**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey conducted 3/24/2025 to 3/28/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition for 1 of 7 residents (Resident #142) reviewed. Specifically, Resident #142 was not provided with supervision and maximum cueing with eating and was not provided meals in the dining room as planned. Findings include: The facility policy [Activities of Daily Living] Assistance and Supervision. approved 1/18/2018, documented the Unit Manager and licensed practical nurse team leaders monitored the activity of daily living and supervision provided to the residents and gave appropriate guidance and assistance to nursing staff. The certified nurse aides provided the activities of daily living assistance and supervision to their assigned residents. The personal care profile and care plan were referenced for the type of activities of daily living and supervision needed by a resident. Resident #142 had diagnoses including Parkinson's disease (a progressive neurological disorder), dysphagia (difficulty swallowing), and dementia. The 2/19/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, had no behavioral symptoms, and required supervision/touching assistance for eating. The Comprehensive Care Plan, initiated 7/24/2023 and revised 3/7/2025, documented the resident had an activities of daily living function and mobility deficits related to muscular weakness. Interventions included the resident required supervision or touching assistance for eating, was to be in the dining room for all meals and needed maximum encouragement for eating. The resident had an eating functional maintenance plan to have the staff set-up the resident's meals, strongly encourage the resident to eat in the dining room for all meals and required supervision to stand by assistance and constant verbal cues to eat and not just drink at meals. Turn off the television when providing care in the resident's room to increase participation as they were easily distracted and had increased difficulty participating in activities of daily living when their attention was divided. The resident's care instructions ([NAME]) documented the resident required supervision or touching assistance and maximum encouragement at meals and was to be in the dining room for all meals. The percentage of meal consumption from 03/20/2025 to 3/27/2025 documented: - on 3/20/2025 breakfast was 26-50%, lunch was not documented; and dinner was 0-25%; - on 3/21/2025 breakfast was 0-25%, lunch was 0-25%, and dinner was 0-25%; - on 3/22/2025 breakfast was 0-25%, lunch was 26-50%, and dinner 51-75%; - on 3/23/2025 breakfast was 0-25%, lunch was 0-25%, and dinner was 26-50%; - on 3/24/2025 breakfast was refused, lunch was 0-25%, and dinner was 51-75%; - on 3/25/2025 breakfast was 51-75%, lunch was 0-25%, and dinner 0-25%; - on 3/26/2025 breakfast was 26-50%, lunch was 0-25%, and dinner 0-25%; - on 3/27/2025 breakfast 0-25%, and lunch 0-25%. The following observations of Resident #142 were made: - on 3/24/2025 at 12:02 PM staring straight ahead and not eating their lunch. There was no staff encouragement provided to the resident throughout the meal. - on 3/26/2025 at 11:36 AM, Licensed Practical Nurse #20 asked the resident if they wanted to have lunch in the common area across from the nursing station and the resident agreed. At 12:17 PM, the resident had their meal on an overbed table. There was a partially eaten hot dog in their hand, resting on their leg. At 12:26 PM, the resident continued to hold the hot dog in their hand, resting on their leg. The resident was staring straight ahead. The rest of their meal tray included meat loaf, cheesy potatoes, beets, chocolate milkshake, and pears and was untouched. Staff did not provide encouragement or assist the resident with their meal. - on 3/27/2025 at 8:59 AM in bed with their breakfast tray in front of them on the overbed table. The tray included two juices, chocolate milk, eggs, biscuits and gravy, and a cut up banana. All the items appeared untouched. The resident was watching television. Licensed Practical Nurse #34 administered the resident's morning medications and did not encourage the resident to eat or offer food alternatives. From 11:56 AM to 12:58 PM, the resident was in the dining room and received their lunch tray which included a hotdog with mustard, a small portion of turkey noodle bake, and bacon brussels sprouts. The resident did not eat anything on their tray. At 12:30 PM Certified Nurse Aide #42 passed by the resident without stopping and encouraged them to eat their hotdog. The resident only drank their chocolate milk and was not offered an alternative when they did not eat their lunch. - on 3/28/2025 at 8:58 AM sitting on the side of their bed looking out window. The resident had untouched toast with jam and two pieces of bacon on their breakfast tray. The resident drank all their chocolate milk and some of their juice. At 9:17 AM, the resident had not touched their meal. During an interview on 3/28/2025 at 9:34 AM, Certified Nurse Aide #33 stated a resident's meal assistance level was on the resident care instructions. If a resident required supervision with max cueing that meant staff had to constantly encourage the resident to pick up a utensil and put it to their mouth. Resident #142 required supervision with max cueing for their meals. The resident was provided cueing for lunch but not as much during breakfast. They stated they were not present for lunch on 3/27/2025 so they did not know if the resident was cued. It was important to provide cueing and supervision so the resident could get proper nutrition. During an interview on 3/28/2025 at 9:58 AM, Licensed Practical Nurse #34 stated the resident care instructions documented a resident's assistance level for meals. Resident #142 required supervision for meals. Supervision with max cueing meant the resident had to be reminded to take a bite, take a drink, and have someone always supervising. They expected Resident #142 to be supervised and receive max cueing with meals. If the resident was alone in their room or in the independent dining room with no one cueing them, they were not receiving supervision with max cueing as planned. During an interview on 3/28/2025 at 10:21 AM, Registered Nurse Unit Manager #19 stated resident care instructions documented what the resident's assistance level was for meals. Resident #142 required supervision with max cueing for meals which meant staff went in and out to supervise and offer food to the resident. They expected the resident receive assistance during meals as care planned. If the resident was in the independent dining room they should receive cueing during meals. It was important to provide cueing and supervision, so they received proper nutrition. During an interview on 3/28/2025 at 12:25 PM, the Assistant Director of Therapy/Occupational Therapist #31 stated Resident #142's functional maintenance program was initiated in January 2024 and updated in March of 2024. Resident #142 required supervision with maximum cueing due to the resident having trouble maintaining attention when eating. The resident consumed liquids but did not eat when unattended. This did not mean someone had to sit with Resident #142 constantly during their meal, but they should be giving the resident consistent cues to eat if they were not paying attention. If Resident #142 was in their room during breakfast, the cueing would be more intermittent. If the resident was in the dining room and had not touched their food, staff should provide more frequent cueing. They stated if the resident did not touch their food and was not provided with cueing, that was a problem. If a resident needed cueing and did not receive it, they could have decreased intake and weight loss. 10 NYCRR 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification and abbreviated (NY00333993) surveys conducted 3/24/2025-3/28/2025, the facility did not ensure residents received adequate supervision to prevent accidents for 2 of 13 residents (Residents #164, and #171) reviewed. Specifically, -Resident #171 had dysphagia (difficulty swallowing), was on aspiration (inhaling food/fluid into the lungs) precautions and the resident was provided ice chips without a physician order or supervision. -Resident #164 was at high risk for elopement (leaving premises/safe area without facility knowledge), the resident frequently wandered in non-residential areas, and there was no documented evidence of a plan to limit the resident's wandering to potentially unsafe areas. Additionally, the resident's wander alert device was not checked for function as planned. Findings include: The facility policy Aspiration Precautions Guidelines, revised 7/24/2018 documented if orally fed, maintain the resident's head of bed at 45° or higher for at least 30 minutes after meals and consumption of food/liquids, unless otherwise ordered by medical. Provide constant supervision/assistance at mealtime. Observe closely for signs/symptoms of aspiration (respiratory distress, coughing, wheezing, cyanosis [bluish discoloration from low oxygen levels], and tachycardia [high heart rate]). The facility policy Care Planning, revised 1/22/2019 documented the interdisciplinary team would develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. The facility policy Electronic Wandering Security System, revised 2/13/2019 documented an electronic security system designed specifically for those residents identified as being at risk for elopement was installed to allow residents to ambulate independently in a controlled, safe environment, while preventing them from leaving the building without staff awareness. The nursing staff applied and maintained the bracelet/anklet, the nurse would verify the placement of the bracelet/anklet every shift, and the nursing department or maintenance department would be designated to check the functionality of the device daily using the designated tester. Functionality would be documented in the resident medical record or maintained in the maintenance department. 1) Resident #171 had diagnoses including dysphagia (difficulty swallowing), dysarthria (slurred speech), and facial weakness following a stroke. The 2/15/2025 Minimum Data Set assessment documented the resident was cognitively intact, complained of difficulty or pain with swallowing, had a feeding tube, and received partial/moderate assistance with most activities of daily living. The 3/18/2025 at 12:23 PM Licensed Practical Nurse #30 progress note documented the resident returned from a barium swallow study. Findings included aspiration of thin and nectar thick barium, penetration of honey and pudding puree barium. Recommendations included baseline diet intake (FOIS level 1, Functional Oral Intake Scale, nothing by mouth) and [NAME] free water protocol (allows patients to drink small sips of water or have ice chips between feedings). The 3/18/2025 at 1:55 PM Speech Language Pathologist #32 progress note documented the resident would remain nothing by mouth at that time and would work towards treatment for safe oral intake of purees and manage chronic pharyngeal residue. The plan did not include provision of ice chips. The 3/20/2025 at 10:35 AM Speech Language Pathologist #32 progress note documented the resident's diet changed to nothing by mouth with oral gratification to allow pureed items. The resident remained dependent on their tube feedings for nutrition and hydration. The resident was to be upright in a chair to consume by mouth and aspiration precautions were in place. The 3/20/2025 physician order documented nothing by mouth with oral gratification diet, pureed consistency, no liquids consistency; aspiration precautions maintain every shift. The Comprehensive Care Plan initiated 2/12/2025 and revised 3/20/2025 documented the resident had a potential for alteration in nutrition related to nothing by mouth status with oral gratification to allow pureed items. Interventions included aspiration precautions, pureed solids/honey thick liquids, must be out of bed and in a chair for meals, and may have 60 milliliters of ice chips upon request when upright in a chair and not in bed outside of mealtimes. The undated care instructions documented the resident was on aspiration precautions, could have 60 milliliters of ice chips with a teaspoon when upright in a chair, not in bed, and outside of mealtimes. There was no documented evidence the resident had a physician order to consume water or ice chips. The 3/24/2025 at 11:16 Physician #47 progress note documented the resident was evaluated for history of dysphagia. The resident continued to aspirate despite therapy, worse with thin liquids than with honey thickened liquids. Resident #171 was observed: - on 3/26/2025 at 10:12 AM, lying in bed with the head of bed elevated at 45 degrees. They had a 20-ounce cup full of ice chips on their bedside table and no staff was present. They stated they ate them in bed when their mouth was dry, or they were thirsty. - on 3/27/2025 at 9:00 AM, lying in bed with the head of their bed elevated at 45 degrees. Certified Nurse Aide #25 brought in a 20-ounce cup full of ice chips and put them on their bedside table and exited the room. At 9:05 AM, lying in bed with the head of their bed elevated at 45 degrees eating ice chips with a spoon. - on 3/28/2025 at 9:30 AM, lying in bed with a 20-ounce cup of ice chips on their bedside table with no staff present. During an interview on 3/27/2025 at 1:20 PM, Certified Nurse Aide #25 stated they cared for Resident #171 that morning and brought them ice chips. They did not follow the care instructions, the resident was in bed and not in a chair, and they brought more than 60 milliliters of ice chips. They stated if they ate the ice chips in bed and not in a chair it put the resident at risk to choke, and it was important to follow the care instructions for Resident #171's safety. During an interview on 3/28/2025 at 9:48 AM, Certified Nurse Aide #29 stated Resident #171's diet recently changed, and they were allowed to have 1 pureed item at mealtime and ice chips upon request. Their care instructions said 60 milliliters of ice chips which was a small amount, and they had given the resident 20-ounces which was much more than that. They let Resident #171 have the ice chips while they were lying in bed because they thought the resident knew to sit up while eating them. They did not think the resident was on aspiration precautions. They should have the resident go to the dining room to be monitored while eating and would not have left the ice chips at their bedside without supervision. During an interview on 3/28/2025 at 10:14 AM, Licensed Practical Nurse #30 stated Resident #171's diet had recently changed, and they were allowed to have ice chips. They did not think there was a restriction on how much they could eat, and they were not aware it said 60 milliliters. The black cup at the resident's bedside was much more than 60 milliliters and the certified nurse aides should follow the care instructions for Resident #171's safety. If they left the ice chips while the resident was lying in bed and not in the chair it put them at risk for aspiration. During an interview on 3/28/2025 at 10:38 AM, Assistant Director of Therapy #31 stated Speech Language Pathologist #33 was working with Resident #171 and upgraded their diet to allow them to have 1 or 2 pureed items at mealtime and 60 milliliters of ice chips in between mealtime but they had to be out of bed and sitting in a chair. They were on aspiration precautions which meant they were supposed to have staff supervision while consuming their food or ice chips. They expected nursing to follow the recommendations they were all educated on and only give the resident 60 milliliters of ice chips at a time and not fill a 20-ounce cup and leave it at Resident #171's bedside. The resident should have a small amount of ice chips at a time with staff supervision and if they consumed them while lying in bed it put them at a higher risk for aspiration. During an interview on 3/28/2025 at 1:51 PM, Registered Nurse #14 stated the care instructions contained all the information the certified nurse aides needed to provide care and they should review them often to see if any changes were made. Resident #171 was on aspiration precautions which meant they required staff supervision while they consumed food or ice chips. The certified nurse aides were educated to know the size of their cups and 60 milliliters which was about 2 ounces of ice chips and would have been one of their medium sized plastic cup. Resident #171 should not have received a 20-ounce cup of ice chips while they were lying in bed and without direct supervision because it put them at a higher risk for aspiration or choking. Speech Language Pathologist #33 declined an interview prior to the survey exit. 2) Resident #164 had diagnoses including early onset Alzheimer's disease and history of falling. The 12/20/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, wandered 4-6 days placing the resident at a significant risk of getting to a potentially dangerous place, had no upper or lower extremity impairments, did not use a mobility device, required supervision/ touching assistance with walking 10 feet, walking 50 feet with two turns, and walking 150 feet, and used a wander/elopement alarm daily. The 12/12/2024 Elopement Assessment completed by Licensed Practical Nurse Unit Manager #5 documented the resident was a low risk for elopement. Nursing progress notes documented: - on 12/12/2024 at 10:16 PM by Licensed Practical Nurse #15 the resident was wandering the unit on several occasions. - on 12/13/2024 at 2:40 PM by Licensed Practical Nurse #9 the resident wandered down towards the lobby and was redirected by staff. - on 12/13/2024 at 2:50 PM by Registered Nurse #14 the resident was noted to have impaired cognition, wandered off the unit to the lobby, and was easily redirected. A new Elopement Assessment was completed, the resident was a high risk for elopement, and a wander alert device was applied to the resident's right ankle. The 12/13/2024 at 2:48 PM Elopement Assessment completed by Registered Nurse #14 documented the resident was high risk for elopement. The 12/13/2024 physician order documented to check for the presence of the electronic security bracelet/ anklet (wander alert device) every shift and check the function every night shift. On 12/13/2024 the Comprehensive Care Plan was updated and documented the resident was at high risk for unsafe wandering/ elopement. The resident ambulated without a device, had dementia, a history of wandering, and impaired cognition and memory. Interventions included a wander alert device on the right ankle, complete wandering/ elopement risk assessment per policy, and place a picture of the resident with the receptionist and other units as appropriate. The 12/2024 Treatment Administration Record documented check electronic security bracelet/ anklet function every night shift. Nursing progress notes by Licensed Practical Nurse #12 documented on 12/13/2024 at 11:02 PM, 12/16/2024 at 11:53 PM, 12/21/2024 at 11:15 PM, 12/22/2024 at 11:13 PM, 12/23/2024 at 10:47 PM, 12/26/2024 at 10:52 PM, and 12/30/2024 at 10:49 PM there was no meter to check the function of the resident's wander alert device. A 12/14/2024 at 5:01 PM, Licensed Practical Nurse #9 progress note documented a certified nurse aide (unidentified) and they were able to redirect the resident out of another resident's rooms. The resident then walked down the hallway towards the education room and the North Unit. The resident was redirected back to their unit and the doors to the education room and North Unit were closed. At 5:22 PM, the resident wandered into the lobby and was easily directed back to the unit. The doors leading to the lobby were closed to prevent the resident from wandering off the unit. Licensed Practical Nurse #9's 12/15/2025 progress notes documented at 12:10 PM, the resident was wandering on and off the unit. The certified nurse aide (unidentified) directed the resident back from the elevators. The resident appeared agitated and was going in and out of other resident's rooms. At 1:49 PM, the resident wandered down to the time clock and was difficult to redirect. At 1:52 PM and 4:40 PM, the resident was wandering at times and was difficult to redirect. Licensed Practical Nurse #9's 12/28/2024 progress notes documented at 10:32 AM the resident was brought back to the unit from the Human Resource office area and the double doors were closed. At 11:44 AM, the resident wandered off the unit into the employee cafeteria through the kitchen entrance. The supervisor was able to redirect the resident to the lobby area and eventually back to the unit. At 5:11 PM, the resident wandered off the unit into the lobby and was brought back to the unit. There was no documented evidence the resident's care plan was revised to include interventions when the resident attempted to wander to potentially unsafe areas of the facility. Nursing progress notes by Licensed Practical Nurse #12 documented on 1/1/2025 at 11:17 PM, 1/3/2025 at 10:51 PM, 1/4/2025 at 10:55 PM, 1/5/25 at 11:59 PM, 1/6/25 at 10:42 PM, and 1/7/25 at 11:45 PM there was no meter to check the function of the resident's wander alert device. A 1/5/2025 at 12:20 PM, Licensed Practical Nurse #17 behavior monitoring note documented the resident was pacing periodically, wandering into inappropriate areas, was exit seeking, and restless. This behavior lasted over 60 minutes and non-pharmacological interventions such