**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during a Complaint investigation (Complaint #NY00374344- 635063) the facility did not ensure physician orders for the resident's immediate care were in place on admission for one (1) (Resident #7) of three (3) residents reviewed for admission orders. Specifically, Resident #7 was re-admitted to the facility on [DATE] and their admission medication orders were not entered into the electronic medical record and implemented until 09/10/2025.The finding is:The policy and procedure titled Electronic Physician Orders (Create, Confirm, Processing Orders) dated 08/28/2024, documented Admission/readmission orders for the care of a resident are received from a Licensed Physician/Nurse Practitioner/Physician Assistant upon admission/readmission of a resident to the facility. Orders will either be entered into the electronic medical record system by the nurse/pharmacist following confirmation from the Practitioner or directly entered by the medical provider. The nurse/pharmacist will communicate with the ordering provider when the data entry process is complete to alert the provider to electronically sign.Resident #7 had diagnoses that included schizophrenia, anxiety disorder, and hypertension. The Minimum Data Set (a resident assessment tool) dated 09/08/2025 documented an entry tracking record and was still in progress with no resident additional information.The comprehensive care plan documented there was a care plan focus initiated on 07/05/2019 for alteration in cardiac status related to hypertension, hyperlipidemia, obesity, and edema. Additionally, potential for alteration in mood was initiated on 07/05/2019 related to depression, schizophrenia, and bipolar disorder. Interventions included to administer medications as ordered and to monitor for side effects and effectiveness. The base line care plan was not provided.Review of the hospital Discharge summary dated [DATE] documented Resident #7's discharge medications: acetaminophen (Tylenol) 650 milligrams by mouth every four hours as needed; amlodipine (blood pressure medication) 7.5 milligrams by mouth every day; aripiprazole (antipsychotic medication) 30 milligrams by mouth every day; aspirin 81milligrams by mouth every day; bisacodyl suppository (laxative)10 milligrams rectally every day as needed; Vitamin D-3 (supplement) 25 micrograms two tablets by mouth every day; cholestyramine 4 gram packet by mouth every day; clonazepam (anti-anxiety medication) 0.5 milligrams by mouth every day; Vitamin B-12 (supplement) 500 micrograms by mouth every day; dicyclomine (medication used to treat irritable bowel syndrome) 20 milligrams by mouth four times a day; famotidine (medication used to treat heartburn) 20 milligrams by mouth every day; finasteride (medication for enlarged prostate gland) 5 milligrams by mouth every day; furosemide (diuretic) 20 milligrams two tablets by mouth every day; loperamide (used to treat diarrhea) 2 milligrams by mouth every two hours as needed; losartan (blood pressure medication) 25 milligrams by mouth every day; melatonin (supplement for sleep) 5 milligrams by mouth every day at bedtime; metoprolol succinate (blood pressure medication)100 milligrams by mouth every day; oxcarbazepine (seizure medication) 300 milligrams by mouth every day; oxybutynin (bladder medication) 300 milligrams by mouth twice a day; artificial tears 1.4(%) percent ophthalmic eye drops to both eyes twice a day; simvastatin (cholesterol medication) 20 milligrams by mouth every day at bedtime; tamsulosin (medication for enlarged prostate gland) 0.8 milligrams by mouth every day at bedtime; tolterodine (bladder medication) 4 milligrams by mouth every day; and trazadone (antidepressant) 100 milligrams by mouth every day at bedtime.Review of the Health Status Note dated 09/09/2025 at 10:15 AM entered as late entry by Licensed Practical Nurse Unit Manager #1, documented Resident #7 returned to the facility on [DATE] at 15:04 PM (3:04 PM), they were alert and oriented to self and surroundings, and made their needs known. Licensed Practical Nurse Unit Manager #1 further documented discharge instructions were clear, recommended medication changes and were given to the provider for further review.Review of the Telephone/Verbal Order Signature Details report dated 09/01/2025 - 09/30/2025 revealed Resident #7's medication orders were not entered into the electronic medical record until 09/10/2025 and were electronically signed by the medical providers on 09/10/2025 at 11:44 AM, 12:22 PM, 12:28 PM, 3:14 PM and 4:19 PM.Review of the Medication Administration Record dated 09/01/25 - 09/30/2025 documented Resident #7 had not receive any medications until 09/10/2025.During an observation and interview on 09/10/2025 at 9:10 AM, Resident #7 was observed sitting up at the side of their bed, appeared well-kempt and in no distress. Resident #7 stated they had returned from the hospital on Monday 09/08/2025 sometime in the evening, they received their morning medications from the hospital prior to being re-admitted but had not receive any further medications after they arrived at the facility. Resident #7 stated they asked their nurse yesterday for their medication but never received anything. They stated they took several medications and were concerned about missing their blood pressure medication.During an observation on 09/10/2025 at 9:25 AM, Licensed Practical Nurse #3 entered Resident #7's room and informed them there were no medication orders listed in the computer and would have to wait until orders were entered before they could administer medications to them.During an interview on 09/10/2025 at 9:40 AM, Licensed Practical Nurse #3, stated Resident #7 had re-admitted back to the facility on [DATE] and were unsure why their medication orders were not entered into the computer. Licensed Practical Nurse #3 pulled up the electronic medication administration record (EMAR) on their computer and stated Resident #7 did not appear on their computer screen. They stated they were familiar with Resident #7, knew they took several medications during the day, and had not worked since Resident #7 was re-admitted to the facility. Licensed Practical Nurse #3 stated they had just informed their Director of Nursing and the Medical Director that Resident #7's admission orders had not been entered into the electronic medical record.During an interview on 09/10/25 at 10:12 AM, Licensed Practical Nurse Unit Manager #1 stated they had worked the evening shift (3:00 PM - 11:00PM) on 09/08/2025 as both the supervisor and medication nurse on another unit. Licensed Practical Nurse Unit Manager #1 stated they were not aware Resident #7 had been readmitted until later that evening on 09/08/2025, they completed the quick admit into the electronic medical record which consisted of entering Resident #7 status in the computer as returned from hospital and the time of arrival. Licensed Practical Nurse Unit Manager #1 stated they saw batch orders listed for Resident #7 and assumed they were their complete set of orders and had been activated. At this time, Licensed Practical Nurse Unit Manager #1 pulled up Resident #7's electronic medical record and noted under the order tab 23 orders remained listed in the que and were not activated. They stated the orders in the que appeared to be only the batch orders and did not contain any medications listed from the hospital discharge summary. Licensed Practical Nurse Unit Manager #1 stated on 09/09/2025 they had Physician Assistant #1 review Resident #7's hospital discharge summary and clarified orders but they had not entered any orders from the discharge summary into the electronic medical record after being reviewed by Physician Assistant #1. During an interview on 09/10/2025 at 10:37 AM, the Director of Nursing stated they had just been made aware by the Medical Director that Resident #7 did not have admission orders entered into their electronic medical record and had received no medications since their readmission on [DATE]. The Director of Nursing stated depending on the time of admission it was the responsibility of either the unit manager or the nursing supervisor to enter admission orders from the discharge summary into the electronic medical record and notify the on-call provider to review, confirm and sign all orders. The Director of Nursing stated they would expect admission orders to be entered into the electronic medical record on the day of admission to ensure medications were received and administered timely and avoid any delays or adverse effects. The Director of Nursing stated Resident #7's admission orders should have been entered into the electronic medical record by the nursing supervisor on 09/08/2025.During a telephone interview on 09/10/2025 at 12:24 PM, Licensed Practical Nurse #2 stated they worked on 09/09/2025 from 7:00 AM until 7:00 PM and did not remember administering any medications to Resident #7. They stated other staff members had informed them Resident #7 had just returned from the hospital and their electronic medical record did not show any medications were due to be administered. They stated the Unit Manager or Nursing Supervisor were responsible for completing admission orders. Licensed Practical Nurse #2 stated if a resident was due for a medication or treatment their name would show up in the electronic medication administration record (EMAR) and would be either yellow meaning a medication was due or red indicating a medication was overdue. Licensed Practical Nurse #2 stated they were not familiar with Resident #7's routine medications, and they did not request any medications during their shift. They stated they just assumed no medications were due to be administered during their shift for Resident #7.During an interview on 09/10/2025 at 11:08 AM, Physician Assistant #1 stated the nursing staff would notify them when a new admission arrived at the facility to confirm and sign admission orders after they had been entered into the electronic medical record. They stated they were the on-call provider on 09/08/2025 and were not notified to review admission orders for Resident #7 upon readmission. Physician Assistant #1 stated on 09/09/2025 they had reviewed Resident #7's hospital discharge summary with Licensed Practical Nurse Unit Manager #1 but no orders had been electronically sent to them to be confirmed and signed. They stated they had just been made aware that Resident #7's admission orders had not been entered into the electronic medical record and they had not received their medications. Physician Assistant #1 stated Resident #7's missed doses of medications were not medically dangerous but could have exacerbated their anxiety symptoms. They stated the delay in entering admission orders into the electronic medical record was unacceptable.During a telephone interview on 09/10/2025 at 11:28 AM, the Medical Director stated they expected the nursing staff to notify them or the on-call provider when an admission arrived, they would review and electronically sign admission orders after they had been entered by nursing staff. The Medical Director stated they had just been notified Resident #7 readmitted to the facility on [DATE] and their admission orders had not been entered into the electronic medical record. They stated they would expect admission orders be entered into the electronic medical record on the same day of admission to ensure timely administration.10 NYCRR 415.11

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the standard survey, completed on 12/6/24, the facility did not ensure that residents who were unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene for two (Residents #10 and #25) of six residents reviewed. Specifically, Resident #25 had visible food residue in their top and bottom dentures on multiple observations; Resident #10 had visible chin hair and long nails with brown debris underneath on multiple observations. The findings are: The policy and procedure titled ADL Care Guidelines dated 10/2021, documented care givers will review the resident's nursing care instructions at the beginning of each shift to assure that care is given according to the individual's plan of care. It also documented that the resident will be assisted with oral hygiene as appropriate, and dentures will be removed nightly and placed in a labeled denture cup with a cleaning tablet. The ADL policy documented female residents with excessive facial hair will be shaved at least weekly, if indicated and routine hand care will be done with bath and as needed. Fingernails should be cleaned underneath, and shaped. The policy and procedure titled Fingernail and Toenail Care, dated 7/3/2012, documented resident's fingernails would be monitored during their weekly skin assessments or on bath days. 1. Resident #25 had diagnoses including unspecified dementia, stroke, and lower back pain. The Minimum Data Set (a resident assessment tool), dated 10/17/24, documented Resident #25 was moderately cognitively impaired, and always understood and understands. Resident #25 required partial/moderate assistance with oral hygiene, and partial/moderate assistance with transfers out of bed to their wheelchair. Review of Resident #25's dental consult, dated 2/8/24, revealed they had a full upper denture and a partial lower denture, with a note staff to assist patient with daily cleaning of dentures, nightly and as needed. The comprehensive care plan last revised 10/25/24, documented Resident #25 had an ADL self-care performance deficit related to muscle weakness, and limited physical mobility related to weakness. The care plan also documented the resident had oral/dental health issues related to poor oral hygiene, and to provide mouth care as per ADL personal hygiene. There was no documentation that the resident had dentures or how to care for them. Review of the Closet Care Plan (used by staff to guide care) updated on 11/25/24, revealed the area labeled personal care had blank boxes where upper and lower dentures should have been checked and there were no instructions for denture care. Review of the Certified Nurse Aide task documentation for Resident #25 revealed from 12/3/24-12/5/24 oral hygiene was documented as Not Applicable. During an observation and interview on 12/2/24 at 9:22 AM, Resident #25 was in bed, there was visible food debris in both their upper and lower dentures. Resident #25 stated staff did not clean their dentures very often and could not recall the last time they were removed and cleaned. During observations and interviews, on 12/4/24 at 8:28 AM and 12/5/24 at 8:53 AM, Resident #25 had visible food debris in both their upper and lower dentures. They stated staff had not remove them to soak them. During an interview on 12/5/24 at 8:58 AM, Licensed Practical Nurse #1 stated that if a resident wore dentures, it should be documented on their care plan, so the staff knew to clean them. During an interview on 12/5/24 at 9:24 AM, Unit Manager, Licensed Practical Nurse #2 stated that the care plan should reflect if a resident wore dentures so the certified nurse aides would know to clean them. They stated it was important for dentures to be removed at night and soaked for proper hygiene, because bacteria could grow underneath them. They were not aware that Resident #25's dentures were not documented on their care plan. During an interview on 12/5/24 at 10:54 AM, Certified Nurse Aide #2 stated they looked at a resident's care plan to determine what type of oral care a resident needed. Certified Nurse Aide #2 stated that resident's dentures should be removed at night and placed in a denture cup to be sanitized. It was important for good hygiene and for their dignity to have clean teeth. They stated they did morning care on resident #25 that morning and they did not remove their dentures. Certified Nurse Aide #2 stated they could not recall the last time Resident #25's dentures were cleaned; they were in their mouth whenever they did the resident's morning care. During an interview on 12/6/24 at 10:52 AM, the Director of Nursing stated that nursing care plans should be updated by the unit managers. Dentures should be documented on the care plan, so staff know to properly clean them. They expected Certified Nurse Aides to remove residents' dentures every night to soak them because it was important for good hygiene and dignity. 