player in the room. There were no pens, markers, or crayons in the room. An activities calendar was on the wall of the room. The TV was off. When interviewed on 7/26/21 at 2:44 PM, Resident #2 stated there was not much to do around the facility and the resident did not have any puzzles or reading materials available. During observations on 7/27/21 from 10:01 AM to 10:20 AM, the resident was sitting in the hallway outside the room. In the resident's room there were no activity materials or a radio. The TV was off, and the resident was watching animals roam outside. During observations on 7/28/21 from 10:30 AM to 11:15 AM, the resident was sitting in a wheelchair outside in an enclosed courtyard. There were no staff or visitors with the resident. There were 2 other residents sitting in wheelchairs over 6 feet away with social distancing of all the residents. This resident was not communicating with the others. During observations on 7/28/21 from 1:15 PM to 2:00 PM, the resident was sitting in a wheelchair in the enclosed courtyard alone. There were no other residents or staff in the courtyard. There were no activity materials in the resident's room. There was no radio in the room, and the TV was off. During observations on 7/29/21 from 10:15 AM to 11:00 AM, the resident was sitting in a wheelchair at the end of the hall outside their room. There were no activity materials, no radio and the TV was off in the resident's room. The resident stated they were watching 4 deer earlier outside along the wood line. When interviewed on 7/28/21 at 1:09 PM, activity aide #4 stated the resident was cognitively intact. When the resident was assessed on admission, they refused any activity materials. The aide did not think the resident had a personal computer or a cell phone. The activities aide stated activities staff rounded the units weekly asking if a resident wanted anything and did not document when a resident was asked or refused anything. The activities aide did not remember asking the resident if the resident wanted any independent materials after the initial admission offering. The activities aide stated there were books, magazines, word puzzles, a radio/CD player and computer available if a resident wanted to use them. The resident should have been reapproached to ask about activity materials. When interviewed on 7/28/21 at 4:18 PM, the Director of Recreation stated a cognitively intact resident should receive at least 15 minute activity sessions 2 to 3 days a week, unless they refused. The Director stated the Activities Department lost 2 full time positions during the pandemic and the facility census was growing. The Director stated the resident had initially declined independent materials, and the resident should have been reapproached about these items The Director stated the care plan was not followed and expected staff to document in a progress note any material offerings and refusals. When interviewed on 7/29/21 at 12:37 PM, the resident stated they would read books or magazines if they were offered and brought to them. They would listen to the radio if they had one. When interviewed on 7/30/21 at 10:06 AM, certified nurse aide (CNA) #6 stated the resident was cognizant. The CNA had not seen the activities staff ask the resident if they wanted any independent materials of preference. The CNA stated the resident was on the CNA's full time assignment list and had known the resident since admission. The CNA had seen activities staff round weekly on the unit and offer reading materials to other residents in the past. The CNA stated the resident was able to self-propel a wheelchair on the unit and used both arms for other tasks. The resident was able to voice needs and wants. 2) Resident #31 was admitted to the facility with diagnoses including nontraumatic intracerebral hemorrhage (brain bleed/stroke), hemiplegia (paralysis affecting one side), and malignant neoplasm of the cerebellum (brain tumor). The 11/10/20 Annual Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance for most activities of daily living (ADLs), and activity preferences included: listening to music and participating in their favorite activities. The comprehensive care plan (CCP) revised 2/8/21 documented the resident needed assistance to participate in leisure activities due to their cognitive status. The resident required assistance with setting up music on a boom box in their room and the resident had compact discs (CDs) available in their room which were brought in from family. The resident was unable to play music on their own. The 7/17/19 Initial Recreation Assessment documented the resident enjoyed music; rock, and all other kinds. The 5/31/21 activity progress note documented the resident was in the lounge mainly in the mornings for stimulation. The activities team would set up the resident with the resident's own CDs and the resident listened to hard rock in their room or in the lounge. The Care Card (care instructions) active on 7/30/21 documented the resident enjoyed the following independent activities: watching TV, listening to music, and looking at magazines. The resident needed set up for TV or music in the lounge or in their