as toileting, offering food/ drink, and small group activities did not change their behavior. Licensed Practical Nurse #9 progress notes documented: - on 1/10/2025 at 5:41 PM the resident wandered into the lobby and other resident rooms all day. - on 1/11/2025 at 3:58 PM the resident wandered in and out of rooms. - on 1/16/2025 at 5:09 PM the resident wandered off the unit into the kitchen and was brought back to the unit by staff. A 1/17/2025 at 5:03 AM progress note by Registered Nurse #1 documented the resident wandered all night, was found in other resident's room, and in the lobby by the front door. The resident was easily redirected. A 1/22/2025 at 2:49 PM, Licensed Practical Nurse #20 behavior monitoring note documented the resident was wandering into inappropriate places, wandered off the unit into the lobby, and had increased confusion. Their behavior occurred a few times and non-pharmacological interventions were effective. On 1/30/2025 at 4:25 PM, Licensed Practical Nurse #11 documented the resident was walked to the unit by kitchen staff who stated the resident was standing next to the steam table. The resident was currently seated in a chair by the nurse's station and would continue to be monitored. During an observation on 3/28/2025 at 10:37 AM, the employee time clock was in a hallway behind the main elevator bank near an alcove that went to the employee cafeteria, an entrance to the main kitchen with access to the steam tables, and an area where the meal carts were stored. The employee cafeteria had another entrance that accessed the hallway near the Human Resource office area. The doors to the employee cafeteria and main kitchen were open. The resident was observed on 3/27/2025 at 10:10 AM, walking the long hallway holding a doll. At 10:20 AM, wandering into other resident's rooms in the long hallway, and at 1:26 PM, walking the long hallway. During an interview on 3/28/2025 at 12:18 PM, Licensed Practical Nurse #11 stated the wander alert devices only alarmed if a resident was near the main entrance or near the Human Resource office area as there was an exit near that area to the adult day program. They did not think the system would alarm if a resident went into the main kitchen, employee cafeteria area, or time clock area. Nursing was supposed to check for the presence and function of the wander alert device. If they did not have a scanner/ meter to test the function of the wander alert device a supervisor should have been made aware. The meter was observed in the top drawer of the medication cart. They stated one evening an unknown kitchen staff brought the resident back to the unit. The resident was found by the steam tables in the serving area of the main kitchen. They alerted the Nursing Supervisor and documented the incident. During an interview on 3/28/2025 at 12:35 PM, Licensed Practical Nurse #9 stated Resident #164 used to wander the unit, go to the lobby, was found by the time clock, in the kitchen, employee cafeteria, and Human Resource office area. They alerted the nursing supervisor each time the resident was brought back to the unit from nonresidential areas and documented the incidents in their notes. They would do a visual check and document any observed issues. Nursing staff should observe the placement and test the function of the wander alert device daily, and document in the chart. If staff were unable to find the wander alert device scanner/ meter to check the function of the wander alert device, they should alert a supervisor. They never heard of any issues with the wander alert device meter missing or not working. A telephone interview was attempted with Licensed Practical Nurse #12 on 3/28/2025 at 3:21 PM and a voicemail was left. No return call was received prior to exit. During an interview on 3/282/2025 at 3:24 PM, Licensed Practical Nurse Unit Manger #5 stated wander alert devices should be checked daily for placement and function. If a nurse was unable to locate the wander alert device scanner/ meter to perform the function test they should alert the supervisor. During an interview on 3/28/2025 at 4:35 PM, the Director of Nursing stated each unit had a wander alert device scanner/ meter to check the function of wander alert devices. If they were unable to locate the wander alert device scanner/ meter they should alert the supervisor. They were unaware Resident #164 was found in the main kitchen near the steam tables and stated a supervisor should have been made aware and completed a nursing assessment. 10NYCRR 415.12 (h)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00343302 and NY00370767) surveys conducted 3/24/2025-3/28/2025 the facility did not ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Residents #143) reviewed. Specifically, Resident #143's telepsychiatry recommendations for non-pharmacological interventions for behavioral symptoms were not implemented. Findings include: The facility policy SEASONS Memory Care Program, updated 12/20/2019, documented the program provided the residents a safe environment while enlarging their life with appropriate and purposeful activity that accommodated the individual's strengths, interests, and needs while promoting autonomy and assisting them in maintaining their level of ability. This was to reduce anxiety and boredom driven behaviors. The facility policy Behavior Monitoring, approved 2/10/2020, documented the facility ensured that mood, behaviors, social problems or psychosocial adjustment difficulties of the individual were reported, recorded, monitored, and care plan interventions were developed to address those observed behaviors. Evaluation of the effectiveness of those interventions was monitored on an ongoing basis by the interdisciplinary team. Non-pharmacological Interventions were implemented to help manage behaviors. Resident #143 had diagnoses including dementia with agitation, and depression. The 1/29/2025 Minimum Data Set documented the resident had severe cognitive impairment, continuous inattention, verbal and other behavioral symptoms one to three of seven days, and took antidepressant and antipsychotic medications. A 6/5/2024 physician order documented telepsychiatry appointments as needed for depression. The comprehensive care plan initiated 8/1/2024 and revised 3/20/2025, documented the resident had the potential for alteration in mood and behavior related to Alzheimer's, agitation, and anxiety. The resident was resistive to care; hit, bit, scratched, and pinched staff; and verbally threatened and swore at staff. The resident was depressed and had a history of suicidal ideation; was exit seeking and attempted to kick out windows or punch walls; was socially inappropriate and disruptive; had self-abusive acts of hitting themself in the face; refused medications and meals; and had unpredictable behaviors. Interventions included provider review of medications for intrusive and aggressive behaviors; ensure the resident held their doll or a soda bottle to prevent taking other residents' items; administer medications as ordered; approach the resident from the front in a calm, gentle manner; assure the resident did not attempt to stand on or push a chair; encourage to verbalize feelings; document behaviors; psychiatric consults as needed; monitor pain; remove from stressful situations; bring to the nurses' station if they were up early; offer drinks or snacks; offer busy work like folding clothes; and trazodone (antidepressant often used as a sleep aid) was started for increased insomnia and inappropriate wandering. The 11/14/2024 at 4:22 PM Social Worker #37 progress note documented they discussed the resident's continued aggressive behaviors and telepsychiatry recommendations with the nurse practitioner. The resident's next telepsychiatry appointment was scheduled for 12/16/2024. The 12/16/2024 Telepsychiatry progress note by Telepsychiatry Nurse Practitioner #46 documented they saw the resident via real time audiovisual for a follow-up to the 8/28/2024 visit. There was no improvement with the resident's agitation and combativeness. The resident admitted to getting angry with staff and feeling scared at times but could not explain why. Recommendations included it may be beneficial to meet with Registered Nurse Engagement Specialist #28 to develop a non-pharmacological behavioral care plan. Staff could reschedule a follow-up appointment approximately 4 weeks after institution of recommendations to assess response. The 12/18/2024 Telepsychiatry Nurse Engagement Behavioral Care Plan Interventions by Telepsychiatry Registered Nurse #28 documented they received communication asking for additional nonpharmacological recommendations per the telepsychiatry provider's recommendation. The resident had a history of abuse from their father and ex-husband. Staff at the facility was challenged by the resident's combativeness, yelling and screaming, difficulty redirecting from exit seeking, and not sleeping through the night but on and off throughout the day. Interventions like a baby doll, one-to-one reassurance, snacks and beverages, and redirection were short-lived. The non-pharmacological interventions recommended were: - antecedent behavior consequence (before, behavior, and after charting) to assist with identifying triggers such as when the resident's behavior was best, worst, what happened before the behavior, and the environment. - when the resident was exit seeking: avoid using negatives and no statements when redirecting or distracting, approach from the front and allow the resident space without touching them while smiling and cueing them to follow. - when the resident was combative with care: provide soft music, dimmed lights while displaying positive/favorite pictures, offering a snack prior or something to occupy their hands, and always stop when the resident resisted. - provide trauma-informed care as dementia residents could live in the past; introduce self when entering the resident's room; frequent reassurance they were okay; identify triggers such as where and when the abuse took place such, were they frightened at night and stayed up because of this; or when redirecting the resident from exiting, could their combativeness be related to their history of abuse. - encourage proper sleep by maximizing bright light exposure during the day especially between 9:30 AM to 11:30 AM, shades up early in the morning and down in the evening, limit daytime napping, and provide frequent exercise opportunities. The 12/18/2024 at 12:09 Social Worker #37 progress note documented telepsychiatry recommendations were reviewed with the physician. The physician agreed and the resident's Depakote was increased from 375 milligrams to 500 milligrams at bedtime. They would follow up for effectiveness. There was no documented evidence the non-pharmacological telepsychiatry recommendations were reviewed or implemented. The 2/10/2025 Social Worker #37 Care Plan Meeting progress note did not include documentation of discussion regarding telepsychiatry non-pharmacological recommendations for the resident's behavioral symptoms. The following observations of the resident were made: - on 3/24/2025 at 12:42 PM in another resident's room, clutching their babydoll. When staff attempted redirection, the resident did not want to leave the room. The resident laid down in the other resident's bed. - on 3/27/2025 at 8:47 AM, in a room next to theirs, asleep in a stationary high back winged chair with their meal tray in front of them. At 9:02 AM, the resident was woken by staff and reminded to eat their breakfast. The resident went back to sleep after the staff member left. At 11:51 AM, asleep in a recliner chair directly in front of the nursing station. During an interview on 3/28/2025 at 9:34 AM, Certified Nurse Aide #33 stated Resident #143 wandered while grabbing other people's items and had a cart to push around. The cart was taken away because staff thought the resident might hurt someone. Resident #143 wandered a lot at night and tried to get other residents out of bed. Staff were supposed to walk with the resident. They stated staff should try to get the resident to activities, walk with them, or do distraction activities so they were not sleeping throughout the day. The resident did not have any interventions for their yelling or distress, they just tried talking to the resident. It was not a preference of the resident to have their door shut and sometimes other residents shut the door because of the resident yelling. Resident #124's yelling lessened when they were out in the common area. The resident should not be left in their room alone with the door shut when they were distressed or yelling and often tried to get out of bed when that happened. They were unaware of any television preferences for the resident. During an interview on 3/28/2025 at 9:58 AM, Licensed Practical Nurse #34 stated the Unit Manager was responsible for updating the care plans. They were unsure what interventions Resident #143 had for their behaviors. They tried walking with the resident and gave them soda as they liked that. The resident wandered a lot at night. There were no interventions to keep the resident up at night as they were taught to let the resident do what they wanted with sleep and waking. They tried aroma therapy and tried to talk to Resident #124 to calm them down. The resident should not be left in their room yelling and/or distressed without intervention. If the resident had specific television preferences, they should be utilized. During an interview on 3/28/2025 at 10:21 AM, Registered Nurse Unit Manager #19 stated they had meetings every Friday to discuss the effectiveness of care planned interventions. Resident #143 wandered a lot at night. The resident did not sleep much during the day, just took small naps which were appropriate for them. If the resident was sleeping a lot during the day, it was part of their care to try and get the resident to activities. Resident #124 had a lavender scent patch for comfort, and they had a little laptop they put the resident's shows on. The resident did not know why they were yelling. If a resident was in their room with the door shut yelling the staff should intervene. If the resident preferred children's cartoons for the voices, it should be care planned. It was important to have personalized behavior and wandering interventions for residents to provide comfort for the residents. Their care plan should be centered around their likes and dislikes. During an interview on 3/28/2025 at 11:59 AM, Social Worker #37 stated they were responsible for mood and behaviors, psychotropic medications, and comfort measure care plans. The care plans and the interventions should be personalized because every resident was different and required different interventions to help calm them. They reviewed notes for all residents receiving telepsychiatry and incorporated the recommendations after they were approved by the provider. They documented the review under a social services note. They stated the non-pharmacological telepsychiatry interventions from 12/2024 were not incorporated in the resident's plan of care and they should have been. They stated they were unaware of the recommendation for antecedent, behavior and consequence charting to identify triggers. It should be on the resident's care plan they had a history of abuse, and the resident did not like to be touched. They were aware Resident #124 had yelling and distressing behaviors. The resident was scared and did not understand what was happening and yelled out. The staff should not leave the resident in a room by themself when they yelled. It was important for residents with dementia to be provided with interventions when they were distressed so they were provided with comfort and did not have undo stress. 10 NYCRR 415.12 124

Based on observations and interviews during the recertification survey conducted 3/24/2025-3/28/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 2 of 5 medication rooms (Unit 1 North and Unit 3) reviewed. Specifically, lorazepam (a controlled substance) was stored in unlocked refrigerators (not double locked) that were not permantly affixed in Unit 1 North's and Unit 3's medication rooms. The facility policy Medication Rooms on Nursing Units, revised 7/30/2024, documented a double locked box in the refrigerator would be used for the storage of controlled substances that required refrigeration. The facility policy Medications Administration Methods, revised 1/25/2024, documented controlled substances should be stored in a double-locked cabinet until immediately before administration. During an observation on 3/25/2025 at 9:22 AM, the medication refrigerator in the Unit 1 North medication room had an exterior lock on the main door that was not engaged and a locked interior drawer containing a bottle of liquid lorazepam. During an observation and interview on 3/25/2025 at 9:26 AM, the Unit 3 medication room had a table top sized refrigerator with two locks on the main exterior door that were not engaged and a locked drawer inside containing two bottles of liquid lorazepam. Licensed Practical Nurse #2 stated they counted with the other nurse that morning and it was their responsibility to lock the refrigerator after they counted. They did not lock the door after they counted, it should have been locked because lorazepam was a controlled substance and required a double lock. Locking the refrigerator was important because someone could access it, and a narcotic error or discrepancy could occur. During an interview on 3/28/2025 at 1:23 PM, Registered Nurse Clinical Educator #1 stated controlled substances were double locked behind the locked door to the medication room. The medication refrigerator had a lock on the exterior door and a locked box inside it for controlled substances. If there was lorazepam in the refrigerator drawer, both the drawer and the main refrigerator door should be locked at all times to maintain the safety of that controlled substance. If those locks were not in place then someone could gain access to those medications and a diversion could occur. 10 NYCRR 415.18 (d)

Based on observations and interviews during the recertification and abbreviated (NY00333993) surveys conducted 3/24/2025-3/28/2025, the facility did not ensure the provision of food and drink that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 lunch meals tested (3/24/2025 and 3/28/2025 lunch meals). Specifically, the 3/24/2025 lunch meal entree was difficult to cut; and the 3/28/2025 lunch meal was not served at palatable and safe temperatures. Findings include: The facility policy Food Temperature Requirements and Holding Time, revised 6/28/2019, documented the Director of Dining Services or designee was responsible for assuring the proper temperatures and holding times of foods were maintained during the preparation and service of meals. The 3/24/2025 posted lunch menu documented cube steak with brown gravy, garlic mashed potatoes, peas and onions, and pineapple chunks. The following observations and interviews were made during the 3/24/2025 lunch meal: - at 12:41 PM Resident #383 stated sometimes the food was served cold and tasted bland. - at 12:50 PM Resident #19 stated the cube steak was hard, and staff called for a replacement meal for them. - at 12:50 PM Resident # 58 stated the cube steak was tough, and staff called for a replacement meal for them. - at 12:54 PM Residents #80's spouse stated the meat was very tough. Their spouse did not have teeth, and they could not cut the cube steak with their knife. They complained for months about the meat being too tough. - at 1:18 PM Resident #10 stated their cube steak was too tough, and staff called for a meal replacement. - at 1:23 PM Resident #49's meal ticket documented the resident required food that was easy to chew. The cube steak was attempted to be cut, and force was used to move the knife back and forth. Staff called for a meal replacement. During an observation on 3/27/2025 at 11:58 AM with Licensed Practical Nurse #20, Resident #383's lunch meal was tested for taste, temperature, and palatability. The resident was provided with a replacement tray. The applesauce measured at 65.1 degrees Fahrenheit; the turkey bake was 134.6 degrees Fahrenheit; Brussels sprouts were 123.9 degrees Fahrenheit; coffee was 129.2 degrees Fahrenheit; and milk was 55.7 degrees Fahrenheit. During an interview on 3/27/2025 at 12:08 PM, Licensed Practical Nurse # 20 stated they were unsure what the proper food temperatures should be, but hot food should be served hot and cold food should be served cold. During an interview on 3/28/2025 at 10:56 AM, the Food Service Director stated cold food should be served below 40 degrees Fahrenheit and hot food should be served between 140 and 150 degrees Fahrenheit. The food was tasted prior to being sent to the units and the cube steak served on 3/24/2025 was tested by Assistant Food Service Director #26 who described the cube steak as a little tough. Cube steak was a tough product, cuts of meat varied, and they were limited in the types of cube steak they could order due to budget constraints. They were aware of the significant number of meal replacements requested during the 3/24/2025 lunch meal due to reports from residents that the steak was either difficult to chew or unappealing. If a meal ticket documented easy to chew then food items should be tender enough to cut with a fork. They stated food held within a danger zone could have impacted both taste and palatability. They had not received complaints about the temperature or the quality of the food. 10NYCRR415.14(d)(1)(2)