2. Resident #10 had diagnoses including multiple sclerosis (a disease where the immune system effects the protective covering of nerves), diabetes mellitus type 2, and pressure ulcer (injury to the skin and tissues from prolong pressure to the area) of the sacrum (area at the base of the tailbone) and ischium (area of the lower buttocks). The Minimum Data Set, dated [DATE], documented Resident #10 was cognitively intact, understood and understands. Resident #10 required supervision/touching assistance with hygiene, and substantial/maximal assistance with bathing. The comprehensive care plan initiated on 11/4/24, documented Resident #10 had an ADL self-care performance deficit related to muscle weakness. Interventions included the resident was independent/set up for grooming and extensive assist of one for bathing. During observations on 12/2/24 at 12:43 PM and 12/3/24 at 11:11 AM, Resident #10 was observed to be lying in bed wearing their own personal night gown. Resident #10 was observed have long fingernails with brown debris underneath and ½ inch long white chin hairs. During an observation and interview on 12/4/24 at 9:42 AM, Resident #10 was observed to continue to have long nails with brown debris and chin hairs. Resident #10 stated they minded having long chin hairs and would like the staff to help remove them and they would also like to have their fingernails cut. Resident #10 added they would like to have their hands and nails cleaned but staff do not give them anything to wash them with. Resident #10 stated they were new to the facility and still were getting used to the ways staff did things. During an observation on 12/4/24 at 10:13 AM, Certified Nurse Aide #8 and #9 performed morning care for Resident #10 by washing, rinsing, and drying the resident's neck, underneath their breasts and armpits, peri area and buttocks. Resident #10 was dressed in their personal gown and was not gotten out of bed. Certified Nurse Aide #8 and #9 did not wash nor offer to clean Resident #10's hands and nails or assist with removal of their chin hair. During an interview and observation on 12/6/24 at 10:29 AM, Resident #10 was observed to continue to have long nails with brown debris and chin hairs. Resident #10 stated that no staff members had offered to cut and clean their nails or assist them with chin hair removal during the week. During an interview on 12/4/24 at 1:30 PM, Certified Nurse Aide #8 stated that they did not perform nail care to Resident #10 and that they usually were not responsible to provide nail care to residents. They stated they did not know who was responsible to provide nail care. Certified Nurse Aide #8 stated that they did not notice the debris under Resident #10's nails and should have looked at their hands during care. They stated they did not offer Resident #10 to wash their hands and they should have. Certified Nurse Aide #8 stated the Activities Department usually was the department that would shave and/or cut a resident's hair. Certified Nurse Aide #8 stated they also did not offer to assist Resident #10 with chin hair removal and probably should have. Certified Nurse Aide #10 stated it was important to offer a resident to wash their hands because they touched everything, and it was an everyday activity. They stated it was important to remove chin hair because it was an everyday appearance to make a resident more presentable. During an interview on 12/4/24 at 1:59 PM, Certified Nurse Aide #9 stated when they performed morning care to a resident, they washed everything including a resident's hands and nails. Certified Nurse Aide #9 stated they did not offer Resident #10 hand washing, nail care and chin hair removal because they were only helping Certified Nurse Aide #8. Certified Nurse Aide #9 stated they should have placed Resident #10's hands in water and offered the resident a razor/shaver. During an interview on 12/5/24 at 12:16 PM, Licensed Practical Nurse #10 stated that the Certified Nurse Aides were responsible to perform nail care on a resident's shower day unless the resident was a diabetic. They stated that residents should be offered hand hygiene every day; prior to and after they eat; and when they used the bathroom. They stated that Resident #10 should have been offered hand hygiene and chin hair removal during morning care for infection control and dignity issues. During an interview on 12/6/24 at 12:41 PM, the Director of Nursing stated that morning care for a resident consisted of washing a resident from head to toe, including washing their hands. They stated nail care should be completed by the nursing staff and offered to the residents whenever their nails were long, or debris was noted for infection control and hygiene issues. The Director of Nursing stated the Certified Nurse Aides should also be offering/performing chin hair removal/shaving when needed due to dignity and respect for the resident. During an interview on 12/6/24 at 1:47 PM, Certified Nurse Aide #4 stated they were responsible for care on Resident #10 on 12/6/24. They stated they knew they should perform or offer nail care to Resident #10 every day during morning care, but they did not. Certified Nurse Aide #4 stated they had performed chin hair removal on Resident #10 last week but did not assist or offer today or at all this week. Certified Nurse Aide #4 stated they usually were the staff member that shaved the residents on the unit, and they have the other Certified Nurse Aides do the nail care. 10NYCRR 415.12 (a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 12/6/24, the facility did not ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #30) of one resident reviewed for positioning and mobility. Specifically, the staff did not ensure that Resident #30's left and right palm guards (assistive device that positions the fingers away from the palm) were worn as recommended by occupational therapy. In addition, there was inconsistent documentation that range of motion exercises were provided to the resident per their care plan. The finding is: The policy and procedure titled Range of Motion and Ambulation revised 9/15/2020, documented that every effort would be made to ensure that residents do not lose range of motion, ability to walk or activities of daily living abilities unless the loss is unavoidable. Certified nursing assistants are expected to assist with range of motion in accordance with the care plan and document that range of motion has been provided prior to the end of their shift in the electronic medical record. The policy and procedure titled Splint revised on 10/19/2015, documented that physical therapy/occupational therapy will determine the need of splint for the resident. Nursing, resident, and family members as indicated will be instructed in the wearing schedule and would be written on the plan of care/care guide. Resident #30 had diagnoses which included cerebral vascular accident- (stroke), dysphasia (impairment of speech and verbal comprehension), and muscle weakness. The Minimum Data Set (a resident assessment tool) dated 11/26/24, documented Resident #30 had severe cognitive impairment, was rarely/never understood, and rarely/never understands. The Minimum Data Set documented Resident #30 had upper extremity functional