room. The 7/2021 Activity Log documented the resident had activities documented on 17 out of 29 days of the month. On 7/26/21 at 10:30 AM, the resident was observed in their room; no music was playing for the resident. On 7/28/21 at 12:30 PM, the resident was observed in the lounge/dining room, nodding off at a table. There was no music playing. On 7/29/21 at 9:32 AM, the resident was observed in the lounge/dining room; oldies music was playing from the television. During an interview on 7/30/21 at 8:11 AM, certified nurse aide (CNA) #7 stated activities aide #4 came to the unit to provide activities; they also played music in the lounge and some residents had CD players in their rooms. When prompted, the CNA stated the resident had a CD player available in their room and they thought the resident liked 80's music. The CNA stated the resident usually watched their roommate's TV. On 7/30/21 at 9:12 AM, the resident was observed in the lounge/dining room; oldies music was playing, and the resident's head was down. During an interview on 7/30/21 at 9:46 AM, registered nurse (RN) Unit Manager #8 stated the resident enjoyed rock music and the RN had listened to the music with the resident; the resident's mom visited daily which provided the resident with stimulation. During an interview on 7/30/21 at 10:19 AM, activities aide #4 stated the activities department had been providing a lot of 1:1 activities with residents due to the COVID-19 pandemic. CD players were available for residents to use. The resident's mother visited often; the resident would participate in simple games such as dice rolling or bean bag tossing. The resident enjoyed rock music and had CDs in their room; the staff could bring the resident's music into the lounge to listen to. The activities aide stated it would be helpful if the nursing staff assisted with music for the resident; they were covering three units and they did not always have availability to set up music for the resident. 10NYCRR 415.5(f)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey, the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 of 7 residents (Resident #136) reviewed for nutrition. Specifically, Resident #136 had weight loss, was ordered a nutritional supplement, did not receive the ordered amount, the supplement was left with the resident without confirmation of consumption and was documented as consumed when it was not. Additionally, the resident had drinks spilled on her breakfast tray, the tray was removed before consumption and a replacement meal was not provided. Findings include: The Medication Administration policy revised 5/7/19 documented: - Medications are administered in accordance with written orders for the attending physician or physician extender. - Medications are administered at the time they are prepared. - The person who prepares the dose for administration is the person who administers the dose. Resident #136 was admitted to the facility on [DATE] and had diagnoses including chronic kidney disease and Alzheimer's disease. The 4/11/19 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance of one person for bed mobility, transfers and dressing and was able to feed herself after set up. The comprehensive care plan (CCP) dated 10/29/18 documented the resident was resistive to care, refused to get out of bed, and refused medications. Interventions included reassure the resident and reapproach 5-10 minutes later and try again. The nutrition progress note dated 2/18/19 documented the resident had continued weight loss down to 127 pounds, which showed a significant weight loss over 6 months. The resident was accepting of nutritional supplements. Nutritional Supplement The physician order dated 2/18/19 documented Resource 2.0 (a nutritional supplement) every day and evening shift for weight loss, give 240 cubic centimeters (cc) 2 times per day. The CCP updated 4/5/19 documented the resident was at nutrition risk related to history of weight loss. Interventions included monitor nutrition intake, provide supplements and snacks as ordered. The physician progress note dated 5/28/19 documented the resident was being seen for moderate protein-calorie malnutrition based on a 9 pound weight loss over the last 6 months. The plan was to encourage a high protein diet, consult dietary, and monitor weight. The 5/2019 medication administration record (MAR) documented Resource 2.0 was administered on the day shift by licensed practical nurse (LPN) #4: - on 5/30 with 120 cc accepted; and - on 5/31 with 120 cc accepted. The resident was observed in her room with one full small plastic cup (120 cc) of Resource: - on 5/30/19 from 10:59 AM to 12:44 PM the drink was on her overbed table, from 12:44- 1:12 PM the drink was on the nightstand, out of reach; and - on 5/31/19 from 8:38 AM to 9:08 AM a full cup of Resource was removed from the room with the resident's breakfast tray. On 5/31/19 at 2:30 PM, LPN #4 stated in an interview that she provided Resource to the resident on 5/30 and 5/31 and marked it on the MAR as administered. She stated she gave the resident one 120 cc cup of Resource 2.0 and left it in the resident's room, as the resident was able to hold