Based on observations, record review, and interviews during the recertification survey conducted 3/24/2025-3/28/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards in the main kitchen. Specifically, the main kitchen had food items past their expiration dates, undated food items, the walk-in freezer had ice buildup on an open box of food, and food was stored on the floor. Findings include: The facility policy Dietary Food and Supply Orders-Storage, revised 10/26/2018, documented food and non-food supplies were stored in a food storeroom and in refrigeration or freezer areas of the kitchen, in conformance with applicable sections of the New York State Health Code, rules and regulations. Containers of food were stored at a minimum of six inches above the floor to protect the food from splash and other contamination. Food was protected from contamination by dust, insects, rodents, unclean equipment and utensils, unnecessary handling, drainage and overhead leakage at all times during storage. Food removed from original containers or packages was protected from contamination by storage in clean, covered, labeled and sanitized containers. Food not readily identifiable was stored in properly labeled original product containers or in containers labeled to identify the food by common name. The following observations were made in the main kitchen with the Food Service Director on 3/24/2025 at 10:29 AM: - the walk-in cooler contained one 1-quart plastic container of diced beets dated 3/20/2025, one 4-inch metal pan of sliced carrots dated 3/20/2025, and one 20.8-inch by 12.8-inch x 2.5-inch pan of minestrone soup dated 3/3/2024. - the walk-in freezer contained 1 box of vegetarian chicken wings that was not securely closed. The box had ice buildup on the outside and the inside. One box of pulled white turkey was stored on the floor, and one 20.8-inch by 12.8-inch x 2.5-inch pan of vegetable lasagna had 2 inches of ice buildup and was dated 12/6/2024. - the cooks cooler contained 2 pounds of undated sliced American cheese wrapped in plastic and 1 pound of sliced provolone cheese wrapped in plastic dated 3/13/2025. - the salad cooler contained a 1-gallon plastic container with 2 cups of thousand island salad dressing with a best used by date of 12/4/2024. During an interview on 3/24/2025 at 11:02 AM, the Food Service Director stated all food items should be labeled and dated and used within 3 days when removed from their original package. Food items in their original containers with a best used by date or expiration date should be discarded after the date on the container. This ensured the best product and food safety. Food should not be stored on the floor or have ice buildup on the box or inside the box because it could possibly cause contamination of the food. 10NYCRR 415.14(h)

Based on interview and record review during the recertification survey conducted 3/24/2025 through 3/28/2025, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Specifically, the facility did not provide the facility matrix for all residents and access to all resident electronic health records requested by the New York State Department of Health (NYS DOH) surveillance team in a timely manner. Findings include: The Centers for Medicare and Medicaid Services survey form Entrance Conference Worksheet provided to the Administrator/designee upon survey entrance documented the following items were required during the recertification survey: - the complete matrix for all residents within 4 hours of entrance. - access to all resident electronic health records and specific information on how surveyors could access the electronic health record outside of the conference room by the end of the first day of survey. The New York State Department of Health surveillance team entered the facility on 3/24/2025 at 10:02 AM. The Team Coordinator met with the facility's Director of Nursing at 10:40 AM to review the documents required for survey as outlined on the entrance conference worksheet. The Director of Nursing was provided with a hard copy of the entrance conference worksheet. The worksheet included the time frame for providing the complete matrix for all residents and facility computers with access to all resident electronic health records. On 3/24/2025 at 3:16 PM, the Director of Nursing stated facility computers with access to resident electronic health records were on the evening shipment and would not be available until after dinner time. On 3/25/2025 at 8:26 AM, the Team Coordinator sent an email to the Director of Nursing requesting the complete matrix for all residents that should be provided within 4 hours of entrance and attached a blank matrix with instructions for completion. On 3/25/2025 at 8:35 AM, Administrative Assistant #41 stated the Director of Nursing was in a meeting and the facility computers never arrived at the facility. The Team Coordinator sent an email to the Director of Nursing as a reminder that access to resident electronic health records was to be provided to the survey team by the end of the first day and asked if they had a time frame for the arrival of the computers. On 3/25/2025 at 9:20 AM, the Director of Nursing delivered three facility computers to the conference room with access to electronic health records. They stated they were aware all six surveyors needed access, and they would be able to deliver three more computers when they arrived on the truck that afternoon. On 3/25/2025 at 10:06 AM, the Director of Nursing sent the completed matrix for all residents. On 3/25/2025 at 11:00 AM, the Director of Nursing stated the facility computers did not arrive on the truck, and they were unsure when they would arrive. On 3/25/2025 at 11:08 AM, the Director of Nursing delivered three computers with access to electronic health records to the conference room. They stated they were able to borrow the computers from the therapy department and would switch them out when the others arrived. 10 NYCRR 483.70(i)

Based on observations, record review, and interviews during the recertification survey conducted 3/24/2025-3/28/2025, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for 7 of 7 resident beds (beds for Resident #15, #29, #31, #38, #91, #99, and #106) reviewed. Specifically, Resident #15's mattress was not securely placed within the bedframe brackets; Resident #29's mattress did not fit within the bedframe mattress brackets resulting in a gap between the mattress and the assist rail; Resident #99's mattress was not securely placed in the bedframe brackets resulting in an entrapment zone that exceeded the United States Food and Drug Administration's recommended dimensional limits; and Residents #31's, #38's, #91's, and #106's assist rails were not routinely inspected for possible zones of entrapment. The facility policy, Bed Rail use (Side Rails, Assist Rails, Transfer Rails, Bed Enablers), revised 9/27/2018, documented upon installation and routinely the resident was assessed for the use of the assist rail and risk for entrapment. The use of an assist rail required a physician's order that included the number and type of rail(s). The Bed Side/Rail Assessment was completed by the registered nurse/designee in conjunction with the interdisciplinary team initially, quarterly and as needed; and bed assessments were completed by the maintenance department in conjunction with the clinical team per facility policy. The November 2005 High-Low Bed Instruction Manual documented all the mattresses supplied by their company worked together with the siderails to meet the Food and Drug Administration's regulations and guidelines at the time of purchase. If other mattresses were used, it was up to the end user to determine whether their mattress was suitable for minimizing entrapment risks. The undated owner's manual for the alternating pressure mattresses utilized by the facility, including bariatric, documented due to concerns over the possibility of patient entrapment, the use of rails of any length was a matter currently addressed by various regulations from local, national, and international government agencies, and by individual facility protocol. It was the responsibility of the facility to be in compliance with those laws. There was no documented evidence of facility assist rail inspections for 2024 or 2025. 1) Resident #15 had diagnoses including hand contractures (shortening of the muscle), cerebral palsy (a neurological condition), and muscle weakness. The 3/13/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not reject care, required substantial/ maximal assistance with bed mobility, was dependent for transfers, and did not use a bed rail. A 2/26/2024 Side Rail/ Assist Rail Assessment completed by Licensed Practical Nurse Unit Manager #43 documented the resident used bilateral enabler/assist bars. There were documented alternatives that were considered or attempted, entrapment risk and the risks/ benefits of usage were reviewed with the resident, and the resident consented and agreed to the use of the side rail/ assist rails. There were no additional documented Side Rail/ Assist Rail Assessments in the resident's medical record. The 11/14/2024 physician order documented the resident used a right assist rail for bed mobility related to diagnosis of muscle contractures. The Comprehensive Care Plan initiated 7/14/2024 and revised 3/12/2025 documented the resident had an activity of daily living deficit related to muscle weakness and cerebral palsy. Interventions included substantial/ maximal assistance of 2 or more with bed mobility using a bed assist rail on the right side and substantial/ maximum assistance using a mechanical lift with transfers. The 3/11/2025 Physical Therapist #35 progress report documented the resident required moderate/ maximal assistance with bed mobility and used handheld assistance or the bed assist rail. The resident was observed in their bed with 1 right sided assist rail with their mattress unsecure in the bedframe brackets: - on 3/24/2025 at 12:35 PM and 1:00 PM. - on 3/25/2025 at 9:22 AM and 1:45 PM. - on 3/26/2025 at 9:20 AM. - on 3/27/2025 at 9:04 AM and 1:38 PM. During an interview on 3/26/2025 at 11:57 AM, Licensed Practical Nurse #9 stated they were not aware of any issues with mattresses not fitting securely in the bedframe brackets. This would be something they would want to be made aware of especially if a resident had an assist rail as it could pose a safety issue. If they were made aware they would place a work order and notify a supervisor. During an interview and observation on 3/27/2025 at 1:42 PM, Certified Nurse Aide #44 stated the resident typically stayed in bed per their preference. Their mattress was not secure in the bedframe brackets, and they used the right sided enabler bar for bed mobility. During an interview on 3/28/2025 at 1:02 PM, Registered Nurse Unit Manager #6 stated the side rail/ assist rail assessment was completed at least quarterly and as needed by a registered nurse. They were unaware Resident #15 did not have a Side Rail/ Assist Rail Assessment completed since February 2024. They expected nursing to observe mattresses to ensure they fit in the bedframe brackets. If a resident had an assist rail and their mattress was not in the bedframe brackets it could pose a safety risk. 2) Resident #29 had diagnoses including osteoarthritis and a Stage 4 sacral pressure ulcer (full tissue loss with exposed bone, muscle and tendon). The 2/5/2025 Minimum Data Set assessment documented the resident was cognitively intact, required maximum assistance for bed mobility, used a pressure reducing device for their bed, and did not use an assist rail. The Comprehensive Care Plan initiated 10/24/2019 and revised 3/5/2025, documented the resident had an activities of daily living deficit. Interventions included one assist for bed mobility and bed rails. The Comprehensive Care Plan initiated 8/2/2024, documented the resident used assist rails on the right side of their bed to assist with bed mobility. Interventions included the interdisciplinary team reviewed and documented assist rail use quarterly and as needed. There was no documented evidence of a physician order for an assist rail. The 3/21/2025 Physical Therapist #35's discharge summary documented the resident utilized an assist rail on the right side of their bed. During an observation and interview on 3/24/2025 at 12:25 PM, the Resident #29's bed had a 1/4 assist rail on the right side; was pushed up against the wall on the left side; had a perimeter, alternating pressure mattress with contoured foam bolsters around the sides and ends of the mattress; was not securely nestled into the four bed frame brackets; and had a gap the width of approximately 4.25 inches between the mattress and the assist rail when the mattress was pushed up against the wall. The resident stated they once had two assist rails, but the facility removed them which impaired their ability to move. One assist rail was put back on and now they could move better. They were unsure of the timeline of those events. The 5/2/2024 Registered Nurse #27 Side Rail/Assist Rail Assessment documented the resident had assist bars on the right and left side of their bed; had a condition that caused the resident to move in the bed or tried to exit from the bed; and was discussed by the interdisciplinary team and the benefit outweighed the risk. There were no additional documented Side Rail/ Assist Rail assessments in the resident's medical record. During an observation on 3/26/2025 at 9:29 AM, the resident was transferred into bed with the use of a stand aid. The mattress was against the wall and there was a gap between the mattress and the assist rail. During an interview on 3/27/2025 at 1:29 PM, Certified Nurse Aide #16 stated bed frames had curved metal brackets on each corner the mattress should be nestled into, so it would not slide. That was important because the mattress could fall off the frame and the resident could fall. If a mattress did not fit properly on the bed frame it could also cause a gap between it and the assist rail which a resident could get stuck in. Resident #29 had an air mattress; the left side of their bed was against the wall; and there was an assist bar on the right side. Upon looking at the resident's bed and pushing the mattress toward the wall, they stated the mattress was not secured as it jumped right over the bracket on the left upper side of the bed frame causing a big gap and it should not be like that. During an interview on 3/27/2025 at 1:57 PM, Licensed Practical Nurse #2 stated mattresses should fit firmly into the four brackets on the bed frame and if the mattress fit properly, it should not slide. There was a potential for a gap if the mattress was not secured on the bed frame which could result in a resident getting a body part stuck. Resident #29 had an air mattress, one assist rail for bed mobility, and the left side of their bed was up against the wall. After looking at the resident's bed they said that the mattress was not secured within the brackets and slid when pushed creating a gap between the assist rail and the mattress. During an interview on 3/28/2025 at 1:31 PM, the Registered Nurse Clinical Educator #1 stated if a resident was approved to have an assist rail a medical order was obtained; the care plan was updated; the maintenance department was notified to place the assist rail; and an assist rail assessment form was completed by the Unit Manager and was updated quarterly thereafter. Housekeeping kept an inventory of the mattresses and if a specialty mattress was recommended, maintenance would retrieve and apply that mattress. They did not know if the type of mattress was taken into consideration when putting on a particular bed frame. They believed maintenance did monthly checks on all the beds to include frame and mattresses but did not know specifically what their process was. The four brackets on the bed frame kept the mattress on the bed and if a mattress did not fit within those four brackets, it was not the right mattress for that bed and should be switched out or reassessed. If one side of a bed was against the wall and the mattress moved the opposite way it could cause a gap between the wall and the mattress and lead to entrapment or a fall out of bed. During an interview on 3/28/2025 at 2:18 PM, the Director of Nursing stated if an assist rail was recommended and approved, the maintenance department would apply it. Maintenance took care of the beds and mattresses and were supposed to be doing routine checks, but they were unsure how often those checks were done. Checks were important to ensure the mattresses fit properly and to prevent injuries and entrapments. Mattresses should fit within the four brackets on the bed frame, so it did not slide and cause a risk for entrapment. There should be no gaps between the mattress and assist rails; assist rail use should be in the care plan; the assist rail assessments should be done quarterly and be accurate; and assist rails did not require a physician's order. During an interview on 3/28/2025 at 3:48 PM, the Director of Maintenance stated mattresses should not move about on the bed frame or slide away from the assist rails. Mattresses should fit within the four bed frame brackets. Mattresses that did not fit in those bed frame brackets created a potential entrapment zone. Entrapment zone checks were important for the safety of the residents. They stated entrapment zone checks were not completed in 2024. 3) Resident #99 had diagnoses including Alzheimer disease and muscle weakness. The 1/2/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not reject care, used a walker and wheelchair, was independent with bed mobility and transfers, had no falls since admission/ entry or reentry, and did not use a bed rail. The last documented bed inspection was completed on 2/21/2024. The 7/30/2024 physician order documented the resident was to have a right assist rail on their bed for bed mobility related to a diagnosis of weakness/ impaired mobility. The Comprehensive Care Plan initiated 12/10/2020 and revised 7/29/2024 documented the resident used a right assist rail for bed mobility to promote independence. Interventions included a right assist rail, resident/ responsible party was educated regarding the benefits and risks of assist rail use, resident/ responsible party was educated on the use of assist rail device to promote maximum functional ability, physical/ occupational therapy evaluations were completed as needed per physician orders, and the interdisciplinary team reviewed and documented assist rail use quarterly, and as needed. The 2/6/2025 Side Rail/ Assist Rail Assessment completed by Registered Nurse Unit Manager #6 documented the resident used bilateral enabler/ assist bars. There were no documented alternatives considered or attempted, entrapment risk and the risks/ benefits of usage were reviewed with the resident, and the resident consented and agreed to the use of the side rail/ assist rails. The 3/14/2025 Physical Therapist #35 progress report documented bed mobility assessment and training was facilitated with the resident using the right-side assist rail. The undated certified nurse aide care instructions documented the resident had a right assist rail and required supervision/ touching assistance with chair/ bed to chair transfers and bed mobility. The resident's bed was observed to have 1 right sided assist rail, and their mattress was not secure within the bedframe brackets, and slid of the bedframe with gentle knee pressure on: -3/24/2025 at 12:22 PM and 1:53 PM. -3/25/2025 at 9:17 AM and 12:59 PM. -3/26/2025 at 9:26 AM. During an interview on 3/26/20225 at 11:57 AM, Licensed Practical Nurse #9 stated they were not aware of any issues with the resident's mattress not fitting securely in the bedframe brackets. This would be something they would want to be made aware of especially if a resident had an assist rail as it could pose a safety issue. If they were made aware they would put in a work order and notify a supervisor. During an interview and observation on 3/26/2025 at 11:58 AM, Maintenance Assistant #10 stated they looked at beds with assist rails to determine if there were any entrapment zones. They had a Food and Drug Administration approved bed entrapment measurement tool with them. They stated Resident #99 had a standard mattress and standard bedframe. When they initially tested Resident #99's bed to determine if there were any entrapment zones the mattress was not secure in the bedframe brackets causing the mattress to slide away from the assist rail and it did not pass entrapment zone 3 (area between the rail and mattress). Once the mattress was securely placed in the brackets of the bed frame and tested again the bed did not have any entrapment zones identified. They were unsure the last time the resident's bed was inspected for entrapment zones. If they had been made aware of any issues with the bed via a work order the maintenance department would have addressed, it. During an interview on 3/26/2025 at 12:27 PM, Certified Nurse Aide #39 stated they were assigned to Resident #99 and did not notice their mattress was not secure in the bedframe brackets. They made the resident's bed and put new sheets on the bed. They last checked the resident's mattress was secure in the bedframe brackets at 6:30 AM. If they noticed any issues with the mattress not fitting into the bedframe brackets, they would tell the nurse. During an interview on 3/28/2025 at 1:02 PM, Registered Nurse Unit Manager #6 stated side rail/ assist rail assessments were completed at least quarterly and as needed by a registered nurse, the interdisciplinary team determined which residents were candidates for assist rails and would determine alternatives to trial. After a physician order was obtained and a therapy evaluation was completed the Director of Nursing gave final approval to have assist rails installed and the maintenance department installed the rails onto the residents' bedframes. The maintenance department was responsible for inspecting the residents' beds and checking for entrapment zones. If staff observed any issues with a residents' mattress not secured in the bedframe brackets or issues with the assist rails, they should tell a nurse as it posed a possible safety issue. They completed Resident #99's side rail/ assist rail assessment in February 2025. When they completed the assessment, they visualized their bed, spoke with the resident and/ or representative about the risk/ benefits associated with the assist rail usage, and reviewed the resident's medical record. They stated when they reviewed Resident #99's February side rail/ assist rail assessment it was not accurate as the resident only had a right sided assist rail. They did not realize the resident did not have capacity to make medical decisions until they reviewed their record. They stated nursing staff should ensure the mattress fit in the bedframe brackets when they were transferring the resident in and out of bed. They had not been made aware of any issues. During an interview on 3/28/2025 at 2:18 PM, the Director of Nursing stated if an assist rail was recommended and approved, the maintenance department would apply it. Maintenance took care of the beds and mattresses and was supposed to be doing routine checks, but they were unsure how often those checks were done. Checks were important to ensure the mattresses fit properly and to prevent injuries and entrapments. Mattresses should fit within the four brackets on the bed frame, so it did not slide and cause a risk for an entrapment. During an interview on 3/28/2025 at 3:48 PM, the Director of Maintenance stated mattresses should not move about on the bed frame or slide away from the assist rails. Mattresses should fit within the four bed frame brackets. If the mattress was not in the bedframe brackets it could create a potential entrapment zone failure. There were no documented entrapment zone checks completed in 2024, and all resident beds should be inspected annually or per the manufacture's specifications which ever was the higher level of requirements to ensure safety. It was difficult to inspect all the beds as there were some residents who refused to get out of bed. They would report to the nurses that residents refused to get out of bed, but did not notify administration. During a follow up interview on 3/28/2025 at 4:15 PM, the Director of Nursing stated the Side Rail/ Assist Rail assessments were to be done quarterly and as needed and should be accurate. 10NYCRR 415.29(b)