limitation in range of motion on one side. The comprehensive care plan dated 12/13/17, documented that Resident #30 had limited mobility and was on a restorative nursing program. The program included assistive active range of motion (exercises performed by resident with some help from staff) to bilateral (both) lowers extremities and passive range of motion (exercises performed on the resident by nursing staff) to bilateral upper extremities three times weekly on Mondays, Wednesdays, and Fridays. Resident #30 wore right and left palm guards as tolerated except for range of motion, hygiene, meals and when asleep. Review of the Occupational Therapy Discharge summary dated [DATE] documented nursing caregivers were instructed on the restorative nursing program which included bilateral upper extremities passive range of motion. The splinting/orthotic schedule was reviewed with nursing staff to preserve Resident #30's current level of function. During intermittent observations on 12/2/24 at 3:27 PM, Resident #30's right hand was curled into a fist. The left hand was gripping the wheelchair seat, there were no palm guards in the resident's hands. On 12/4/24 at 9:16 AM, 3:54 PM, and 12/5/24 at 10:48 AM there were no palm guards in Resident #30's left or right hand. Review of the Order Audit Report dated 12/5/24 revealed an active standing physicians order dated 11/30/22 for right and left palm guards to be worn except for range of motion, hygiene, and while asleep. The Medication Administration Record dated 12/1/24-12/31/24 documented right and left palm guards were to be worn except for range of motion, hygiene and while asleep. There were no start or end dates and there were no staff initials that documented the palm guards were worn. There was an x documented from 12/1/24-12/31/24. Review of the Documentation Survey Reports for 9/2024,10/2024,11/2024 and 12/2024 revealed Resident #30 was on a restorative nursing program for upper extremity and lower extremity range of motion three times weekly on Mondays, Wednesdays, and Fridays. There were multiple blanks where the range of motion wasn't documented as completed. During observation and interview on 12/5/24 at 1:48 PM, Certified Nursing Assistant #5 stated that palm guards prevented worsening contractures (loss of joint mobility) and verified Resident #30 had no palm guards in their hands per the care plan. They checked Resident#30's room, and the palm guards were missing. They never realized that Resident #30 did not have them on this morning. Rolled up wash cloths should have been used for Resident #30 to hold onto until the palm guards were located. Certified Nursing Assistant #5 stated the night shift was responsible for dressing Resident #30 and they got the resident out of bed. Certified nursing assistant's provided range of motion with morning care or when they go back to bed in the afternoon. Documentation was completed after the task was provided or by the end of the shift. During an interview on 12/5/24 at 10:23 AM, Certified Nursing Assistant #6 stated Resident #30 tolerated the palm guards when they wore them. Certified nursing assistants were responsible to provide range of motion and the blanks in the documentation indicated range of motion was not done. During an interview on 12/5/24 at 2:06 PM, Licensed Practical Nurse #1 stated that Resident #30 should wear right and left palm guards. Licensed Practical Nurse #1 observed the resident and stated they were not wearing their palm guards. Licensed Practical Nurse #1 checked the residents care plan and stated the resident was care planned to wear the palm guards at all times except for range of motion, hygiene, meals and while sleeping. Licensed Practical Nurse #1 stated palm guards prevented contractures and skin potential breakdown. Certified nursing assistants were responsible to ensure residents had their devices when they were gotten up for the day. Certified Nursing Assistant #5 should have checked the care plan and Licensed Practical Nurse #1 would have expected to be notified if the palm guards were missing. During an interview on 12/5/24 at 2:30 PM, Licensed Practical Nurse #2, Unit Manager stated Certified Nursing Assistant #5 should have read the care plan and communicated to Licensed Practical Nurse #1 the palm guards were not in Resident #30's room. Licensed Practical Nurse #1 should have informed them, and they would have notified therapy to replace the palm guards. Licensed Practical Nurse #2, Unit Manager stated there was no process of monitoring documentation for range of motion and it was a team effort. During an interview on 12/6/24 at 10:36 AM the Director of Therapy #1 stated Resident #30's palm guards were recommended by occupational therapy and updated on the care plan. Certified Nursing Assistant #5 should have made sure the palm guards were on after reading Resident #30's care plan. Nurses were responsible to ensure that the certified nursing assistants put on the palm guards, performed range of motion, and completed the documentation. The blanks on the Documentation Survey Report indicated uncertainty that range of motion was being done as recommended. Palm guards were important because they prevented further contractures for Resident #30. During an interview on 12/6/24 at 2:10 PM, the Director of Nursing stated they expected that Resident #30 would wear the palm guards if they are care planned and Certified Nursing Assistant #5 should have put them on. The Unit Manager, Licensed Practical Nurses and all staff were responsible to make sure the resident's care plan was followed. The palm guards were a standing physician's order on the medication administration record which alerted the nurses to ensure the certified nursing assistants had put them on but did not have to sign for the palm guards. Range of motion exercises were expected to be done with morning care and documented when completed in the electronic medical record by the assigned certified nursing assistants. If the resident was unavailable or refused, they would expect the resident to be reapproached later. During an interview on 12/6/24 at 2:05 PM, the Administrator stated it was important to ensure that the residents care plan was being followed. 10NYCRR 415.12(e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed 12/6/24 the facility did not ensure that residents with an indwelling foley catheter (tube inserted into the bladder to drain urine) received the appropriate care for one (Resident #45) of two residents reviewed. Specifically, staff did not maintain proper infection control practices for a resident with a foley catheter. The finding is: The policy and procedure titled Indwelling Catheter Care dated 2/2019, documented to keep the drainage tubing/catheter junction closed. Ensure the catheter is properly secured to upper thigh with securement device. 