her cup and drink independently. LPN #4 was unsure if the resident drank the Resource on 5/30 and 5/31, it was up to the CNAs to report if the resident consumed it. The nutrition progress note dated 5/31/19 at 4:01 PM documented the resident had confirmed weight loss from 122 pounds to 116 pounds. Intake appeared stable with good acceptance of supplements, Resource 2.0 was ordered for 240 cc twice per day, but the resident was typically only drinking 120 cc. She recommended to change the Resource to 120 cc three times per day for better compliance and to increase caloric intake. The physician order dated 6/3/19 documented Resource 2.0, 120 cc three times a day for supplement. The resident was observed with a full 120 cc plastic cup of Resource on her overbed table on: - on 6/3/19 from 9:25 AM to 10:17 AM; and - on 6/4/19 from 9:43 AM to 12:20 PM. The 6/2019 MAR documented: - on 6/3/19, LPN #4 administered 120 cc of Resource 2.0 to the resident during the day shift; and - on 6/4/19, the resident refused 120 cc of Resource 2.0 when administration was attempted by LPN #4. When interviewed on 6/4/19 at 11:41 AM, Assistant Unit Manager LPN #3 stated the procedure for administering ordered nutritional supplements was for the nurse to provide it during the medication pass, remain with the resident as it was consumed, and to document the amount consumed. If the resident refused, the nurse should try again and then document on the MAR if refused. He stated nurses should not leave ordered supplements with the resident, even if the resident was able to feed herself, as the actual amount consumed may not be recorded. It was not acceptable to record the amount on the MAR without knowing how much the resident drank. He stated the resident was ordered to have 240 cc (a large Styrofoam cup or 2 small plastic cups) twice per day, and it was just changed to 120 cc three times per day. The amount noted on the MAR was considered the amount the resident consumed. He added CNAs were not responsible for reporting to the nurse how much of the supplement was consumed. During an interview with Registered Dietitian (RD) #5 on 6/4/19 at 12:16 PM, she stated the resident was receiving Resource 2.0 for weight loss and it was to be administered by the nurses as part of the medication pass, since it was a physician ordered supplement. The RD based her nutritional assessment on the resident's acceptance of the supplement as documented on the MAR. When interviewed on 6/4/19 at 12:20 PM, LPN #4 stated she provided the resident 120 cc of Resource 2.0 each morning by placing a straw in the cup and leaving it on the resident's overbed table. She did not stay with the resident to offer the drink or monitor consumption. When she brought the drink to the resident, she considered it administered and recorded the amount she provided to the resident and did not consider it the same as a medication pass because it was just a drink. She was unsure of how much supplement the resident consumed. If she saw the drink was still in the room later, she did not adjust the MAR and was unsure if she could do so. The LPN stated she was unaware the order was changed from 240 cc to 120 cc and had always given the resident 120 cc prior to the 6/3/19 order change. The LPN accompanied the surveyor to the resident's room and confirmed the cup on the nightstand was the 120 cc of Resource 2.0 she provided in the morning. No replacement meal: The following was observed on 5/31/19: - At 9:05 AM, the resident was sitting upright in bed, with her head to the side, and appeared to be sleeping. - At 9:06 AM, CNA#8 entered the resident's room with a breakfast tray and exited the room at 9:08 AM with a full breakfast tray. The resident did not yell out or make any noticeable sounds during the time the CNA was in the room. The tray was observed to have liquid spilled over the food and all the food was still on the tray. CNA #8 stated the resident's drink spilled on the tray and she had to get her another one. - From 9:08 AM to 10:00 AM, no staff were observed entering the resident's room. - At 9:53 AM, breakfast service was completed in the dining/serving area and no other trays were prepared. A nursing progress note dated 5/31/19 at 11:34 AM, entered by LPN #4 documented the resident was combative during care, spit out her medication, and threw her breakfast tray all over herself and the bed. On 5/31/19 at 2:30 PM, LPN #4 stated during an interview according to CNA #8, the resident threw her breakfast tray, and she did not see her do it. On 5/31/19 at 2:40 PM, CNA #8 stated she brought the resident's breakfast tray to her, the resident refused the tray, flailing her arms causing the drink to spill over the tray and yelling she did not want it. The CNA stated she was going to get another tray for the resident, but the resident refused and she did not replace the tray. She stated she did not reapproach the resident later to offer her a tray and she should have. When interviewed on 6/4/19 at 11:41 AM, Assistant Unit Manager LPN #3 stated he had not known the resident to verbally refuse meals. If the resident refused or spilled drinks on her meal, he expected staff to provide a new meal, try again, and let the floor nurse know so they could offer the meal. 10 NYCRR 415.12(i)(1)