Based on observations, record review, and interviews during the abbreviated survey (NY00369577), the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 3 residents (Resident #2) reviewed. Specifically, Resident #2 did not receive assistance at meals as care planned. Findings include: The facility policy, Activities of Daily Living Assistance and Supervision, revised 1/4/2018 documented the Unit Manager/designee would ensure that a plan of care for receiving activities of daily living assistance and/or supervision was incorporated into the daily nursing care of each resident. Resident #2 had diagnoses including Alzheimer disease and self-feeding difficulties. The 11/28/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, did not reject care, required partial/moderate assistance with eating, and received a mechanically altered diet. The Comprehensive Care Plan updated on 12/5/2024 documented the resident had an activity of daily living self-care performance deficit and impaired physical mobility related to muscle weakness. Interventions included to provide partial or moderate assistance, one-person physical assistance with eating. The 8/27/2024 physician orders documented comfort measures only, no weights, no tube feeding, and no intravenous fluids. The Comprehensive Care Plan and care instructions updated on 12/5/2024 documented the resident had a potential for alteration in nutrition related to Alzheimer's disease and dementia. Interventions included to provide adaptive equipment at meals, monitor and record intake of solids and fluids, monitor for signs of dehydration/malnutrition, provide half portions of regular puree solids and thin liquids, meals in the dining room, offer 120-240 milliliters of fluids between meals three times daily, and provide 120 milliliters Mighty Shake (oral nutrition supplement) at meals. The resident's food was to be in bowls, staff was to place 1 drink in front of the resident at a time to encourage intake of food items, load utensil, tap the resident's right hand to initiate feeding, and check oral cavity at the end of the meal for possible pocketing of food. The following observations of the resident were made: - on 1/29/2025 at 9:05 AM seated in the dining room at a table for breakfast. Their meal included 4-ounce nutrition shake, 8 ounces whole milk, pureed potatoes in a bowl, pureed toast in a bowl, and pureed egg and ham in a bowl. Their food items were all in front of the resident. There were 2 nosey cups (adaptive cup) and 1 large maroon spoon. Their meal ticket documented partial to moderate assistance. The resident was drinking from their nosey cup independently. At 9:18 AM, the resident was independently eating their pureed toast. At 9:20 AM, Certified Nurse Aide #2 asked the resident if they wanted any condiments on their pureed eggs and told the resident what food items were in front of them. The resident continued to eat slowly and did not receive staff assistance or encouragement. At 9:32 AM, certified nurse aide asked the resident if they were done with their meal and removed the meal tray. The resident had consumed 100% of their milk and Mighty Shake (oral nutrition supplement), 75-100% of their pureed toast, 0-25% of their pureed egg and ham, and 0-25% of their pureed potatoes. - on 1/29/2025 at 12:18 PM, in the dining room seated at a table for lunch. All their meal items and drinks were in front of them. The resident had 4 ounces of nutritional shake, an 8 ounce unopened container of whole milk, 1 bowl of pureed beets with the lid on it, 1 bowl of puree potatoes, 1 bowl of pureed meatloaf, and 1 bowl of applesauce. The resident was drinking their nutrition supplement independently. At 12:25 PM, the resident was observed using their large maroon spoon to take spoonfuls of mashed potatoes by themself. At 12:27 PM, Certified Nurse Aide #2 walked over to the resident and spoke to them and left. The aide continued to circulate in the dining room without assisting the resident. From 12:45 PM -12:58 PM, the resident continued to eat slowly and was not assisted or encouraged by staff. At 1:02 PM, Certified Nurse Aide #1 asked the resident if they were done and removed their meal tray. The resident had consumed 100% of their oral nutrition supplement, 0-25% of applesauce, 25-50% pureed mashed potatoes, and 0-25% of their pureed meatloaf. Their 8 ounces of whole milk remained unopened, and the lid remained on the bowl of beets. During an interview on 1/29/2025 at 1:08 AM, Certified Nurse Aide #1 stated staff knew what level of assistance to provide residents by looking at their care plans and it was also listed on the meal ticket. They stated they were assigned to help in the dining room during the lunch meal. Resident #2 did not eat well and drank better at meals. Their intakes were usually 25-50% at meals. They did not know what level of assistance the resident required at meals and checked their care plan. They stated the resident's care plan indicated they were to receive partial to moderate assistance of 1 at meals and the resident did not receive their care planned assistance at the lunch meal. They stated staff that were assigned to the dining room should be checking the resident's meal tickets and care plans to ensure they received the assistance required. If a resident did not receive the level of assistance as care planned it could impact their nutritional status. During an interview on 1/29/2025 at 1:36 PM, Certified Nurse Aide #2 stated they were assigned to the dining room at breakfast that day. They stated staff knew what level of assistance to provide residents by looking at their care plans and it was also listed on the meal ticket. They stated partial/ moderate assistance meant the resident required verbal and sometimes physical cues. If a resident did not receive their care planned level of assistance at meals it could impact the resident's intakes and possibly weights. They stated Resident #2 drank better than they ate. Their intakes were usually 25-50% at meals and very seldom completed all their meals. They were unsure of the resident's level of assistance required at meals. During an interview on 1/29/2025 at 2:24 PM the Director of Therapy stated Occupational Therapy determined the level of assistance a resident needed at meals. Partial to moderate assistance with eating meant staff should provide physical and verbal cues to encourage mealtime intakes. Resident #2 required partial moderate assistance of 1 with meals. During an interview on 1/29/2025 at 3:02 PM Registered Nurse Unit Manager #3 stated they expected staff to open all food items for the residents at meals and assist as care planned. If they had any questions, they should check the resident's care plan or ask the nurse. If a resident did not receive their care planned level of assistance at meals it could impact their nutritional status. 10NYCRR 415.12(a)(3)

Based on observation, record review, and interview during the recertification survey conducted 4/19/23 -4/27/23 the facility failed to determine if medication self-administration was clinically appropriate for 1 of 1 resident (Resident #98) reviewed. Specifically, Resident #98 was observed on 5 days with Odomzo (generic name sonidegib, a chemotherapeutic medication) in a cup at their bedside and there was no assessment to determine the resident's ability to safely self-administer medications or a physician order for self-administration of medications. The facility policy Self Administration of Medication dated 5/2018 documented residents who desired to self-administer medications required review and approval of the interdisciplinary care planning team members and an order from the attending physician. The medications would be stored in a locked drawer in the resident's room, and the self-administered medications would be monitored by licensed nursing staff. Resident #98 was admitted to the facility with diagnoses including basal cell carcinoma of the skin. The 2/17/23 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and was independent with activities of daily living (ADL). The 10/16/18 comprehensive care plan (CCP) documented the resident had deficits in ADL function. Interventions included the resident was independent with most ADLs. The resident had basal cell carcinoma and interventions included administer medications per medical orders. The 6/30/22 physician orders documented Odomzo capsule 200 milligrams (mg) once every 24 hours for basal cell carcinoma. There was no order for the resident to self-administer medications. A 3/17/23 progress note by physician #40 documented the resident was seen for a mandated 30/60 day visit. The resident had basal cell cancer, was stable, and was followed by oncology. The resident had two cancerous lesions removed and they had healed, and the resident continued to receive Odomzo. There was no documentation of the resident's ability to safely self-administer medications. During an observation and interview on 4/19/23 at 10:33 AM the resident stated they took a pill for their cancer. The resident entered their room and returned to the hallway with a reddish colored pill and swallowed it. They stated they took the pill approximately 2 hours after eating their breakfast every day. The resident showed the pamphlet titled sonidegib (Odomzo) that came with the medication. The April 2023 medication administration record (MAR) documented Odomzo 200 mg capsule was administered on 4/19/23 at 7:11 AM by licensed practical nurse (LPN) #10. On 4/20/23 at 10:39 AM, Resident #98 was observed in their room. The resident stated they were getting ready to take their Odomzo. The resident walked to their over the bed tray table and retrieved a reddish colored pill from a clear plastic medication cup and swallowed the pill. They stated one day they had forgotten to take the medication until 3:00 PM. The resident stated they did not set any alarms to remind them to take their pill, and they were usually pretty sharp. The April 2023 MAR documented Odomzo 200 mg capsule was administered on 4/20/23 at 8:32 AM by LPN #10. On 4/21/23 at 9:30 AM, the resident was observed seated in a straight back chair in the hallway, the resident gave permission to the surveyor to enter their room, and a reddish colored capsule with sonidegib 200 mg printed on the capsule was observed in a plastic medication cup on the resident's over the bed tray table. The April 2023 MAR documented Odomzo 200 mg capsule was administered on 4/21/23 at 6:53 AM by LPN #10. On 4/24/23 at 9:23 AM, the resident was not in their room and a reddish colored capsule with sonidegib 200 mg printed on the capsule was observed in a plastic medication cup on their over the bed tray table. The April 2023 MAR documented Odomzo 200 mg capsule was administered on 4/24/23 at 8:09 AM by registered nurse (RN) Unit Manager #22. On 4/25/23 at 9:38 AM, Resident #98 was observed in the dining room conversing with another resident and at 10:05 AM, a reddish colored capsule with sonidegib 200 mg printed on the capsule was observed in a plastic medication cup on the resident's over the bed tray table in their room. The April 2023 MAR documented Odomzo 200 mg capsule was administered on 4/25/23 at 7:00 AM by LPN #10. There was no documented evidence that Resident #98 had been assessed for the ability to safely self-administer medications or had a physician's order to self-administer medications. During an interview on 4/25/23 at 11:02 AM LPN #10 stated if a resident was able to self-administer their own medications it would be listed on the MAR and the resident would need a physician order to do so. They stated when they administered the medication to a resident, they were supposed to ensure the resident took the medication prior to leaving the resident and the time stamp on the MAR was when the medication was given to the resident. They stated they did not watch Resident #98 take their medication, as the resident usually came to them and asked for their medication in the morning. They were unaware the resident was keeping medication in their room to take later. They stated they should have watched the resident take their medication for safety reasons and to ensure they were taking their ordered medications. If they were aware the resident wanted to take their medications at a different time or wanted to keep their medications in their room, they would have notified the Nurse Manager or a medical provider. During an interview on 4/25/23 at 11:16 AM RN Unit Manager #22 stated a resident needed a self-medication administration assessment completed before they were able to take their own medications or to keep medications in their room. The resident would also need a physician order and it would be listed on the MAR. The nurse who administered medications should ensure that the resident had taken all their medications per physician orders. Resident #98 did not have a self-medication administration assessment, did not have a physician order to administer their own medication, and they were unaware the resident was keeping medication in their room to take later. Resident #98 never mentioned they kept medication in their room to take later or they wanted to self-administer their own medications. If they were aware the resident wanted to take their medications at a different time, they would have notified the physician to get an order for the resident's preferred time. If the resident wanted to self-administer their own medications, they would have assessed the resident's ability, discussed the resident's wish with the interdisciplinary team, and obtained a physician order. The RN stated they had provided Resident #98 with their medications on 4/24/23 and thought the resident had taken all their medications at that time. They stated it was important for residents to take their medications as ordered and if a resident was keeping medication in their room, it was a potential safety concern. During an interview on 4/26/23 at 4:33 PM nurse practitioner (NP) #39 stated a resident needed a medical order to self-administer their medications. They stated Resident #98 received a chemotherapy medication for their active basal cell cancer. It was important for the nurse to ensure the resident was taking their prescribed medications as ordered. If they were aware the resident wanted to take their medication at a different time, they would have changed the order time. During an interview on 4/26/23 at 4:33 PM the Director of Nursing (DON) stated residents needed an order to administer their own medications and they should have a self-medication administration assessment completed annually and as needed. The nurse who gave the resident their medication should ensure that the resident took all their medications per physician orders. If they did not it was a potential accident hazard. 10 NYCRR 415.3(e)(1)(vi)

Based on record review and interview during the recertification survey conducted 4/19/23-4/27/23 the facility failed to provide the appropriate liability and appeal notices to Medicare beneficiaries for 1 of 3 residents (Resident #438) reviewed. Specifically, Residents #438 remained in the facility after discontinuation of Medicare Part A services and the facility did not provide the resident with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 (Centers for Medicare and Medicaid Services) for Medicare Part A as required. Findings include: The CMS form instructions for the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 (expiration date 1/31/26) documents that a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) CMS-10055 must be issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service - FFS) beneficiaries in situations where Medicare payment is expected to be denied. The SNF ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice prior to services ending. Resident #438 was admitted to the facility with diagnoses including Alzheimer's Disease, hypothyroidism, and chronic kidney disease. The 10/14/22 Minimum Data Set (MDS) assessment documented it was a SNF PPS (Prospective Payment System) Part A discharge (end of stay) assessment. The SNF Beneficiary Protection Notification Review documented the resident's Medicare Part A skilled services start date was 9/19/22 and the last covered day of Part A service was 10/14/22. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. An SNF ABN form CMS-10055 was not provided to the resident. The explanation why the form was not provided was checked as other: Private Pay. During an interview on 4/27/23 at 8:48 AM the MDS Coordinator stated they issued SNF ABN CMS-10055 frequently at the same time they issued the Notice of Medicare Non-Coverage (NOMNC) CMS-10123. They stated that the only time they would not issue a SNF ABN CMS-10055 was if a resident was discharged to the community the day after their covered Medicare Part A services ended. The MDS Coordinator stated if a resident remained in the facility past their covered Medicare Part A services, issuing a SNF ABN CMS-10055 was required. They stated MDS registered nurse (RN) #33 issued the NOMNC CMS-10123 to the resident. The resident went to long-term care in the facility and should have been issued a SNF ABN CMS-10055. During an interview on 4/27/23 at 9:11 AM MDS RN #33 stated they issued SNF ABN CMS-10055 when they were instructed to by the MDS Coordinator. They stated that the SNF ABN CMS-1005 was supposed to be issued in almost all circumstances unless the resident was discharging home the day after Medicare Part A services were done. They stated they did not know why the SNF ABN CMS-10055 was not issued for Resident #438. Any resident staying in the facility for long term care after being discharged from Medicare Part A services should have been issued a SNF ABN CMS-10055. 10 NYCRR 415.3(g)(2)(iii)