1. Resident #45 had diagnoses that included obstructive and reflux uropathy (obstruction in urinary tract), history of urinary infections and dementia. The Minimum Data Set (a resident assessment tool) dated 11/20/24 documented Resident #45 had moderate cognitive impairment, required substantial/max assistance with toileting and had an indwelling urinary catheter. The Clinical Physicians Orders dated 11/14/24 through 12/5/24 documented to flush foley with 30 milliliters of normal saline every day and as needed, and document foley output every shift. There were no other catheter care orders. The comprehensive care plan initiated 11/15/24 documented Resident #45 had an activities of daily living self-care performance deficit related to weakness. Interventions included extensive assist was required for toileting, bedpan use and foley care. The [NAME] provided as of 12/6/24, documented Resident #45 required extensive assist was required for toileting, bedpan use and foley care. The [NAME] posted in the resident's room on 12/5/24 during the observation did not indicate Resident #45 had a foley catheter. During an observation on 12/2/24 at 11:15 AM, Resident #45 was in bed. The foley catheter bag was attached to the bedframe and the bottom of the urinary drainage bag was directly on the floor; the spigot (spout used to empty urine from the collection bag) was not secured and was also touching the floor. The urinary drainage bag was dated 11/18/24 and the catheter tubing and bag contained yellow urine. During an observation on 12/5/24 at 9:18 AM, Resident #45 was in bed and the urinary drainage bag was attached to the bed frame, the catheter tubing and urine collection bag was on the floor. The urinary drainage bag was dated 11/18/24 and the catheter tubing contained cloudy yellow urine with mucous shreds. During an observation and interview on 12/5/24 at 1:04 PM to 1:21 PM, Certified Nurse Aide #5 placed the urinary collection bag spigot inside an undated urinal to empty urine from the collection bag. After draining the urine from the bag, they tapped the inside of the urinal with the spigot several times, clamped the spigot and then reconnected the spigot to the urinary drainage bag without sanitizing it. Resident #45's foley catheter was not secured to the securement device (leg strap) on the residents left thigh. Certified Nurse Aide #5 stated the securement device should be used so the resident's urine can flow better. They stated they should have wiped the spigot with an alcohol pad after emptying the drainage bag for infection control purposes. They stated they didn't have any alcohol pads and it slipped their mind to clean the spigot. Additionally, they stated they could have gotten alcohol pads from the clean utility room or from the nurse. During an interview on 12/5/24 at 1:44 PM, Licensed Practical Nurse #4 stated the spigot should be drained over a graduate, cleaned with alcohol to remove bacteria and germs for infection control purposes. During an interview on 12/5/24 at 2:00 PM, Unit 500 Manager Licensed Practical Nurse #2 stated an alcohol wipe should be utilized after draining urine from spigot to ensure nothing yucky was being left behind for infection control purposes. During an interview on 12/6/24 at 8:59 AM, the Infection Preventionist stated the process for emptying a foley catheter would be to perform hand hygiene, wear gloves, pull the spigot out of its holder, cleanse the spigot with an alcohol swab, empty the bag contents into a cylinder or urinal, cleanse the spigot again with an alcohol swab and replace into the holder. The Infection Preventionist stated they would expect the nursing staff to be careful not to hit the insides of the urinal/graduate with the spigot. The urinary drainage bag spigot should never be out of its holder laying on the floor nor should the foley drainage bag and tubing ever be laying directly on the floor because it could introduce bacteria into the bladder. During an interview on 12/6/24 at 9:56 AM, Licensed Practical Nurse #7 stated the foley catheter bag and tubing should not be touching or on the floor. The foley drainage bag should be replaced if it had been on the floor. Additionally, they stated the catheter drainage bag should be dated and changed every month or as needed. During an interview on 12/6/24 at 10:18 PM, Unit 500 Manager Licensed Practical Nurse #2 stated they expected foley catheter drainage bags and tubing to be kept off the floor for infection control purposes. It was the nursing teams responsibility to ensure catheter drainage bag and tubing weren't on the floor. During an interview on 12/6/24 at 1:45 PM, the Director of Nursing stated they expected foley catheter drainage bags and tubing to be kept off the floor. They stated the spigot should not touch the graduate and should be cleaned, disinfected after use for infection control purposes. 10 NYCRR 415.12(d)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews during a Standard survey completed 12/6/24, the facility did not ensure acceptable parameters of nutritional status, such as usual body weight for one (Resident #65) of two residents reviewed. Specifically, Resident #65 had a significant weight loss and there was a lack of meal and nourishment acceptance being documented or recorded. In addition, the medical provider was not made aware of the significant weight loss. The finding is: 1. Resident #65 had diagnoses that included dementia, protein-calorie malnutrition, and macular degeneration left eye (loss of the central field of vision because of deposits of the retina). The Minimum Data Set, dated [DATE] documented Resident #65 had severe cognitive impairment, required supervision/touch assist for eating, weight was 105 pounds and weight loss marked no or unknown. Additionally, Resident #65 was on a therapeutic diet. During breakfast and lunch meal observations on 12/5/24 at 9:11 AM and 12:53 PM, Resident #65 was sitting in the unit dining room with meal. Meal ticket on tray it was noted alert- extensive assist feeding. No staff present at table to provide assist during meal. Staff that were present were observed assisting other residents in the unit dining room. Meal ticket did not indicate what supplements they were to receive. Shake was observed on breakfast tray and boost was present on lunch tray. The Order Summary Report dated 12/6/24 documented No Added Salt diet, Regular texture, thin consistency with start date 7/3/24. Obtain admission weight and height, one time only for admission. Review of the Medical Orders for Life Sustaining Treatment (MOLST) last updated 9/18/24, revealed Resident #65 had a do not attempt resuscitation, do not intubate, send to hospital order when medically necessary. There were limited medical interventions which included no feeding tube, administer intravenous fluids, and use antibiotics to treat infections. The comprehensive care plan for Resident #65 initiated on 7/3/24 identified as current by the Director of Nursing, documented the resident had potential for nutritional risk related to body mass index 19.6, dietary restrictions secondary diagnosis of hypertension (high blood pressure), leaves greater than 25 percent of some meals uneaten at times. Dated 8/20/24 significant weight loss and 11/8/24 weight loss trend noted. Goal was to maintain adequate nutritional status as evidenced by maintaining weight within 1-5 pounds of current weight. Interventions included monitor meal consumption records, monitor weights as per policy, provide and serve supplements: shake at lunch and dinner, monitor acceptance and effects. On 8/29/24 shake was changed to Boost plus, on 9/20/24 shake added at breakfast and on 11/8/24 magic cup added every lunch. Report significant weight losses to medical doctor and interdisciplinary care team for input. Additionally, Resident #65 had limited self-care skills related to weakness, required extensive assist for feeding. Review of the Closet Care Plan last revised on 10/2/24 documented eating as extensive assist of 1 on unit. Review of the Weights and Vitals Summary dated 12/6/24 revealed the following weights and weight status: -7/2/24 admission weight was 114 pounds. -8/20/24 weight was 107 pounds. -9/13/24 weight was 105 pounds which showed a change/loss of 7.9 percent or 9 pounds since 7/2/24. -10/7/24 weight was 103 pounds which showed a change/loss of 9.6 percent or 11 pounds since 7/2/24. -11/11/24 weight was 100.5 pounds which showed a change/loss of 11.8 percent or 13.5 pounds since 7/2/24. -12/6/24 weight 98 pounds which showed a change/loss of 14 percent or 16 pounds since 7/2/24. Review of the Initial Nutrition Assessment completed by the Dietary Technician dated 7/3/24, revealed admission weight on 7/2/24 was 114 pounds with a body mass index of 19.6. Diet order of No Added Salt regular consistency thin liquids provides 1600-1700 kilocalories, 65-75 grams protein and 1200 