**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 label and maintain drugs and biologicals in accordance with currently accepted professional standards including the expiration date when applicable for 2 of 6 nursing units (B and KB) reviewed for medication storage and labeling. Specifically, inspection of medication carts revealed B and KB units had insulin multi dose vials that were outdated and not discarded after 28 days for 2 residents (Residents #11 and 145). Findings include: The facility policy Medication Administration revised [DATE] documented all newly opened multi dose vial containers should be dated with the expiration date which is 28 days from the open date. Licensed nurses must check the expiration dates prior to the administration of any multi dose vial container to ensure the medication is not expired. If the medication has expired it must be discarded immediately. 1) Resident #145 was admitted to the facility on [DATE] and had diagnoses including diabetes and osteomyelitis (bone infection). The [DATE] Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and received insulin daily. A physician order dated [DATE] documented Humolog insulin inject per sliding scale (units of insulin administered dependent on result of fingerstick blood glucose) subcutaneoulsy before meals. On [DATE] at 10:59 AM, the KB-unit medication cart was inspected with licensed practical nurse (LPN) #11. An open vial of Humalog insulin for Resident #145 was labeled as being expired on [DATE]. The LPN stated it should have been discarded after 30 days. The 6/2019 medication administration record (MAR) documented the resident received sliding scale Humalog insulin coverage on [DATE] at 11:30 AM, [DATE] at 7:30 AM, 11:30 AM and 4:30 PM and on [DATE] at at 7:30 AM. 2) Resident #11 was admitted to the facility on [DATE] with diagnoses including diabetes. The [DATE] MDS assessment documented the resident had severe cognitive impairment and received insulin daily. A physician order dated [DATE] documented Insulin glargine (Lantus) inject 8 units subcutaneously two times a day for diabetes. On [DATE] at 11:39 AM, the B-Unit South medication cart was inspected with LPN #9, an open vial of Lantus for Resident #11 was observed with a handwritten expiration date of [DATE]. The LPN stated the vial was outdated and was only good for 30 days. She immediately reordered the medication for the resident and disposed of the outdated vial. The 6/2019 medication administration record (MAR) documented the resident received Lantus insulin 8 units on [DATE] at 8:00 AM and 8:00 PM and on [DATE] at 8:00 AM. 10NYCRR 415.18 (d)

Based on observation, record review and interview during the recertification survey, the facility did not ensure the provision of food and drink was palatable, attractive, and at a safe and appetizing temperature for 2 of 3 meals tested. Specifically, food was not served at palatable and safe temperatures. Findings include: The kitchen form titled HACCP Critical Control Points Daily Temperature Log and Daily Taste Panel Guidelines documented recommended serving temperatures for tray items, with meat, poultry, seafood and eggs to be greater than 145 degrees Fahrenheit (F) to ensure hot food at the point of consumption. The facility policy Food Safety and Procurement revised 11/15/17 documented the facility would store, prepare, distribute and serve food in accordance with professional standards for food service safety. On 5/31/19 at 12:40 PM, a meal test tray was obtained while dining room meal service was still in progress on Unit D. The following temperatures were observed: the fried fish was 107 degrees Fahrenheit (F), the New England clam chowder soup was 144 degrees F, the milk was 47 degrees F, and the coleslaw was 48 degrees F. At 12:50 PM the Food Service Director took the temperature of the fried fish using a facility thermometer which was observed at 103 degrees F. The fish temperature was observed at 101 degrees F using a surveyor thermometer. On 6/3/19 at 9:47 AM, a test tray was observed on Unit B. The test tray was obtained at the completion of the breakfast meal service. The following temperatures were observed using the surveyor thermometer; the chocolate chip pancake was 117 degrees F, the eggs were 98 degrees F, and the oatmeal was 140 degrees F. As dietary aide #1 prepared the test tray she stated the eggs would not be hot because the kitchen just brought them to the unit and the eggs never stayed hot. During an interview with the Food Service Director on 6/3/19 at 1:00 PM, she stated food is expected to be hot and ready to be served to the resident when it comes from the kitchen and nursing staff should not have to reheat food on the unit. She was unaware the eggs served at the end of the breakfast meal were 98 degrees F and stated unit B takes longer to serve than the other units because more residents eat in their rooms. 