Based on observation, record review, and interview during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 10 residents (Residents #108 and 109) reviewed. Specifically, Resident #108 was not assisted with shaving, nail care, or eating; and Resident #109 was not assisted with eating. Findings include: The facility policy, ADL Assistance and Supervision revised 1/8/18 documented the nursing assistant would provide assistance with daily activity (ADL) assistance/supervision to assigned residents and assist other nursing assistants in providing (ADL) care as needed. The Team Leader would monitor the (ADL) assistance/supervision provided for residents throughout the shift and give appropriate guidance to the nursing assistants. The Unit Manager would record the ADL assistance on the EMR (electronic medical record), monitor assistance/supervision provided for residents, and provide appropriate guidance to the nursing staff. The facility policy, Shaving a Male Resident revised 5/8/18 documented a nursing assistant would shave the face of a male resident if the resident was unable to do the procedure safely by themself. This procedure would be carried out daily, or as needed. The facility policy, Hygiene/Grooming revised 7/24/18 documented designated nursing staff would ensure that residents were clean and appropriately groomed at all times. The individual preferences of residents for personal care and grooming would be established and documented. Residents would be provided with care to maintain or improve abilities to perform hygiene and grooming tasks, as needed. AM care included oral hygiene; a partial bath; perineal care (as necessary/ordered) and any specific hygiene care (such as catheter or colostomy care) on days when no shower/bath was scheduled. Hygiene care was repeated before and after meals and throughout the day as needed. 1) Resident #108 was admitted to the facility with diagnoses including Alzheimer's disease and hypertension. The 2/23/23 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, had no behaviors, required limited assistance of 1 for eating, and extensive assistance of 2 for bathing, dressing and personal hygiene. The comprehensive care plan (CCP) initiated 10/2/22 and revised 1/2/23 documented Resident #108 required limited assistance of 1 for eating and was a messy eater, and extensive assistance of 2 for bathing and personal hygiene. Interventions included to provide finger foods if the resident wandered, set up their meal without the tray, provide cues to help facilitate bringing food and drinks up to their mouth to minimize mess, approach in a calm, gentle manner, and re-approach if the resident refused care. The 4/26/23 resident care instructions documented the resident could safely be assisted with meals from a feeding assistant, required limited assistance of 1 for eating, required cues for eating, could not understand what was required of them, required guidance from staff, and required extensive assistance of one for personal hygiene and bathing. The following observations of Resident #108 were made: - on 4/19/23 at 12:34 PM sitting in the dining room approximately 3-4 feet away from the table feeding themself lunch and spilling food on themself and the floor. The resident had ¼ inch- ½ inch long facial hair. The resident was not assisted with eating or positioning. At 12:43 PM, licensed practical nurse (LPN) # 34 called for a staff member to get them a towel and cleaned up the spilled food under the resident's chair. The LPN did not position the resident closer to the table or assist them with eating. - on 4/20/23 at 12:43 PM, sitting at a dining room table with facial hair approximately ½ inch long. - on 4/21/23 at 11:21 AM, sitting in the dining room approximately 1-1/2 feet away from the table while waiting for lunch. The resident had facial hair on their chin and face approximately ½ inch long. At 11:34 AM the resident was eating lunch and spilling their food. Certified nursing assistant (CNA) # 36 walked by the resident and did not offer to push the resident closer to the table or assist them with eating. At 11:40 AM, the resident continued to attempt to feed themself and was spilling food on their lap. The resident was sitting approximately 1-1/2 feet away from the table and was sitting at an angle. Several staff members walked by the resident and did not assist them with positioning or eating. At 11:46 AM support aide # 37 asked the resident how they were doing and did not help with eating or positioning. At 11:53 AM the resident dropped their peaches on the floor and bent over to pick them up. Their chair remained at an angle away from the table. The resident continued to spill food on their pants and was not helped by staff. At 12:15 PM the resident completed their meal and there was food on their pants, on the floor, and on the table in front of their plate. CNA # 36 handed the resident chocolate milk, and the resident spilled the milk on their pants and on the floor and CNA #36 did not attempt to assist the resident. - on 4/24/23 at 12:39 PM, sitting at the dining room table eating lunch and spilling food on the table and their lap. Staff did not cue or assist the resident with eating. At 12:40 PM, LPN #34 removed the resident's plate while they were still eating and placed their dessert in front of them. LPN #34 did not ask the resident if they were finished eating their meal. - on 4/25/23 at 9:43 AM, walking down the hall with facial hair approximately a ½ inch long with a brown substance under their fingernails. - on 4/26/23 at 10:03 AM, sitting in the dining room with food particles and stains on their pants, long facial hair, and a brown substance under their fingernails. During an interview on 4/26/23 at 10:05 AM, CNA # 36 stated Resident #108 should sit at a 90-degree angle for eating. Resident #108 required limited assistance of one for eating, extensive assistance of 2 for ADL care, and the CNAs were responsible for ADL care. The resident should have been cued and assisted with eating. The CNA stated Resident #108 had not been shaved in 3 weeks. They stated they should re-approach the resident with care if they became agitated and did not know why the resident had not been shaved. During an interview on 4/26/23 at 10:30 AM, LPN # 34 stated Resident #108 required set up with limited assistance for eating. They stated they asked for towels and cleaned up food under the resident's chair and did not assist the resident with eating. They stated Resident #108 required extensive assistance of 1-2 for their ADLs and did not refuse care. LPN #34 stated they would assist the CNAs with shaving and nail care but had not assisted with Resident #108's shaving or nail care. During an interview on 4/26/23 at 10:45 AM RN #35 stated Resident #108 required extensive assistance of 1-2 for ADL care and should be reapproached if agitated. They stated shaving and nail care was completed by CNAs and should be done with morning care. Resident #108 required limited assistance of 1 for eating and should be pushed up to the table for positioning. 2) Resident #109 was admitted to the facility with diagnoses including vascular dementia and unspecified occlusion (blockage) of the coronary artery. The Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, had no behaviors, and required supervision with assistance of 1 for eating. The comprehensive care plan (CCP) initiated 8/17/20 and revised 1/5/23 documented the resident had ADL deficits related to muscular weakness. Interventions included limited assistance of 1 for eating, divided plate, and assist with appropriate use of silverware, cut all items into bite-sized pieces to be easily scooped with spoon or stabbed with a fork, and place any items from bowls onto divided plate. The resident may require intermittent verbal and/or tactile cues for appropriate use of silverware, assistance to be fed with non-finger food items (varied daily based on mood and behaviors), and one item at a time was recommended. The 4/26/23 resident care instructions documented Resident #109 was on aspiration (inhaling food/fluid into lungs) precautions, could be safely assisted with meals by a feeding assistant, and required limited assistance of 1-person physical assistance for eating and intermittent cueing to use their silverware. The following observations were made of Resident #109: - on 4/19/23 at 12:25 PM, sitting in the dining room eating lunch with their drinks and dessert on a tray on the windowsill behind them. The resident was not eating the main meal. At 12:49 PM LPN #34 handed the resident a glass of orange juice and did not cue or assist the resident with eating. At 12:57 PM LPN #34 handed the resident their strawberries after the main meal was completed and all other residents were removed from the dining room. The resident remained in the dining room unattended and was not assisted or cued with eating. - on 4/21/23 at 11:38 PM, registered nurse (RN) #35 handed the resident their lunch on a divided plate and told the resident to use their spoon. The resident picked the spoon up and smashed their food around the plate, did not eat, and set their spoon down. No cueing or assistance with eating was provided by staff. At 12:04 PM, the resident finished a cup of coffee while the rest of their drinks and dessert were on a tray behind them. At 12:12 PM the resident was trying to drink out of an empty coffee cup while their drinks were behind them. No staff assistance with drinks was offered. At 12:16 PM, the resident had a plate of baked ziti and continued to attempt to eat. CNA # 26 handed the resident their milk and did not offer to feed or assist the resident during the meal. At 12:25 PM, the resident had consumed less than 25% of their meal, drank 240 milliliters (ml) of coffee, and 60 ml of their milk. At 12:27 PM, CNA #36 handed the resident their orange, took away the resident's untouched main meal and did not offer an alternative meal, cueing, or assistance. - on 4/24/23 at 12:27 PM, sitting in a recliner chair across from nursing station with milk and only a dessert in front of them. Their plate of food remained in the dining room untouched. The resident was not helped or cued by staff. During an interview on 4/26/23 at 10:13 AM CNA #36 stated Resident #109 required assistance of 1 for eating. The resident often mixed drinks in their food. Staff were supposed to offer alternative items such as sandwiches to the resident, but they often just took their plate away. Resident #109 often expressed hunger. CNA #36 stated they did not know why staff did not think about giving additional alternatives to the resident if they did not eat. During an interview on 4/26/23 at 10:45 AM LPN #34 stated Resident #109 required supervision, cueing, and set up with their meals but would require feeding assistance at times. The resident would mix their drinks in their food. They stated staff should offer the resident a sandwich if they did not eat. During an interview on 4/26/23 at 10:55 AM RN #35 stated Resident #109 had declining vision, required limited assistance of 1 for eating, would often require cues to remind them of food still on their plate, and would require a staff member to pull up a chair and assist them with eating when they were not eating well. They stated staff needed to be re-educated if Resident #109 did not eat and staff did not offer any alternative meal items. 10NYCRR 415.12 (a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM for 2 of 4 residents (Residents #66 and #93) reviewed. Specifically, Resident #93 was not wearing their bilateral palm devices (helps prevent hand contractures) as care planned during multiple observations; and Resident #66 did not have their neck brace applied appropriately and was not wearing positioning and palm devices as care planned for multiple observations. The facility policy Splint, Brace Care updated 5/23/2018 documented that appropriately trained nursing staff would provide assistance as needed through a scheduled program of applying and removing a splint or brace, monitor the resident's skin and circulation under the device, and reposition the limb as needed. The program for use of splints and/or braces was documented by therapy on the interdisciplinary care plan and the nursing assistant documented the splint/brace program in the electronic medical record (EMR) along with any refusals which must also be verbally reported to the Unit Manager. 1) Resident #66 was admitted to the facility with diagnoses including dementia and contractures (tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) of the right and left hand. The 2/13/23 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, did not reject care, required extensive assistance of one for bed mobility, dressing, toileting, was totally dependent on one for hygiene, totally dependent on two for transfers, and had limited range of motion (ROM) in bilateral (both sides) arms and legs. The comprehensive care plan (CCP), revised 06/15/2021, documented that resident was at risk for limited ROM due to muscle weakness and contractures. Interventions included a neck support brace during meals only, to be applied while supine (lying flat on the back) in bed or reclined in the wheelchair while in a supine position prior to meals. If the resident refused the neck brace, they were to be assisted by the nurse for the meal. The resident was to have a carrot hand contracture device placed in their right hand and a rolled washcloth was to be place in their left hand during AM care. If the resident refused the carrot hand contracture device, a rolled washcloth was to be used in place of the carrot. Ensure hips were aligned while in their wheelchair with the head rest applied, foot buddy, wedge on left side with arm on top of wedge, like an arm rest, and bean pillow under right elbow and brought up between forearm and bicep, so their elbow was slightly extended. The 2/8/23 occupational therapist (OT) evaluation documented the resident had bilateral upper extremity contractures. Resident #66 was totally dependent for all meals, attempted to initiate self feeding, and required their neck support device on for all meals. The resident was on a nursing rehabilitation program for splint assistance that included a blue neck support applied prior to all meals. Instructions for application included to apply neck support while the resident was supine in bed or reclined while in their wheelchair to achieve a supine position. Staff were to remove the pillow and allow the resident's head to relax back onto the bed or wheelchair, align the resident's head and neck to midline, and apply the neck support with the small side slightly below the chin. The neck support strap was to be loosely applied behind the neck, the strap was marked on the back to indicate application location, and red stitches indicated where the stopping location was. If the resident refused to wear the neck brace they were be assisted with eating by a nurse. A second nursing rehabilitation program for splint assistance included a carrot in the resident's right hand and a rolled washcloth in the resident's left hand after AM care. Instructions included to utilize a rolled washcloth in the resident's right hand if the carrot was refused. A third nursing rehabilitation program instructed to ensure the resident's hips were aligned while in their wheelchair with an applied head rest, foot buddy on wheelchair legs, wedge on left side with their arm on top of the wedge, like an arm rest, and a bean pillow under the right elbow and brought up between the forearm and bicep so the elbow was slightly extended. The 3/22/23 nurse practitioner (NP) progress note documented the resident had contractures to bilateral upper extremities with very limited range of motion (ROM) in both the upper and lower extremities and bilateral hand splints were in place. The care instructions ([NAME]) documented that a rehab carrot was to be placed in the resident's right hand and a rolled washcloth in their left hand after AM care. If the resident declined the carrot, staff were to use a rolled washcloth. The [NAME] also included instructions for the application of the neck support for meals and placement of body positioning devices. Resident #66 was observed without a right or left hand contracture device in place: - on 4/19/23 at 1:40 PM while sitting in their wheelchair in the dining room. - on 4/21/23 at 10:27 AM while sitting in their wheelchair in their room, and at 12:06 PM while sitting in their wheelchair in the dining room. - on 4/24/23 at 9:01 AM while sitting in their wheelchair in the dining room, at 9:24 AM while lying in bed, at 12:23 PM while sitting up in their wheelchair in the dining room, and at 2:17 PM while lying in bed. The 4/2023 activities of daily living (ADL) record, completed by certified nursing assistants (CNAs), documented following for the right and left hand contracture devices: - on 4/19/23 applied on the day and evening shift. - on 4/21/23 not applicable on the day shift and not applied on the evening shift. - on 4/24/23 applied on the day shift and not applied on the evening shift. Resident #66 was observed: - on 4/21/23 at 1:03 PM in the dining room being assisted with their meal by an LPN. The resident's neck was tilted down against their chest, and they did not have on the neck brace on while eating. - on 4/24/23 at 12:54 PM registered nurse (RN) Clinical Educator #42 applied the neck brace while the resident was sitting up in their wheelchair. The resident's neck was tilted down and slightly to the right. The neck brace was not applied according to the care planned directions. - on 4/25/23 at 12:52 PM CNA #43 tilted the resident's head back by the top of the resident's head/forehead while the resident was in an upright seated position and slid on the neck brace. The neck brace was not applied according to the care planned directions. The 4/2023 ADL record, completed by CNAs, documented the functional maintenance plan that included the application of the resident's neck support device for swallowing per plan of care was: - followed for all three meals on 4/21/23. - followed for all three meals on 4/24/23. - followed for breakfast and lunch on 4/25/23. Resident #66 was observed without positioning devices implemented per their CCP: - on 4/21/23 at 10:27 AM and at 12:06 PM sitting in their wheelchair without a supportive pillow device for their right arm/wrist. - on 4/24/23 at 12:23 PM with no black wedge for their left arm shelf support. The 4/2023 activities of daily living (ADL) record, completed by certified nurse aides (CNAs), documented the functional maintenance plan that included the application of positioning devices in the wheelchair per plan of care were: - followed for both day and evening shifts on 4/21/23. - followed for day and evening shifts on 4/24/23. During an interview on 4/26/23 at 11:11 AM CNA #48 stated staff followed resident specific care instructions on the [NAME] or the care plan. They stated Resident #66 required a pink wedge when they laid down and it had to be on for two hours and off for two hours. The resident also required a neck brace while eating along with a carrot for one hand and wash cloth for other. They stated Resident #66 also had a black wedge on their left side and a bean pillow on their right side for positioning while in their wheelchair. They stated nursing staff had been trained by therapy on how to apply the neck brace. They stated they were trained to put the neck brace on in bed if possible. They should remove the resident's pillow and allow the resident's neck to stretch back. If the resident was up in their wheelchair, they should recline the chair to allow the resident's neck to stretch. They stated that they are supposed to monitor the resident's swallow as well as skin integrity while the neck brace was in use. If the resident refused the neck brace, the resident should be assisted with eating by a nurse. CNA #48 stated it was important for the neck brace to be applied appropriately to prevent injury and to straighten the resident's neck for swallowing support and to have a washcloth or carrot in the resident's hands as their hands were very contracted. The devices kept nails from digging into their palm, promoted skin integrity, and kept the contractures from worsening. During an interview on 4/26/23 at 11:36 AM CNA #43 stated they referred to the [NAME] to care for a resident. Resident #66 wore a neck brace while eating. They stated that it was easier to put the brace on the resident while they were in bed, but if the resident was in their wheelchair, they lifted the resident's head up and back to put the brace on. They stated that they usually held the resident's head there for a few seconds to stretch their neck and the resident would tell them when it was enough. They had been trained by therapy on how to put the neck brace on but was unaware that the resident's wheelchair needed to be tilted back when the brace was applied while in their wheelchair. It was important to apply the brace so that the resident did not choke while eating. If the resident refused the brace, a nurse needed to assist the resident with eating. The resident had not refused the brace for them. They stated the resident required a carrot for their right hand and a rolled-up washcloth for their left hand for contracture management. The resident also had a side support/wedge pillow on their left side under their arm, like an arm rest. The CNA stated it was important to apply the contracture devices to stop the progression of the contracture and to open the resident's hands to avoid pressure areas. During an interview on 4/26/23 at 12:12 PM LPN #47 stated they expect CNAs to utilize the iPads and hand-held devices to view to [NAME] for resident specific care instructions. They stated the positioning and contracture management devices as well as specific application instructions were included on the [NAME]. LPN #47 stated that Resident #66 used a neck brace for all meals unless they refused and then they were to be assisted with eating by a nurse. They stated that they were not trained how to apply the brace but that the CNAs on the unit were. LPN #47 stated that they did not usually work on the resident's unit, and they had the CNAs apply the brace prior to meals. LPN #47 stated it was important for the neck brace to be applied