milliliters fluids. Shakes at lunch and dinner provided 600 kilocalories, 22 grams protein and 360 millimeters of fluids. Estimated needs were 1554-1813 kilocalories, 51.8-62.2 grams of protein and 1544 milliliters of fluid per day. Actual intake for solids, liquids, and supplements to be monitored. Review of the dietary progress note dated 8/29/24 revealed weights reviewed, 8/20/24 weight was 107 pounds indicating a significant loss from previous weight. Intake of meals 26-100 percent. Shake provided at lunch and dinner with acceptance generally greater than 50 percent. Shake was changed to Boost plus for increased kilocalories. Monitor acceptance and effects. Review of the dietary progress note dated 9/20/24 revealed weights reviewed, 9/13/24 weight was 105 pounds indicating a 2-pound loss from previous weight. Intake of meals 26-100 percent. Supplements provided, acceptance 25-100 percent. Shake was added at breakfast for increased kilocalorie, monitor acceptance and effects. Review of the Quarterly Nutrition assessment dated [DATE] completed by the Dietitian revealed documented weight on 9/13/24 was 105 pounds with no significant weight change noted. Current diet and supplements provided met residents estimated needs. Intake was fair to good. Meal plan supplemented with Boost plus twice daily and shake daily. Weight indicates some decline since admission. Review of the dietary progress note dated 11/11/24 revealed weights reviewed, 11/8/24 weight 100.5 pounds with weight loss trend noted. Intake of meals usually 26-75 percent. Supplements provided with meals, acceptance generally 100 percent. Magic cup added daily to lunch for increased kilocalorie, monitor acceptance and effects. Review of the undated Nutrition-Amount Eaten 30 day look back revealed out of 90 meals only 20 were documented for meal intakes. Review of the undated Nutrition-Supplement for Breakfast: Boost plus, Lunch: Boost Plus, Dinner: Boost Plus 30 days look back revealed out of 30 days only 13 days were documented and out of 90 supplement opportunities only 25 were documented. Review of all the departments progress notes dated between 9/2/24- 12/6/24 revealed no evidence that the medical provider or the resident representative were notified of Resident #65's significant weight loss. Review of the medical provider notes dated 9/18/24, 9/19/24, 10/24/24, and 11/15/24 revealed no evidence of notification of weight loss. 9/19/24, 10/24, and 11/15/24 documented review of systems, denied weight loss. Review of the Speech Screening dated 7/4/24 revealed swallowing regular consistency with thin liquids within functional limits. Review of Occupational Therapy Screen dated 10/14/24 revealed recommendation to Nursing for feeding was extensive assist with minimal help. During an interview on 12/2/24 between 12:12 PM-12:28 PM Resident #65's family member stated they felt the resident had lost weight. Resident #65's family member stated the resident needs assistance to eat due to confusion and impaired vision. They stated they weren't sure that the resident was receiving the required help and they had expressed this before to nursing. During an interview on 12/5/24 at 1:44 PM, Licensed Practical Nurse #4 stated they should be made aware of weight loss so they can monitor for adequate meal intake. They stated if weight loss was indicated on the 24-hour nurse report they would ask the Certified Nurse Aides what the resident consumed so it could be documented in the progress notes. Licensed Practical Nurse #4 stated the Certified Nurse Aides are responsible for documenting acceptance percentages of meals in the electronic medical record. Licensed Practical Nurse #4 stated they were not aware that Resident #65 had a weight loss. During an interview on 12/6/24 at 10:18 AM, Unit 500 Manager, Licensed Practical Nurse #2 stated the Dietitian enters weights in the electronic medical record, tracks resident's weights and alerts the Unit Managers of weight changes. They stated they were not aware Resident #65 had a weight loss and should have been notified so nursing follow up could be completed. They stated if a meal ticket indicates extensive assist, resident requires assistance with set up and eating to ensure the resident is consuming food properly. During an interview on 12/6/24 at 11:35 AM, Nurse Practitioner #1 stated they had not been informed of Resident #65's weight loss since admission. They stated if they were made aware of weight concerns, they would have document it and followed up. They stated they would expect to be notified of weight changes so it can be discussed with family, weights can be monitored more closely, medication can be reviewed, and determination can be made if it's a decline in disease process. During an interview on 12/6/24 at 12:11 PM, the Dietary Technician stated that residents' weights are reviewed every month, as needed or per medical order. They stated when weight loss is noted they see the resident, make necessary changes such as adding supplements, updating preferences, making a referral to occupational therapy and/or speech, and discuss with interdisciplinary team the need for an appetite stimulant. The Dietary Technician stated weight loss is discussed during morning meeting with the interdisciplinary team and the medical provider would be updated by them or the Dietitian. They stated they update the medical provider by placing something like a note in the medical providers book on the units. The Dietary Technician stated after the medical provider makes recommendations nursing reports the recommendations/orders to them. The Dietary Technician stated there probably wouldn't be any documentation on them notifying the medical provider of weight loss. They stated they did not have a good reason and that it would be documented from now on. Upon reviewing Resident #65's electronic medical record the Dietary Technician stated Resident #65 had a weight loss and did not believe the medical provider was notified. They stated they would consider an 11.84 percent weight loss in 4 months a significant weight loss and that a medical provider should have been updated. The Dietary Technician stated it was important to monitor residents' weights for their overall well-being, determine if their MOLST needs to be updated and if the medical provider needs to be involved. Additionally, the Dietary Technician stated Resident #65's weights should have been monitored more frequently due to their weight trending down. During a telephone interview on 12/6/24 at 12:29 PM, the Dietitian stated supplement and meal acceptance is based on observation and what is placed in the electronic medical record. They stated the documentation of acceptance is inconsistent and lacking. The Dietitian stated they are not able to get a clear picture of the residents' acceptance of supplements and meals based on the information given. The Dietitian stated the medical provider and nursing should be notified of significant weight loss or when weight loss can't be explained immediately, so various interventions such as labs, medication changes, referrals can be done. They stated Resident #65's weight loss was significant and should have been reported by them or the Dietary Technician. During an interview on 12/6/24 at 1:45 PM, the Director of Nursing stated that the certified nurse aides and nurses are responsible to ensure supplements are being administered and recorded. The Director of Nursing stated they expected percentages to be documented so that nursing and dietary could review acceptance. They stated supplements are an important means of nutrition and they are important for calorie intake, maintaining resident's weights, hydration, and skin. The Director of Nursing stated a medical provider should be notified of weight loss immediately by dietary or the unit manager. During a telephone interview on 12/6/24 at 2:23 PM, Medical Doctor #1 stated they would expect to be notified of weight loss as soon as it is noticed so interventions can be implemented. They stated they were not made aware of any weight loss for Resident #65. They stated if Resident #65 were having frequent loose stools this could contribute to weight loss and malnutrition. They stated Resident #65 could be lactose intolerant and that dietary should be involved. 10 NYCRR 415.12(i)(1)