10NYCRR 415.14(d)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the recertification survey, the facility did not ensure it established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for: 8 of 8 residents observed during a medication pass (Residents #4, 5, 11, 31, 150, 166, 168, and 212); 2 of 2 residents (Residents #53 and 222) reviewed for droplet precautions; and 1 of 2 washing machines reviewed. Specifically, a nurse did not complete hand hygiene between Residents #4, 5, 11, 31, 150, 166, 168, and 212 during a medication pass; multiple staff did not use personal protective equipment (PPE, mask, gloves, gown worn to prevent the spread of infection) when caring for Residents #53 and 222 on droplet precautions for influenza; and 1 of 2 washing machines was not maintained per manufacturer guidelines. Finding Include: The 1/11/11 policy, Droplet Isolation Precautions, documented staff should wash hands for a minimum of 20 seconds between residents, wear a mask when within 6 feet of the resident, and if cohorting residents (semi-private room sharing) they should be 6 feet apart, and the privacy curtain should be pulled at all times. The 4/5/17 policy, Hand Hygiene, documented hand hygiene should be completed either with soap and water or alcohol-based hand rub (ABHR) before and after resident contact, and after removing gloves. The 3/21/19 policy, Infection Prevention and Control Program, documented standard precautions applies to all residents and includes hand hygiene, PPE use depending on the care to be provided, and shared equipment is to be cleaned and disinfected between residents. Hand Hygiene: During a medication pass on 5/31/19, LPN #9 did not perform hand hygiene: -from 9:34 AM- 9:47 AM before and after administering medications to Residents #11, 212 and 168; -at 9:55 AM before preparing and administering Resident #150's medications, in between glove changes when applying a medicated cream on the resident, administering eye drops, and then applying lotion and wraps to the resident's legs; -at 10:12 AM, before or after administering medications to Resident #4; -at 10:15 AM, after transporting Residents #31 and 5 in their wheelchairs from the hall to their shared room (the room was labeled as being on contact isolation), and in-between glove changes when medications were administered to both residents in the room; and - at 10:41 upon exiting Resident #31 and 5's room (contact precautions) and preparing and administering medications for Resident #166. The LPN was observed touching the trash container in the room. She did not perform hand hygiene before applying new gloves and after assisting the resident after he spit out some of his nutritional supplement. During an interview on 6/04/19 at 11:46 AM, LPN #9 stated hand hygiene should be completed between each resident and after every treatment. She stated she did not believe she completed hand hygiene between residents during the medication pass observed and she should have. During an interview on 6/04/19 at 11:56 AM, the Infection Control Nurse (ICN) stated nurses should be completing hand hygiene before and after each resident contact. During an interview on 6/04/19 01:16 PM Assistant Unit Manager LPN #10, stated staff should complete hand hygiene before and after care for each resident. Hand sanitizer should be used after glove changes during a dressing change. She expected staff to wash with soap and water after caring for 3 residents and to use hand sanitizer between each one. Staff should be following the instructions on the isolation signs any time the room was entered. Personal Protective Equipment Use: Resident #222 was admitted to the facility on [DATE] and diagnoses included unidentified influenza virus. The 4/16/19 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment. A nursing progress note dated 5/26/19 at 9:50 PM documented Resident #222 was diagnosed with flu and continued on droplet precautions. Resident #53 was admitted to the facility on [DATE] and diagnoses included influenza. The 3/29/19 MDS documented the resident had intact cognition. A nursing progress note dated 5/29/19 at 11:49 AM documented Resident #53 was tested for flu, results were pending, and the resident was placed on droplet precautions. On 5/30/19 at 10:34 AM a nursing progress note documented the resident tested positive for influenza Type A and continued on droplet precautions. The following observations were made on 5/30/19: - At 10:25 AM, a sign was posted outside Resident #222's room stating droplet precautions were in effect and a cart with personal protection equipment (PPE, gloves, mask, gowns) was located under the sign. - At 10:27 AM, certified nurse aide (CNA) #7 entered Resident #222's room with gloves on and did not put a surgical mask or gown on. She exited the room with gloves on. - At 10:30 AM, CNA #7 re-entered Resident #222's room with gloves on and no other PPE. - At 10:34 AM, Resident #53's rooms had a sign posted outside the room indicating droplet precautions were in effect and a cart containing PPE was located under the sign. - At 12:29 PM, CNA #7 entered Resident #53's room with a lunch tray in her hands. She did not don PPE, remained in the room as she set up the tray for the resident, cut up the resident's food, and exited the room without performing hand hygiene. - At 12:30 PM, CNA #7 entered Resident 