correctly to ensure the proper neck position for swallowing to avoid aspiration. They stated the resident had a bean bag device for their arm, a black wedge, and other positioning devices to keep them straight while in their wheelchair; and a carrot for one hand and a washcloth for the other hand for their hand contractures. They stated that the hand contracture devices were important for the resident to use to avoid worsening of the contractures and to prevent their nails from embedding into their skin. During an interview on 4/26/23 at 12:32 PM LPN Unit Manager #49 stated that nursing staff should look at the [NAME] for resident specific care instructions. They expected all positioning and contracture management devices in place per the plan of care and [NAME] instructions. They stated the devices assisted in preventing further contraction, helped with pain management, provided pressure relief, and promoted skin integrity. They stated that they would expect to be notified of any refusals and they were not notified the resident had refused any ordered devices. The resident should have their neck brace on for all meals and staff were trained to apply and remove the brace. They stated the neck should be extended when the brace was applied and preferably while the resident was lying down. If the resident was in their wheelchair, the wheelchair should be tilted backwards to achieve a lying position for neck extension prior to the brace being applied. They stated it was important for the resident's neck brace to be applied properly to ensure their neck was in the correct position to swallow and avoid aspiration. During an interview on 4/26/23 at 2:54 PM occupational therapist (OT) #53 stated if a resident had contractures nursing would request a referral and OT would assess the resident and determine if any interventions were needed. They trialed several different options for hand contracture management for Resident #66 and concluded that the carrot in the right hand and a rolled washcloth in the left hand was best tolerated by the resident. They stated they expected staff would follow the recommendation to wash the resident's palms in the AM and at minimum place the rolled washcloths in their hands. They stated that it was important to have the hand contracture management devices in place to prevent the contractures from worsening. OT #53 stated the resident also had a bean pillow, black wedge, and neck travel pillow for positioning in their wheelchair. The bean pillow was placed under the right elbow and up around the arm to help keep the arm from being contracted against their body, and the wedge on the left side provided support to the arm. They stated the resident was seen originally for the neck brace because they could not hold their head up during meals making it difficult to swallow. Staff had been educated on how to apply the brace properly and should recline the resident's wheelchair to open their neck position. They stated it was easiest to put the brace on when the resident was already in a supine position in bed. It was not appropriate for staff to apply the neck brace while the resident's neck was tilted forward or by tilting the resident's head up manually while the resident was in a seated position. The resident had tight muscles in their neck staff, and this would not allow the right clearance for the resident's throat for adequate swallowing. 2) Resident #93 was admitted to the facility with diagnoses including Alzheimer's disease and contractures of the left and right hand. The 3/31/23 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, did not reject care, required extensive assistance of 2 for dressing, and had impairment in range of motion (ROM) to both upper extremities. The 7/13/21 physician orders documented a right upper extremity blue carrot (contracture prevention device) and a left upper extremity resting splint (to help reduce swelling and pain). The blue carrot was to only be removed for care and the blue resting splint was to be applied in AM and removed at bedtime. The revised 5/23/22 comprehensive care pan (CCP) documented the resident had limitations in ROM related to decreased functional activity with contractures. Interventions included the resident must have carrots or wash cloths at minimum in their hands during the day and if unable to apply carrots, place rolled wash clothes in their hands. The undated care instructions ([NAME]) documented the resident was to have carrots or rolled wash cloths at a minimum in their hands during the day and were to be off at night. The April 2023 treatment administration record (TAR) documented to ensure the right upper extremity blue carrot and left upper extremity resting splint were put in place on the 6:00 AM - 2:00 PM shift and the 2:00 PM to 10:00 PM shift. The blue carrots were to be removed for care only and the blue resting splint was to be applied in the AM and removed at bedtime. The 4/2023 activities of daily living (ADL) record task form documented the resident was to have carrots or wash cloths in their hands at a minimum during the day. On 4/19/23 at 12:14 PM, the resident was observed seated in their high back recliner chair at a table in the dining room. Both resident's hands were contracted, and they did not have any contracture management devices in their hands. At 1:21 PM, the resident was observed lying in bed, both hands remained contracted without a contracture management device in place, and there was a blue carrot on their bed side table. On 4/19/23 registered nurse (RN) #44 signed the TAR indicating to ensure the right upper extremity blue carrot and left upper extremity resting splint were put in place on the 6:00 AM - 2:00 PM was completed on the 6:00 AM- 2:00 PM shift. On 4/19/23 at 1:30 PM certified nursing assistant (CNA) #50 documented on the CNA ADL task form not applicable (N/A) for placement of the right upper extremity blue carrot and left upper extremity resting splint. On 4/20/23 at 9:50 AM, the resident was observed lying in their bed, their hands were contracted, and they did not have a contracture management device in place. The blue carrot was on their bed side table. On 4/20/23 registered nurse (RN) #44 signed the TAR indicating to ensure the right upper extremity blue carrot and left upper extremity resting splint were put in place on the 6:00 AM - 2:00 PM was completed on the 6:00 AM- 2:00 PM shift. On 4/20/23 at 11:56 AM CNA #51 documented on the CNA ADL task form the placement of the right upper extremity blue carrot and left upper extremity resting splint was completed. On 4/21/23 at 9:24 AM, the resident was observed seated in their high back recliner chair in the dining room, the resident's hands were contracted, and they did not have a contracture management device in place. At 11:15 AM, the resident was observed in their low bed sleeping, their hands were contracted, they did not have a contracture management device in place, and a blue carrot was on their bed side table. At 12:02 PM, the resident was observed in their high back recliner chair in the dining room, their hands were contracted, and they did not have a contracted management device in place. On 4/21/23 licensed practical nurse (LPN) #34 signed the TAR indicating to ensure the right upper extremity blue carrot and left upper extremity resting splint were put in place on the 6:00 AM - 2:00 PM was completed on the 6:00 AM- 2:00 PM shift. On 4/21/23 at 1:59 PM CNA #50 documented on the CNA ADL task form not applicable (N/A) for placement of the right upper extremity blue carrot and left upper extremity resting splint. On 4/24/23 at 9:23 AM and 10:23 AM, the resident was observed in their high back recliner chair in the dining room, their hands were contracted, and they did not have a contracture management device in place. At 12:59 PM, the resident was observed seated in their high back recliner chair in the hallway, both of their hands were contracted, and they did not have a contracture management device in place. On 4/24/23 RN #45 signed the TAR indicating to ensure the right upper extremity blue carrot and left upper extremity resting splint were put in place on the 6:00 AM - 2:00 PM was completed on the 6:00 AM- 2:00 PM shift. On 4/24/23 at 1:59 PM CNA #52 documented on the CNA ADL task form the placement of the right upper extremity blue carrot and left upper extremity resting splint was completed. On 4/25/23 at 8:43 AM, the resident was observed in their high back recliner chair in the dining room, their hands were contracted, and they did not have a contracture management device in place. At 11:01 AM, the resident was observed in the hallway seated in their high back recliner chair, both hands were contracted, and they did not have a contracture management device in place. At 11:38 AM, the resident remained in the hallway with no contracture management devices in their hands. During an interview on 4/25/23 at 12:50 AM CNA #35 stated they were floated to the unit on this day, and they were supposed to check the CNA care instructions prior to assisting residents so they knew what level of care to provide and if the resident needed any special devices in place. They stated Resident #93 was on their assignment, they did not check the CNA care instructions before providing care, and they were verbally told what level of assistance each resident needed by another staff member. They stated when they provided care to Resident #93, the resident's hands were contracted, they struggled to wash the resident's hands, and they were unaware the resident needed contracture management devices in their hand. They stated if the resident required any special devices it was listed on the care instructions. It was important to ensure the contracture management devices were in place to ensure the contractures did not worsen. If they were aware of the devices, they would have tried to apply them or use a rolled up wash cloth. They did not tell anyone the resident's hands were hard to open and they should have. During an interview on 4/25/23 at 2:01 PM LPN #34 stated they were floated to the unit on 4/21/23. The TAR indicated what devices the resident needed, and the nurse should only sign if the treatment was completed. They were familiar with Resident #93, their hands were contracted, and they had contracture management devices or rolled wash cloth ordered for their hands. The resident must have had something in their hands on 4/21/23 otherwise they would not have documented it was in place on the TAR. They stated it was important for the resident to have their contracture management devices in place to prevent skin breakdown and to prevent their contractures from worsening. During an interview on 4/26/23 at 11:34 AM LPN #10 stated if a resident required any special devices for contractures it was listed on the TAR and If they signed the device was in place that meant they either observed the device in place or they had applied it themselves. The CNAs should let the nurse know if they could not apply the device, the CNA should document the resident refused, and the nurse should write a note regarding the refusal as well. Resident #93 had contractures, was supposed to have contracture management devices in place or a rolled washcloth. If the resident's contracture management devices were not applied the resident's contractures could worsen. During an interview on 4/26/23 at 11:43 AM, RN unit manager #22 stated Resident #93 had contractures and was supposed to have contracture management devices or rolled wash cloths in their hands to prevent the contractures from worsening and prevent skin breakdown. If the nurse signed the TAR that the device was in place, that meant they either observed the device in place or applied it themselves. The CNAs should not document N/A and should document either the resident refused, or they applied the device. Staff should be checking the resident's care instructions before care to ensure the correct level of assistance and proper care were provided. During a telephone interview on 4/26/23 at 1:19 PM RN #44 stated if a resident had an order for a device for contractures it was listed on the TAR. If they signed the TAR that the device was in place, they either observed the device in place or they applied it themselves. If the resident refused any care or application of contracture management devices the CNA should let the nurse know and they both would document the refusal. They could not recall if they were notified if the resident refused their contracture management devices. During an interview on 4/26/23 at 3:15 PM occupational therapist (OT) #46 stated if a resident had an order for contracture management devices, it was in place for preventative measures to help prevent skin breakdown, and further worsening of their contractures. They stated Resident #93 had bilateral hand contractures and one of their hands was worse than the other. It was very important for the resident to either have blue carrots or rolled wash cloths in their hands daily. The unit staff had been recently educated on this topic in March or early April 2023. The resident's care plan and care instructions documented the need for the blue carrots or rolled wash cloths and listed the instructions on how to apply the devices. If the resident refused, staff should let the nurse know so they could document the refusal. If staff was having a hard time opening the resident's hands, they should let the nurse know so therapy could be made aware and could reassess the resident. They expected staff to follow the resident's care plan to prevent further worsening of their contractures. 10NYCRR 415.12(e)(2)

Based on observation, interview, and record review during the recertification survey conducted 4/19/23-4/27/23, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 4 of 10 medication carts (medication carts 1 and 2 on Unit 100 South and medication carts 1 and 2 on Unit 3) inspected. Specifically, there were 4 insulin pens and 1 eye drop bottle observed without pharmaceutical labels including resident information, medication name, medication dosage, and administration instructions. Findings include: The facility policy, Medication Label and Container Requirements revised 5/20/2018 documented medications accepted from a Pharmacy Services Provider or administered to residents of the facility must be packaged in compliance with all applicable state and federal laws; labels must clearly indicate specific information legibly and completely. Medications will not be accepted at this facility if the general label requirements and package-type specific label requirements are not met including full name of resident, address of resident, name and strength of the medication, directions for administration of the medication, name of prescriber ordering the medication and the prescription number. During an observation on 4/24/23 at 9:21AM, medication cart 1 on Unit 100 South was inspected with licensed practical nurse (LPN) # 6. The medication cart contained an opened bottle of brimonidine tartrate 0.2% eye drop solution (used to treat glaucoma) with a torn pharmaceutical label. There was no identification including resident information, medication name, medication dose, the date the bottle was opened, and Resident #110's name was handwritten on the bottle with a black marker. Additionally, medication cart 1 contained a gray colored insulin pen with no pharmaceutical label including the type of insulin, or an opened date. Resident #156's name was handwritten on the side of the pen with a black marker. During an observation on 4/24/23 at 9:38 AM, medication cart 2 on Unit 100 South was inspected with licensed practical nurse (LPN) #6. The medication cart contained a gray colored insulin pen. The pen had a yellow sticker with Resident # 11's name written with a black marker and there was no pharmaceutical label attached to the pen. Medication cart 2 also contained an aqua colored glargine (long-acting insulin) insulin pen with a piece of white medical tape affixed to it with Resident #37's name written in black marker. There was no pharmaceutical label or opened date on the pen. During an interview on 4/24/23 at 9:45 AM, LPN #6 stated that all nurses were responsible for checking the medication carts for expired medications or medications that did not contain labels. Insulin pens should be labelled when they are opened. During a follow-up interview on 4/24/23 at 2:08PM, LPN #6 stated that eye drops should be in the original box, be labelled with the resident's name, medication name, medication dose, and instructions for use. Insulin pens should be labelled with the resident's name, type of insulin, medication dose, and instructions for use. LPN #6 stated they knew Resident #11's pen was not labelled, and they gave the resident 5 units of insulin from the pen on this date. They stated if a medication was not labelled it could result in the wrong medication or dose being given to the resident. Another nurse may not know what resident the medication belonged to. During an interview on 4/24/23 at 2:17 PM, LPN Unit Manager # 11 stated the medication carts were audited once per month and they were responsible for the audits. LPN # 11 stated that insulin pens and eye drops should be labeled and if they were not, they should be removed from the cart and re-ordered to reduce the risk of a resident receiving the wrong medication. They stated they expected staff to check the medication carts once per shift for expired medications and unlabeled medications. They should pull any unlabeled medications from the carts. During observations on 4/25/23 at 11:45 AM, medication carts 1 and 2 for Unit 3 were inspected with LPN #10. Medication cart 1 contained an insulin pen with no pharmaceutical label or opened date on it. Resident # 142's name was written on the pen in black marker. Medication cart 2 contained an insulin pen with no pharmaceutical label or opened date on it. Resident #180's name was written on the pen in black marker. During an interview on 4/25/23 at 11:45 AM, LPN # 10 stated they were unsure about a medication labelling policy. If medications were unlabeled, nurses should write the resident's name on the pen with a black marker and put a yellow sticker on them with the date and time the pens were opened. LPN #10 stated the resident's insulin pens were stored in individual drawer sections with the resident's name in the cart. The risk of an unlabeled insulin pen could be that it could slide into another resident's drawer area resulting in a resident receiving the wrong medication. During an interview on 4/26/23 at 11:36 AM the Director of Nursing (DON) stated insulin pens were sent to the facility as house stock and would not be labeled. The LPNs, Nurse Managers, and pharmacy staff were all responsible for checking the medication carts. The DON stated they did not feel it was a risk if an insulin pen was unlabeled because the staff referred to the electronic medication administration records (EMARS). During an interview on 4/26/23 at 3:02 PM registered pharmacist (RPH) #14 stated eye drops, and insulin pens were individually dispensed, resident specific, and had pharmaceutical labels including the resident's name, medication name, and medication dose. Insulin pens came with tamper tape and a blank sticker with to write the date opened and date expired on them. RPH #14 stated only one type of insulin that came in a vial was used as house stock. It was not acceptable for a resident's name to be written on an insulin pen with a sharpie marker. If a label fell off, the facility should call the pharmacy and they would re-dispense another insulin pen. RPH# 14 stated the risk of medications not being labeled could be an unclear resident name or medication dose and the potential for a medication error. 10 NYCRR 415.18(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at safe and appetizing temperatures for 2 of 3 meals (4/20/23 and 4/21/23 lunch meals) reviewed, and food items in 1 of 1 steam table observed. Specifically, lunch meals trays on 4/20/23 and 4/21/23 were not served at palatable and appetizing temperatures; and the main kitchen steam table was not holding the temperature for hot food items. Findings include: The facility policy Food Temperature Requirements and Holding Time modified 6/28/2019, documented steamtable thermostats would be turned on 30 minutes prior to meal service and set to maintain hot food between 140-160 degrees F (Fahrenheit). The undated facility policy Test Tray Process documented the Director of Dining, the Assistant Director of Dining, Dietitians, and Diet Technicians were assigned to complete test tray audits monthly. One test tray would be completed monthly. 