Based on observation, interview, and record review conducted during a Standard survey completed 12/6/24, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues with foods being either unlabeled or outdated in the refrigerator. The findings are: The undated facility policy and procedure titled Food Storage Refrigerator/ Freezer documented purpose is to ensure foods are stored properly to minimize spoilage and contamination, and to ensure taste and quality of food. All refrigerated foods should be labeled/ dated and discarded after three (3) days. The facility policy and procedure titled Food Safety Requirements Policy - use and storage of food and beverage brought in for resident's food procurement dated 11/2017 documented the policy is to provide safe and sanitary storage, handling, and consumption of all food. This includes the storage, preparation, distribution, and serving food in accordance with professional standards for food safety. The food service supervisors, cooks, dietary aides, or any persons who are in the kitchen working with any type of food, are responsible for adhering to the food safety requirements. During an observation of the main kitchen on 12/2/24 at 8:51 AM revealed the reach in refrigerator labeled #6 across from the walk-in refrigerator had nine plastic containers revealing the following: -3/4 quart of mixed fruit was not labeled or dated and had black debris floating on the mixed fruit and on the inside sides of the container. -1/4 quart of sliced pears was not labeled or dated and had green/grey debris on the pears. -1 ½ quarts of chopped peaches were not labeled and marked with a date of 11/11. -1 ½ quarts of chopped peaches were not labeled and marked with a date of 9/24/24. -2 quarts of chopped pears were not labeled or dated. -1/4 quart of chopped peaches were not labeled or dated. -1/2 pitcher of unidentifiable brown liquid was not labeled or dated. -1/4 pitcher of unidentifiable yellow liquid was not labeled or dated. -2 ½ quarts of orange pudding like consistency was not labeled or dated. During an interview on 12/2/24 at 9:16 AM, dietary [NAME] #1 stated all food items should be labeled and dated when opened and disposed of after 3 days. They stated all the items identified must be disposed of as they do not know when they were placed in the refrigerator. They stated they believe the black floating debris in the mixed fruit and green/grey debris on the pears is mold and must have been in the refrigerator greater than 3 days. During an interview on 12/2/24 at 9:32 AM, the Dietary Department Director stated all opened food items are to be labeled and dated and disposed of after 3 days from opening. They stated the dietary aides are responsible to date and label the items, although they are ultimately responsible to ensure the staff are following the facility's policies and procedures, and regulations. They stated they believe the black debris and green/grey debris identified in the containers was mold and would have been opened greater than 3 days.They stated this is for food safety to prevent contamination and molding. 10 NYCRR 415.14(h) 14-1.43(e)

Based on observation, interview and record review conducted during a Standard survey completed 12/6/24, the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections, for two (Resident #10 and #43) of four residents reviewed for enhanced barrier precautions (interventions designed to reduce transmission of multi-drug resistant organisms including gown and glove use during high contact resident care activities) during care. Specifically, Resident #10 had chronic pressure ulcers (injury to the skin and tissues from prolong pressure to the area) and the Certified Nurse Aides did not wear proper personal protective equipment during morning care. Additionally, Resident #42 had an ileostomy (a surgical operation in which a piece of the intestine is diverted to an opening in the stomach wall) and the nurse did not wear proper personal protective equipment during care. The findings are: Review of the policy and procedure titled Enhanced Barrier Precautions dated 4/2024 documented that residents in nursing homes are at increased risk of becoming colonized and developing infection with multi-drug resistant organisms, especially those with risk factors like indwelling medical devices or wounds. It is the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of the organisms. The policy documented that enhanced barrier precautions involve gown and gloves use during high-contact resident care activities for residents who were at increased risk of multi-drug resistance acquisition. High contact resident activities include dressing, bathing, providing hygiene, device care or use, and wound care. 1. Resident #10 had diagnoses including multiple sclerosis (a disease where the immune system effects the protective covering of nerves), diabetes, and pressure ulcers of the sacrum (area at the base of the tailbone) and ischium (area of the lower buttocks). The Minimum Data Set (a resident assessment tool) dated 11/11/24, documented Resident #10 was cognitively intact, understood and understands. Resident #10 required substantial/maximal assistance with bathing and had one stage 3 (wound that involves full thickness loss of tissue) pressure ulcer and one unstageable (full thickness skin and tissue loss where the depth of the wound is hidden by eschar [dead tissue] and slough [yellow/white soft, stringy, thick substance]) pressure ulcer. The comprehensive care plan revised on 12/4/24, documented Resident #10 had pressure ulcers related to multiple sclerosis, diabetes mellitus and limited mobility. Interventions included to administer treatments and medications and to follow facility policies/protocols for prevention/treatment of skin breakdown. There was nothing in the care plan about Enhanced Barrier Precautions. Review of the Wound Evaluation and Management Summary noted dated 11/25/24, the Wound Consultant documented that Resident #10 had chronic wounds on their sacrum and left ischium with history of osteomyelitis (a serious bone infection). It was documented that Resident #10 had a stage IV (full thickness skin and tissue loss that exposes bone, muscle, tendon, ligament, or cartilage) pressure ulcer to their sacrum and left ischium with moderate serous drainage (clear/yellow drainage from a wound). During an observation on 12/2/24 at 12:43 PM, Resident #10 was noted to have a precaution sign on the door indicating stop, staff to wear gloves and gown during care. A plastic bin was observed to be outside the resident door in the hallway filled with gowns and masks. During an observation on 12/4/24 at 10:13 AM, precaution signage remained on the door and the plastic bin was now located inside the door entrance to the right-hand side. Certified Nurse Aide #8 and #9 performed morning care to Resident #10 by washing, rinsing, and drying the resident's neck, underneath their breast and armpits, peri area and buttocks. Resident #10 was observed to have open areas to their sacrum and left ischium that were not covered with any dressings. Certified Nurse Aide #8 and #9 did not wear gowns during the morning care observation. During a wound care observation on 12/4/24 at 10:42 AM, immediately following the completion of morning care, Licensed Practical Nurse #10 donned a gown prior to initiating the care. Resident #10's left ischium wound was noted to be moist with area of slough in the wound