222's room without PPE, delivered a lunch tray and exited the room without performing hand hygiene and returned to the dining room where she approached residents at a table. - At 12:36 PM, LPN #15 entered Resident #53's room without PPE and did not perform hand hygiene. LPN #15 offered the resident assistance with her drinks and exited the room with the tray. She set the tray down on a cart in the dining/serving area, opened the refrigerator to obtain an item, and then waited near the food service line. The LPN did not perform hand hygiene. - At 12:59 PM, CNA #6 entered Resident #53's room without performing hand hygiene or donning PPE. The resident was coughing, CNA#6 assisted the resident and exited the room without performing hand hygiene. CNA #6 then entered Resident #222's room and exited without PPE or hand hygiene and entered another resident room and exited. The CNA then went to the dining/serving area, obtained a new tray without performing hand hygiene and entered another resident room without donning PPE or performing hand hygiene. She sat next to the resident's bed and assisted her with the meal. On 5/31/19 the following observations were made: - At 9:10 AM, an unidentified CNA delivered a meal tray to Resident #222's room without donning PPE or performing hand hygiene upon entry and exit. The CNA returned to the dining/serving area and obtained another breakfast tray without performing hand hygiene. On 5/30/19 at 12:27 PM, Assistant Unit Manager, licensed practical nurse (LPN) #3 stated in an interview Residents #53 and 222 were positive for the influenza virus and anyone entering the room should don PPE including a mask, gown, and gloves and perform hand hygiene before entering and exiting. CNA #7 was interviewed on 6/4/19 at 11:25 AM and stated droplet precautions included the use of a yellow gown, gloves, mask, and performing hand hygiene before entering and when exiting the room. She stated she would use the PPE when providing direct care to the resident and would not use PPE for dropping off or retrieving meal trays. She stated she thought the PPE was only for when she was hands on. She stated when delivering or retrieving meal trays, there was no place to set the tray to don/doff PPE or perform hand hygiene, so she would try and do it once she returned to the dining room. During an interview on 6/4/19 at 11:41 AM, Assistant Unit Manager LPN #3 stated all staff were expected to follow proper isolation procedures as detailed on the signs outside the rooms. For droplet precautions, masks, gowns, and gloves should be donned prior to entering the room along with completing hand hygiene. For meal delivery and tray set up hand hygiene and a mask upon entering the room were required. Hand hygiene should be performed upon exiting the room. If staff remained in the room to assist a resident with their meal, he expected staff to don the gown, gloves, and mask while in the room. He stated Residents #53 and 222 were positive for influenza and were on droplet precautions 5/30 and 5/31/19. He stated use of the mask, gloves, and hand hygiene were important to prevent the spread of the virus. During an interview on 6/4/19 at 12:00 PM, CNA #6 stated the procedure for droplet precautions was to use the gown, gloves and mask. There was a sign outside the room if someone did not know. She stated she was confused about how to handle meals, as there was no place to set a tray down to wash her hands or don PPE. She stated she did not have any PPE and did not perform hand hygiene when assisting Residents #53 and 221 and did not think she performed hand hygiene in between residents when clearing trays. She stated she should have washed her hands in the dining/lounge area after putting the used trays away, but she did not do so because she was so busy with meal service. Laundry Services: During an observation on 6/3/19 at 10:21 AM, the laundry room had two washing machines. During record review on 6/3/19 at 2:19 PM, a front load washer-extractor was not maintained as per user manual. The manufacturer instructions for front load washer #1 documented the following: Monthly: - lubricate bearings; - determine of V-belts require replacement or adjustment; - remove back panel and check for leaks; - unlock the hinged lid and check supply dispenser hoses and connections; - clean inlet hose filter screens; - tighten motor mounting bolt locknuts and bearing bold locknuts, if necessary; - use compressed air to clean lint from motor; - clean interior of washer extractor, both basket and shell; and - use compressed air to clean moisture and dust from all electrical components. Quarterly: - tighten door hinges and fasteners, if necessary; - tighten anchor bolts, if necessary; - verify that the drain motor shield is in place and secure; - check all painted surfaces for bare metal; and - clean steam filter, if applicable. The other washer did not have any specific maintenance requirements. During an interview on 6/3/19 at 2:19 PM, the Director of Environmental Services stated the monthly and quarterly maintenance for the washer was done but not documented. Items on the list were fixed as needed/requested. 10 NYCRR 415.19(b)(2)(4)(c)