1. Test Trays Observations - on 4/20/23 at 12:18 PM, a meal tray arrived to resident room [ROOM NUMBER] and a replacement tray was requested for the resident. At 12:20 PM, the food temperatures were measured. The Salisbury steak was 118 F and the milk was 50 F. The Salisbury steak was not hot or palatable, and the milk was not cold or palatable. - on 4/21/23 at 12:23 PM, a meal tray arrived to a resident in the first floor dining room at 12:23 PM and a replacement tray was requested for the resident. At 12:25 PM, the food temperatures were measured. The hamburger was 120 F, the mixed vegetables were 118 F, and the milk was 52 F. The hamburger and mixed vegetables were not hot or palatable, and the milk was not cold or palatable. During an interview on 4/26/23 at 1:38 PM, the Food Service Director stated that milk served at 50 F, Salisbury steak at 118 F, a hamburger at 120 F, and mixed vegetables at 118 F could be acceptable as it was subjective to the resident. They stated that weekly tray audits were done and included having a random test tray brought to a resident floor and checking for appropriate food temperatures and accuracy of the food items on the tray compared to the tray ticket. They stated there had been unacceptable temperature results on the weekly random test trays and these were reviewed during monthly quality assurance meetings. During an interview on 4/26/23 at 1:41 PM, the Assistant Administrator stated that weekly random tray audits were completed and included checking for food temperatures and tray accuracy. They stated that the random tray audits were completed by the Food Service Director, the registered dietitian (RD), or the dietetic technician. During an interview on 4/26/23 at 3:19 PM, dietetic technician #31 stated they had completed weekly random test trays before. They stated that a test tray ticket would be placed in the pile of food tickets for a specific resident floor, and they followed the tray cart from the main kitchen to the resident floor and documented the amount of time it took for delivery. Dietetic technician #31 stated they would take that tray when came off the cart and test the food. They used a calibrated pocket thermometer to record the temperature of the food and tasted the food for palatability. They stated hot food items should be held and served at 140 F or higher and cold food items should be held and served at 40 F or less. Dietetic technician #31 stated that if the food temperatures of the test trays were unacceptable, they would document on the test tray form and give the test tray form to the Food Service Director and to the Assistant Administrator. Dietetic technician #31 stated the milk served at 50 F, Salisbury steak at 118 F, hamburger at 120 F, mixed vegetables at 118 F, and milk at 52 F were not acceptable temperatures. During an interview on 4/26/23 at 4:24 PM, the Assistant Food Service Director stated they participated in test tray audits. The test tray was the last tray selected off the cart to gauge the temperatures that would be taken when the last resident received their tray. They stated the acceptable temperature for hot food was between 140 F and 160 F, and cold food was below 41 F and above 32 F. The Assistant Food Service Director stated they discussed the test trays results with the Assistant Administrator and would come up with a plan of action on how to fix the temperatures that were unacceptable. During an interview on 4/26/23 at 4:35 PM, the Assistant Administrator stated they were responsible for ensuring the test tray audits were completed and the Food Service Director was responsible for reviewing the results. 2. Main Kitchen Steam Table During an observation on 4/20/23 at 12:06 PM, the steam table in the main kitchen tray line area was on and contained lunch items including stuffed peppers and grilled cheese sandwiches. Using a New York State Department of Health (NYSDOH) calibrated thermometer, the stuffed peppers were measured at 125 F and the grilled cheese was measured at 112 F. During an interview on 4/20/23 at 12:06 PM the Assistant Food Service Director stated that hot foods were required to be at a holding temperature of 140 F to 160 F. During an interview on 4/26/23 at 1:38 PM, the Food Service Director stated it was not acceptable for stuffed peppers to be held at 125 F and grilled cheese at 112 F. They stated that hot food items should be held at 135 F to 140 F. During an interview on 4/26/23 at 3:19 PM, dietetic technician #31 stated stuffed peppers at 125 F and grilled cheese at 112 F were not acceptable. They stated the food carts brought to the resident units were not heated and there was no way for food to heat up after it left the kitchen. During an interview on 4/26/23 at 4:35 PM, the Assistant Administrator stated food not held at the proper temperature could allow the growth of microorganisms that could make the residents sick. 10NYCRR 415.14(d)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure residents received and the facility provided food prepared in a form designed to meet individual needs for 2 of 2 residents (Residents # 38 and #52) reviewed. Specifically, Residents #38 and 52 were provided food items that were not consistent with the physician ordered diet. Findings include: The facility's 11/2009 Level 1 (Pureed) diet description documented the food items should be homogenous (smooth) and cohesive (adhere together) and should be pudding - like. There should be no coarse textures, raw fruits/vegetables, or nuts. Any food that required bolus (soft mass) formation, controlled manipulation, or mastication (chewing) were excluded. The diet was designed for residents who had moderate to severe dysphagia (difficulty swallowing). The facility's undated Puree, Chicken Fajita recipe documented to prepare the meat per recipe, place the meat in the food processor with broth, and add the food thickener as needed until desired consistency was reached. 1)Resident #38 was admitted to the facility with diagnoses including schizophrenia, dysphagia, and feeding difficulties, unspecified. The 3/6/23 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required supervision with eating, was on a mechanically altered diet, and did not have coughing or choking during meals. The 1/14/23 quarterly nutrition assessment completed by registered dietitian (RD) #54 documented the resident received regular puree solids and thin liquids at meals. The resident had no chewing or swallowing concerns noted at this time. The 1/24/22 revised comprehensive care plan (CCP) documented the resident had the potential for alteration in nutritional status. Interventions included to provide adaptive equipment at meals, half portions of entrees, vegetables, starches, and double portions of tomato soup at all meals. Provide regular pureed consistency solids, regular liquids, and the resident could have regular consistency scrambled eggs. The resident was on aspiration (inhaling food or fluid into the lungs) precautions. The 3/7/23 quarterly nutrition assessment completed by RD #54 documented the resident received regular puree consistency solids, regular thin liquids, and could have regular scrambled eggs. The resident had no chewing or swallowing concerns at this time. The resident's diet was reviewed with the resident representative as they had admitted to bringing in regular textured food items. The resident representative verbalized understanding of safety and diet. On 3/23/23 social worker (SW) #55 documented a care plan meeting was held on this date. The resident required set-up and supervision at meals, and was on a regular puree solid texture, thin liquid diet. The undated care instructions ([NAME]) documented the resident required supervision with set-up for eating; adaptive equipment including [NAME] (spill proof) cups, divided plate, and built up silverware; received a regular diet with pureed texture with thin liquids; and was on aspiration precautions. During an observation on 4/24/23 at 12:45 PM the resident was sitting at a table in the dining room during the lunch meal. The resident's meal ticket documented a regular puree diet with the word puree highlighted in blue. The ticket documented puree half chicken fajita, puree 1/2 cup refried beans, and puree 1/2 cup fajita blend vegetable. The resident's divided dish contained pureed beans, pureed vegetable, and a chicken fajita that was dry, lumpy, and not smooth (ground meat appearance). At 1:03 PM, certified nursing assistant (CNA) #48 cued the resident to eat their lunch meal. At 1:41 PM, the resident had eaten 25% of the ground chicken. 2) Resident #52 was admitted to the facility with diagnoses including multiple sclerosis and dysphagia (difficulty swallowing). The 2/25/23 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, rejected care 1- 3 of 7 days, required extensive assistance of 1 with eating, coughed or choked during meals or while swallowing medications, and had complaints of difficulty or pain when swallowing. The 2/10/23 comprehensive care plan (CCP) documented the resident had a potential for alteration in nutrition status related difficulty chewing and received a regular level 1 (pureed) consistency and thin liquid diet, and ate in dining room sitting up in their chair, The revised 4/12/23 CCP documented the resident had a deficit with activities of daily living (ADLs) and required limited assistance of one with eating, ate in the dining room, and was to be seated upright in their chair. During an observation on 4/24/23 at 1:15 PM, the resident was in the dining room during the lunch meal. The resident's meal ticket documented a regular puree diet with the word puree highlighted in blue. The resident was to receive pureed chicken fajita. The chicken fajita on the resident's divided plate was dry, lumpy, and not smooth (ground meat appearance). Resident #52 independently fed themselves some of the chicken fajita. During an interview on 4/25/23 at 12:14 PM, cook/ dietary aide #26 stated the lunch meal on 4/24/23 was fajita chicken, peppers and onions, and refried beans. They stated the prep cook knew how many portions of each consistency to make by following the production sheets. During the tray line process, the person who is at the start of the line called out the meal ticket, this included what consistency food and/or beverages that were needed and any adaptive equipment. The person at end of the line checked the meal ticket and the items on the tray to ensure the food and beverages matched. They stated they plated the food during the lunch meal on 4/24/23, they did not recall running out of pureed chicken fajita yesterday and was unaware if they plated the incorrect consistency. If the wrong consistency was plated, the person who checked the tray line should have noticed and requested a new meal with the proper consistency. They stated if a resident did receive the incorrect consistency of food or beverages they could choke. During an interview on 4/26/23 at 1:10 PM, the Food Service Director (FSD) stated the person at the start of the line should call out the food items including the consistency of the items needed. The person at the end of tray line was supposed to check the meal ticket against the food served on the plate to ensure they matched. Once the trays left the kitchen nursing staff should complete another check to ensure everything matched. If the items on the tray did not match the meal ticket staff should request a new tray. It was important for the residents to receive the correct consistency food and beverage items for safety reasons. During an interview on 4/25/23 at 1:23 PM, dietary aide #28 stated the person at the end of the tray line was supposed to check the meal ticket and food on the plate to ensure they matched. On 4/24/23 they worked at the end of the line and checked the meal tickets to ensure accuracy. If they observed a tray to have the improper consistency items, they would request a new tray with the correct consistencies. It was important for the residents to receive the proper consistency for safety reasons. During an interview on 4/26/23 at 2:30 PM, licensed practical nurse (LPN) #47 stated nursing staff should check each meal ticket and food tray to ensure the actual meal matched the meal ticket. If they noticed a resident was provided the wrong consistency, they would let the kitchen and the diet technician know and they would get a new tray for the resident. The resident should not consume the wrong consistency food and beverage items for safety reasons. They would want to be made aware if a resident received the wrong consistency food item and was unaware of any residents that received the wrong diet consistency at lunch on 4/24/23. During an interview on 4/26/23 at 2:43 PM CNA #48 stated staff knew what type of diet a resident was on by either checking their care plan ([NAME]) or looking at the meal ticket. The nursing staff checked the meal tickets and meal trays to ensure they matched prior to serving the residents. Pureed items should be soft and if staff did not think the items were pureed enough or the wrong consistency they should call down to the kitchen and obtain new items. They did not recall Resident #38's lunch tray on 4/24/23 and was unaware the resident received the wrong consistency food item. It was important to ensure the residents received the correct consistency because they could choke. During an interview on 4/26/23 at 2:43 PM, LPN Unit Manager #49 stated they expected nursing staff to check the trays for accuracy prior to serving the residents. If the resident received a wrong consistency food item staff should remove the item or the entire tray, call the kitchen to request the correct items, and let a nurse know. If a resident received the wrong consistency food or beverage items, they could choke or aspirate. They were unaware any residents who received the wrong consistency food on 4/24/23 and would expect staff to let them know when something like this occurred. During a telephone interview on 4/26/23 at 3:14 PM speech language pathologist (SLP) #56 stated a pureed diet meant food items should be a pureed and smooth consistency without lumps. A pureed consistency diet was recommended for a variety of reasons such as issues with swallowing. If a resident received the wrong diet consistency it could lead to possible aspiration issues or worsening dysphagia. During an interview on 4/26/23 at 3:36 PM, nurse practitioner (NP) #39 stated the residents should receive their diet as ordered. If they received the wrong diet consistency it could increase their risk for aspiration. If a resident received the wrong diet consistency, they would expect a nurse to monitor the resident for signs and symptoms of aspiration, such as coughing. They stated nursing should notify them if the resident was exhibiting signs or symptoms of aspiration. 10NYCRR 415.14(d)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 4/19/23-4/27/23, the facility failed to special eating equipment and utensils for residents who needed them for 2 of 2 residents (Residents #30 and 38) reviewed. Specifically, Resident #38 was not provided with adaptive curved utensils or a Kennedy cup (spill-proof drinking cup); and Resident #30 was not provided with weighted utensils and an inner lip plate as care planned. Findings include: The facility policy Adaptive Equipment dated 1/19/18 documented that the Director of Rehabilitation or designated therapy staff would ensure that each resident, as appropriate, was provided any necessary equipment and training in its use, designed to facilitate the resident's ability to function independently. This applied to equipment designated to aid self-feeding. The equipment would be listed on the resident's care plan as appropriate. Certified nurse aides (CNA) would notify the Unit Manager and therapy staff of any decline of use of adaptive equipment. The facility policy Meal Serving-Resident dated 9/24/18 documented that designated dietary staff would be responsible for ensuring that the necessary items were present at mealtime, or were obtained immediately upon request, for the consumption of food. Nursing and other appropriately trained staff would be responsible for fulfilling all non-food requests of residents, feeding residents if needed, and for other dietary services that were part of the resident's care plan. Dietary, nursing, and other appropriately trained staff were also responsible for ensuring all items identified on the tray label were in place, and in reach of the resident. 1) Resident #38 was admitted to the facility with diagnoses including diabetes, dysphagia (difficulty swallowing), and feeding difficulties. The 3/6/23 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required supervision/set-up assistance for eating, did not have difficulty swallowing, and had functional limitations in range of motion (ROM) for bilateral upper and lower extremities. The 10/22/22 comprehensive care plan (CCP) documented the resident had potential for alteration in nutrition. The resident was to receive adaptive equipment for eating/drinking that included a Kennedy cup, a right-handed built-up utensils bent to the left, and a divided plate. The care instructions ([NAME]) documented adaptive equipment for eating and drinking included a Kennedy cup, a right-handed built-up utensils bent to the left, and a divided plate. The 3/7/23 Quarterly Nutrition Assessment by registered dietitian (RD) #54 documented the resident utilized Kennedy cups, right-handed built-up utensils bent to the left, and a divided plate for adaptive equipment at meals. Resident #38's meal tickets dated 4/21/23, 4/24/23, and 4/25/23 documented in red lettering Kennedy cups, built up silverware bent left, and a divided dish. The resident was to receive 2 portions of tomato soup in a mug. The resident required supervision and set-up. Resident #38 was observed without care planned adaptive equipment for eating and drinking: -On 4/21/23 at 9:50 AM the coffee was not in a Kennedy cup. -On 4/24/23 at 12:45 PM chocolate Boost (nutritional supplement) was not in a [NAME] and the tomato soup was in a bowel and not a mug. -On 4/25/23 at 8:52 AM the resident's tray did not include a Kennedy cup or built-up silverware bent to the left. The soup and coffee were in regular hot mugs without lids. 2) Resident #30 was admitted to the facility with diagnoses including dysphagia (difficulty swallowing), muscle weakness, and feeding difficulties. The 1/26/23 Minimum Data Set (MDS) assessment documented the resident had mild cognitive impairment, required supervision/set-up assistance for eating, did not have difficulty swallowing with a mechanically altered diet, and had functional limitations in range of motion (ROM) for bilateral upper and lower extremities. The 4/15/22 comprehensive care plan (CCP) documented the resident had potential for alteration in nutrition. The resident was to receive adaptive equipment for eating and drinking including Kennedy cups, built up utensils, and an Inner lip plate. A 4/3/23 updated intervention included trialing weighted utensils. The resident participated in a nursing rehabilitation eating and swallowing program which included to ensure the resident had left angled built-up utensils, divided plate, Kennedy cups, and hand over hand assist at times due to hand tremors and droppage. Additional instructions included to put space between the Kennedy cups so the resident could grasp them easily without spillage. The care instructions ([NAME]) documented adaptive equipment for eating and drinking included a Kennedy cup, built-up left angled utensils, and an inner lip plate. The resident's hand tremors may cause droppage and weighted utensils were being trialed. Resident #30's meal ticket dated 4/25/23 documented in red lettering Kennedy cups, weighted utensils, an inner lip plate, and an empty bowl at breakfast. The resident required supervision and set-up assistance at meals. The resident was observed: - on 4/25/23 at 8:45 AM their breakfast tray was delivered and included hot mugs with lids that did not fit snuggly to the top of the mug. There were no Kennedy cups on the tray. - on 4/25/23 at 1:06 PM the resident's lunch tray included regular utensils instead of weighted utensils, and a regular plate instead of an inner lip plate. During an interview on 4/25/23 at 12:14 PM cook/dietary aide #26 stated during the tray line process, the person who is at the start of the line called out the meal ticket including the consistency of food and beverages that were needed and any adaptive equipment. The person at end of the line checked the meal ticket against the items on the tray to ensure the food and beverages matched the meal ticket. The top of the meal ticket indicated what type of silverware or plate the resident needed. They stated that the tray line had not run out of adaptive silverware. During an interview on 4/25/23 at 12:40 PM, dietary aide #27 stated they called out the tickets at the beginning of tray line which included the food consistency and adaptive equipment. They stated that they had run out of silverware previously, but they were able to add them to the tray prior to it being sent to the unit. If a resident received the wrong utensils, they may not be able to eat. During an interview on 4/25/23 at 1:23 PM, dietary aide #28 stated they checked the meal tickets at the end of the tray line. They stated that they matched the actual tray with the meal ticket for accuracy. They stated that if items were missing, they would let the supervisor know. During an interview on 4/26/23 at 1:10 PM, the Food Services Director stated the person at the end of the tray line checked the trays for accuracy and the staff on the resident unit also checked the trays for adaptive equipment, allergies, and appropriate diets. If a resident did not receive the correct adaptive equipment, they may have difficulty eating or drinking. During an interview on 4/26/23 at 2:43 PM, CNA #48 stated staff knew what type of adaptive equipment a resident needed by either checking their care plan ([NAME]) or looking at the meal ticket. They stated that if the adaptive equipment did not come up on the tray, they would call the kitchen to see if it was in stock. CNA #48 stated that they were told that Kennedy cups were on order as the facility did not have anymore. CNA #48 stated if they only had one [NAME] Cup for the resident, they would put one drink in, wait for the resident to finish it, then rinse it for the next beverage. It was important to have correct adaptive equipment because therapy ordered it for a reason. During an interview 4/26/23 at 2:30 PM licensed practical nurse (LPN) #47 stated if the correct adaptive equipment was not sent on the tray, they would check the unit pantry to see if there were extras. If the pantry did not have the equipment, they called the kitchen. If a resident did not have the right adaptive equipment, they may not be able to feed themselves. During an interview on 4/26/23 at 2:43 PM LPN Unit Manager #49 stated that they expected staff to ensure each tray matched the meal ticket prior to delivering the tray. They stated that if the care planned adaptive equipment was not present, they expected staff to call the kitchen. They stated they should be notified if the kitchen did not have the adaptive equipment available. They had not heard of issues with adaptive equipment not being not received. If equipment was missing, they would check the rooms on the unit and talk to the Dietary Manager. If a resident did not have the care planned adaptive equipment it could set the resident back in their activities of daily living and decrease independence. Not having the appropriate adaptive equipment was also a safety and dignity issue. During an interview on 4/27/23 at 9:22 AM, the Assistant Director of Rehabilitation stated if a resident did not have appropriate adaptive equipment, they could have diminished intakes, increased aspiration risk, and reduced ability to be independent. 10NYCRR 415.14(g)

Based on observation, interview, and record review during the recertification survey conducted 4/19/23-4/27/23, the facility failed to dispose of garbage and refuse properly for 1 isolated area (the waste fryer oil drums outside the main kitchen). Specifically, the waste fryer oil had been spilled on the ground surrounding the waste drums outside of the main kitchen. Findings include: The undated facility policy Fryer Oil and Grease Removal Guidelines documented after the grease was completely cooled it could be transported to the grease trap or other receptacle designed for environmental oil recycling. Look and check the levels in the environmentally responsible container and see if it needed to be emptied by the oil recycling company. Check the area traveled during the removal process to ensure that oil was not spilled or smudged. If any area was soiled with grease or oil, the area must be cleaned. During observations on 4/20/23 at 1:11 PM and 4/25/23 at 12:55 PM, there were two 55 gallon drums dedicated for waste fryer oil storage outside the back door of the kitchen. The ground around the drums was saturated with spilled grease. A wooden pallet beside the drums was also soiled with grease. The spilled grease extended approximately two feet out and around the drums and pallet which were against the outside of the building. During an interview on 4/25/23 at 1:00 PM, cook #25 stated that they were responsible for disposing of the waste fryer oil outside of the main kitchen. They stated they were not aware of ever spilling any grease there but thought one of the barrels may have had a leak because the ground was pretty mushy. They stated they told the Food Service Director they suspected a leak about 6 months ago, but they would not have documented it anywhere. During an interview on 4/26/23 at 1:16 PM, the Food Service Director stated they were not aware of the puddle of grease outside by the fryer oil waste drums, and they had assumed it was mud. They stated no one had brought it to their attention. The Food Service Director stated the grease soaked ground could attract pests. During an interview on 4/26/23 at 1:16 PM, the Assistant Administrator stated that they were not aware of the spilled grease/fryer oil waste outside of the main kitchen and the grease soaked wooden pallet against the building was a fire hazard. 10 NYCRR 415.14(h)

Based on observation, record review, and interview during the recertification and abbreviated (NY00275715 and NY00300682) surveys conducted 4/19/23-4/27/23, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #178) reviewed. Specifically, during Resident #178's wound treatment licensed practical nurse (LPN) #5 did not perform appropriate hand hygiene. Findings include: The facility policy, Wound Cleansing, modified on 4/25/18 documented wound cleansing would be provided to optimize wound healing and to decrease the potential for wound infection. The procedure included wash hands thoroughly, prepare supplies, apply non-sterile gloves, remove soiled dressing and discard in appropriate receptacle, remove and discard gloves, wash hands thoroughly and apply clean gloves, cleanse wound per physician order, apply treatment and dressing per physician order, and remove and discard gloves, wash hands thoroughly. Resident #178 had diagnoses including osteomyelitis (bone infection) of vertebra (mid spine area), and bacteremia (bacteria in the blood). The 3/23/23 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance of 2 for bed mobility, did not have infections, had 1 Stage 3 (full thickness tissue loss) pressure ulcer, received application of nonsurgical dressings, and received antibiotics 7 of 7 days. The comprehensive care plan (CCP) initiated 3/16/23 documented the resident had a pressure ulcer to the coccyx (tailbone). Goals included the pressure ulcer would not show signs and symptoms of infection. Interventions included, apply treatment per physician order and assess for signs and symptoms of infection. The resident was at risk for infection due to bacteremia. Interventions included to administer treatments per medical order and monitor for any adverse reactions. Physician orders dated 3/29/23 documented Durafiber 2 (wound dressings) apply to coccyx topically every day and evening shift for pressure injury. Cleanse wound with normal saline (NS) and apply Durafiber AG (silver) to wound. Cover with Allevyn Gentle dressing (absorbent, foam dressing). On 4/25/23 at 1:41 PM a treatment to the resident's coccyx wound was observed with licensed practical nurse (LPN) #5: - LPN #5 washed their hands, applied clean gloves, and set up the clean area using a barrier, and a trash receptacle for the soiled dressing. LPN #5 removed the soiled dressing, placed it in the trash bag, removed the soiled gloves, and washed their hands. - LPN #5 applied new gloves without performing hand hygiene and placed a new barrier with dressing supplies. They cleansed the resident's wound with NS and a gauze pad using their gloved left hand. Using only their gloved right hand they cut the Durafiber dressing with scissors, then used their left hand they had cleansed the resident's wound with to apply the clean Durafiber dressing. They cut the Allevyn dressing with their right hand and applied the dressing over the wound. During an interview on 4/25/23 at 1:48 PM, LPN #5 stated their dirty hand was their right hand, and their left hand was their clean hand. It was important to have one hand clean and the other one dirty so that new germs were not introduced to the wound. Their right hand with the scissors was the dirty hand and they should not have used that hand to apply the dressing as it could potentially cause germs to enter the wound. During an interview on 4/25/23 at 2:17 PM, the Infection Preventionist (IP) stated they would expect nurses to gather all supplies for a dressing change and place a barrier. If they placed two barriers, they could use the first barrier for the soiled dressing and gloves and the second barrier for the clean supplies. That way, when a nurse changed gloves and washed their hands the barrier was already in place. A nurse should not be using a dirty hand to apply a dressing to a clean area (wound). The risk would be the potential for infection to the wound. 10 NYCRR 415.19

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 4 of 4 occupied resident floors (First, Third, and Fourth floors) reviewed. Specifically, - the fourth floor had stained ceiling tiles and the elevator alcove had a loose handrail. - the third floor had a damaged bathroom sink, the soiled utility room did not have a paper towel dispenser, and the dining room window was cracked. - the first floor had damaged walls and ceilings, unsealed penetrations, an open junction box in the education classroom closet, and the library had two sliding windows that opened more than 6 inches. Findings include: The undated facility Window Policy documented the Environment: Common Areas/Nursing Units/Service Hall/Lobby Audit form would be reviewed at the monthly risk management meetings. The following observations were made on the Fourth Floor: - on 4/19/23 at 11:46 AM, the elevator alcove had a loose, 1 foot section of handrail. - on 4/19/23 at 11:50 AM, the hall outside of resident room [ROOM NUMBER] had three dried stained ceiling tiles. - on 4/24/23 at 11:56 AM, the hall outside of resident room [ROOM NUMBER] had three stained ceiling tiles, two of the tiles were wet. Work orders dated from 11/20/2020 to 4/4/2023 documented requests for maintenance for the fourth floor stained ceiling tiles, in the hall near resident room [ROOM NUMBER] (in same vicinity as resident room [ROOM NUMBER]). Monthly safety inspection reports dated 2/1/23, 2/27/23, and 4/3/23 documented the fourth floor hall had stained ceiling tiles. The following observations were made on the Third Floor: - on 4/19/23 at 12:15 PM, the bathroom near the nursing station had a damaged sink where the faucet had been installed in the sink. The sink was loosely attached to the wall. - on 4/19/23 at 12:22 PM, the soiled utility room lacked a paper towel dispenser and paper towels. - on 4/24/23 at 2:11 PM, the dining room window had a 3 foot x 2 foot crack and there was clear tape over approximately 18 inches long on the bottom portion. During an interview on 4/24/23 at 2:11 PM activity leader #24 stated the third floor dining room window had been cracked for about a month. They stated the crack had started at the bottom of the window and had worked up to the top of the window. During interviews on 4/24/23 at 2:13 PM and 4/26/23 at 2:25 PM, the Maintenance Director stated that in the fall of 2022 a resident threw something at the third floor dining room window causing the crack. The window was secured while waiting for better weather. The cracked window created a potential hazard. They stated they were not aware the crack in the window was not fully taped and would expect staff to report if the crack was spreading. The Maintenance Director stated that there were no work orders for the broken window. They stated the vendor that was usually used by the facility had recently converted into a window parts supplier and not a window installing company. They stated they had called the vendor and the voicemail was full. The facility had not started the process to get another vendor to replace the window. The following observations were made on the First Floor: - on 4/19/23 at 10:48 AM, resident room [ROOM NUMBER] had a damaged section of wall behind the B side resident bed. - on 4/19/23 at 2:15 PM, resident room [ROOM NUMBER] had a damaged section of wall behind the B side resident bed, and the area around the bathroom door was scratched. - on 4/19/23 at 2:55 PM, the north dining room area, near the handwash sink, had a damaged section of lower soffit sheetrock shelf. The soffit height was approximately 3 feet off the ground. - on 4/19/23 at 2:59 PM, the dementia unit soiled utility room solid ceiling had an unsealed 3/4 inch conduit penetration and an unsealed 4 inch x 4 inch hole with data wires passing through into the space between the solid ceiling and the flat ceiling above. - on 4/20/23 at 9:06 AM, the dementia unit tub room had a 1/2 inch x 10 inch damaged section of solid ceiling. - on 4/20/23 at 9:30 AM, the first floor education classroom closet had dead low voltage wires coming out of an old call bell system junction box. - on 4/20/23 at 9:47 AM, resident room [ROOM NUMBER] had a 3 foot x 3 foot section of damaged wall, the wall radiator metal cover was loose, and the bathroom had a damaged towel bar with only the end posts present. - on 4/20/23 at 9:57 AM, the library had two sliding windows that opened approximately three feet wide. The window locks that prevented the windows from opening more than 6 inches were broken. During an interview on 4/20/23 at 9:57 AM, the Assistant Administrator stated the library windows were used for COVID-19 window visits. During an interview on 4/25/23 at 10:39 AM, the Housekeeping Director stated if housekeeping staff observed damaged walls, they should tell the nursing unit clerks or Unit Managers who would complete work orders. The Housekeeping Director stated different staff was assigned to do a general survey of environmental issues such as clear hallways and ensuring rooms were in good working order. They stated that besides the stained ceiling tiles on the fourth floor, they were not aware of any of the other items identified during the tour of the facility. The Housekeeping Director stated housekeeping staff were in resident rooms everyday cleaning and disinfecting and were trained to identify issues. They stated they toured the resident floors daily and entered resident rooms as needed. Twice a week 2 to 3 rooms on each floor were randomly cleaned and all resident rooms were deep cleaned monthly. The Housekeeping Director stated work orders were completed in order from critical to medium. During an interview on 4/26/23 at 2:25 PM, the Maintenance Director stated work orders could only be found for the fourth floor stained ceiling tiles. They stated there were no documented inspections of resident rooms, and the entire facility was checked monthly by the risk management team which included Administration, Unit Managers, Housekeeping Director, and the Food Service Director. The Maintenance Director stated the first floor library window guards were damaged during one of the COVID-19 window visits in 2020 and 2021. They stated that the facility was the residents' home, and it should look nice and provide a safe environment. During an interview on 4/26/23 at 2:30 PM, the Assistant Administrator stated the cracked window, and the other items observed during the tour of the facility were not homelike. 10 NYCRR 415.29(j)(1)

Based on observation, interview, and record review during the recertification survey conducted 4/19/23-4/27/23, the facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety for 1 of 1 kitchen (main kitchen) reviewed. Specifically, the main kitchen's tray service line cooler was propped open and not maintaining proper temperature, floors were in disrepair, the ceiling was damaged, and cooking and storage equipment was unclean. Findings include: The facility policy Dietary Food and Supply Orders-Storage dated 10/26/2018, documented refrigerator storage was to be 41 F (Fahrenheit) or below. The facility policy Kitchen, Dining and Dietary Equipment Routine Cleaning dated 9/7/2018 documented daily staff assignments included areas of equipment to be cleaned or kept in order after each meal service including the general cooking area, and general kitchen area. Cooking surface of the grill was to be cleaned at least once daily and kept free of encrusted grease and other soil. The monthly cleaning schedule included all counters and shelves, and pots and pans area racks. The undated Weekly Cleaning List documented: - properly clean grill and stovetop; and - properly clean friers (AS NEEDED). 1. Tray Line Cooler During an observation on 4/20/23 at 12:05 PM two refrigerators were propped open on the tray service line during lunch assembly. The left cooler had cottage cheese that was measured at 48 F. The right cooler had hardboiled eggs measured at 54 F and American cheese at 53 F. The door seal was tattered along the bottom edge of the left unit. During an interview on 4/20/23 at 12:09 PM, the Food Service Director stated the cooks checked the final cooking temperatures, and the hot items on the line, but they did not check the cold holding temperatures during meal service. The cold holding equipment was checked once a day, typically in the morning. The Food Service Director stated the coolers were propped open at the start of each meal service and the coolers were stressed to the max. During an interview on 4/20/23 at 12:47 PM, dietary aide #20 stated the cottage cheese was discarded at the end of the shift, the lettuce salads were re-wrapped and moved to another refrigerator in the kitchen, the shelf stable drinks were moved to another cooler, and the items on the bottom shelf (American cheese and hard boiled eggs) remained in the coolers. During an observation on 4/20/23 at 12:50 PM the two coolers from the tray line were closed and pushed against the wall. Dietary aide #20 began removing some of the contents to move to other units. They did not measure the temperature of the contents. During an observation on 4/20/23 at 1:25 PM, the hardboiled eggs were measured at 58 F and the American cheese was measured at 58 F. Both items were in the left side of tray line cooler. A bowl containing individual packets of sour cream was on the bottom shelf of the cooler. The right side of the cooler was empty. During an observation on 4/20/23 at 2:16 PM, the American cheese was measured at 56 F and hard boiled eggs were measured at 55 F. These temperatures were confirmed with the Food Service Director who measured them with the facility and included hardboiled eggs at 55 F, American cheese at 55 F, and the approximately 30 (1) ounce sour cream packets were measured at 53 F. During an interview on 4/20/23 at 2:16 PM, the Food Service Director stated they did not check the temperatures of the tray line coolers after meal service, but they knew they should be shut to come back to temperature. They stated the doors to the coolers had been closed since the end of the lunch service and they were usually locked at that time. The hardboiled eggs, American cheese, and sour cream would have been in that cooler all day. The Food Service Director stated food was allowed to be out of an acceptable temperature range for up to two hours. They stated they were not aware these items had been out of temperature for more than two hours. It was potentially dangerous to leave food out of temperature for more than two hours. 2. General Kitchen Cleanliness On 4/19/23, between 10:30 AM and 11:15 AM, observations of the main kitchen included: - two metal storage racks in the clean area were rusty and not cleanable. The racks contained miscellaneous baking measuring containers, baking sheets, and catering supplies. - the floor near the dish machine area had a 2 foot x 2 foot section of plywood. This material could absorb water, was a potential mold risk, and was not cleanable. - the floor in the dish machine area was missing grout and there was standing water between the tiles. The spaces between the tiles were not cleanable and created a potential for pests in the kitchen. - the metal surfaces of the deep fryer were sticky and not clean. The metal side wall of the steamer, next to the deep fryer, was also sticky and not clean. - the metal side of the stove top, next to the flat top unit was sticky and not clean. - there were two frying pans on a hanging rack near the cook's area that were soiled and caked with black debris. - the solid ceiling over the cook's area was soiled with unknown debris. There was a damaged 2 foot x 6 inch section of solid ceiling. - multiple sections of the tray line area had sections of peeling floor material that was not cleanable and was a tripping hazard. During an interview on 4/19/23 between 10:54 AM and 11:15 AM, the Food Service Director stated the deep fryer was last used for the dinner meal on 4/18/23, was supposed to be cleaned after each use, and should be wiped down and cleaned weekly as per the weekly cleaning list. They stated it appeared that the oil on the deep fryer surfaces had been there for more than one week, and there was no documentation of who was responsible for the last weekly cleaning. The Food Service Director stated the two frying pans hanging in the cook's area were not being used and should have been removed from the kitchen. During an observation on 4/20/23 at 1:05 PM, the main kitchen cooks area had a floor to ceiling sheetrock pillar and the sheetrock was loose and in disrepair. During an interview on 4/26/23 at 1:54 PM, the Maintenance Director stated they were aware of flooring concerns in the dish machine area and there was no official documentation that the facility was in the process of repairing the floor. They stated that the maintenance department had attempted to repair the section of floor under the 2 foot x 2 foot section of plywood, and this area had not yet been fully repaired. The Maintenance Director was not aware of the loose pillar and the damaged solid ceiling in the cook's area. They stated that it was important for the main kitchen to be maintained so that staff could work in a safe environment. During an interview on 4/26/23 at 2:13 PM, the Food Service Director stated they were not aware of the loose pillar in the cook's area and could not find any work orders for the pillar. They stated they thought the metal storage racks were just dirty and was not aware they were rusted. They stated they had checked that the items on the racks were clean but not the condition of the rack itself. The Food Service Director stated it was important for the main kitchen to be maintained so that staff could work in a safe environment. 10NYCRR 415.14(h)