bed. Serosanguinous drainage (watery drainage mixed with blood from a wound) was noted on the gauze pad as the wound was cleansed with wound cleaner and prior to the application of the ordered ointment the wound began to actively bleed. During an interview on 12/4/24 at 1:30 PM, Certified Nurse Aide #8 observed the precaution signage on Resident #10's door and stated they did not pay attention to the signage on the door. They stated they should have worn a gown during morning care. Certified Nurse Aide #8 stated Resident #10 had a wound and because they did not wear a gown, they did not protect themselves from possible germs. During an interview on 12/4/24 at 1:59 PM, Certified Nurse Aide #9 observed the precaution signage on Resident #10's door and stated the sign meant that they were to wear a gown when providing care to Resident #10. They stated that themselves and Certified Nurse Aide #8 did not wear gowns during morning care for Resident #10 because they were not used to being observed performing their duties and they both were nervous being observed. Certified Nurse Aide #9 stated the purpose of wearing gowns for residents that were on enhanced barrier precautions was for infection control reasons. During an interview on 12/5/24 at 12:16 PM, Licensed Practical Nurse #10 stated enhance barrier precautions were when any type of care was given to a resident that had a wound and the area was exposed. Licensed Practical Nurse #10 stated that Resident #10 had chronic pressure ulcers. They stated that at any point during care Resident #10's dressing could come off and that it often did. Licensed Practical Nurse #10 stated staff needed to wear a gown when providing care to Resident #10 because the area could become infected at any time. 2. Resident #43 had diagnoses including major depressive disorder, ileostomy, and gastro-esophageal reflux disease. The Minimum Data Set (a resident assessment tool) dated 10/28/24 documented the resident was understood, understands, was cognitively intact. The comprehensive care plan for Resident #43 dated 10/24/24 identified as current by the Director of Nursing, did not have a focus area, goals or interventions for enhanced barrier precautions. Observation on 12/2/24 at 11:10 AM, revealed signage on Resident #43's room door for precautions with directions to don a face mask, gloves, and a gown. There was a multi-pocket storage container hanging on Resident #43's door with gowns, gloves, masks, and face shields available. There was a bin located outside Resident #43's doorway in the hallway with additional personal protective equipment including masks, gloves, and gowns. During an observation and interview on 12/4/24 at 9:42 AM, Licensed Practical Nurse #9 donned gloves and a mask and performed changing Resident #43's ileostomy bag/flange, they did not wear a gown. Licensed Practical Nurse #9 stated Resident #43 was on Enhanced Barrier Precautions because of the ileostomy. They stated they applied gloves and a mask and should have also donned a gown before changing the ileostomy flange, for infection control, and they stated they have no excuse why they didn't, just that they had forgotten to put on a gown. During an interview on 12/6/24 at 10:42 AM, Nursing Supervisor/Unit Manager Licensed Practical Nurse #5 stated Resident #43 was on Enhanced Barrier Precautions because they had an ileostomy and would have expected Licensed Practical Nurse #9 to have donned gloves, mask and a gown prior to changing Resident #43's ileostomy bag/flange for infection control purposes to protect the resident. During an interview on 12/6/24 at 8:59 AM, the Infection Preventionist stated Enhance Barrier Precautions were used for residents that had any invasive device and/or opening such as wounds or ostomies/colostomies. They stated the purpose of Enhance Barrier Precautions was to shield the care giver from bacteria and to protect the resident from introduction of bacteria. The Infection Preventionist stated personal protective equipment (gloves and gowns) needed to be worn during any direct contact with the resident such as dressing, bathing, or care to the area. They stated they would have expected the nurse to wear a gown when preforming colostomy/ostomy care and would have expected the Certified Nurse Aides to wear a gown when performing morning care to a resident with an open wound. During an interview on 12/6/24 at 12:11 PM, the Director of Nursing stated Resident #43 was on Enhanced Barrier Precautions for the ileostomy and would have expected Licensed Practical Nurse #9 to have donned a gown in addition to the gloves and mask prior to changing the ileostomy bag/flange for infection control purposes. During a further interview at 12:41 PM, the Director of Nursing stated that gowns and gloves were to be worn during any type of care or transfers when a resident had any skin wounds. They stated they were familiar with Resident #10 and Certified Nurse Aides absolutely should have worn gowns during morning care. The Director of Nursing stated the purpose for Enhanced Barrier Precautions was the resident could have an infection without one knowing. They stated that wearing gowns not only protected the resident from possible infection but also the staff from possible infection. 10NYCRR 415.19(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review conducted during the Standard Survey completed on 12/6/24, the facility did not ensure that the resident's person-centered care plan was implemented to meet the resident's medical and nursing needs for six (Residents #10, #25, #36, #41, #43, and #65) of 28 residents reviewed for care planning. Specifically, Resident #10 did not have a care plan developed for skin integrity and had pressure ulcers; Resident #25 did not have a care plan developed for dentures; Residents #36 and #41 did not have a care plan developed for an alleged resident-to-resident altercation; Resident #43 did not have a care plan developed for skin care and incision care with treatments ordered, depression, cardiac, vision, dry nasal passages and supplements with medications ordered, and discharge planning; and Resident #65 did not have a care plan developed for bowel incontinence, safety, falls, and psychoactive medication use. The findings include: The policy and procedure titled Comprehensive Care Planning & Baseline with a revision date of 6/2021 documented a Care Plan will be individualized for each resident using a person-centered approach. The Comprehensive Care Plan will include measurable objectives and timetables to meet the resident's medical, nursing, and psychosocial needs that are identified from admission assessments, the comprehensive assessment and application of the Care Area Assessment. Additional problems, strengths or needs identified by the Interdisciplinary Team will be included in the Comprehensive Care Plan. The Comprehensive Care Plan will be completed no later than seven days following completion of the admission comprehensive assessment. The care plan must be individualized for each individual. All disciplines are responsible for reviewing the plan of care and documenting goals, interventions, monitoring notes and updating as needed. Chronic active diagnoses and acute changes in condition will be card planned by the appropriate discipline in a timely manner. 1. Resident #10 had diagnoses including multiple sclerosis (a disease where the immune system effects the protective covering of nerves), diabetes mellitus type 2, and pressure ulcers of the sacrum (area at the base of the tailbone) and ischium (area of the lower buttocks). The Minimum Data Set, dated [DATE], documented Resident #10 was cognitively intact, understood and understands. The assessment tool documented that Resident #10 had one stage III (wound that involves full thickness loss of tissue) pressure ulcer and one unstageable (full thickness skin and tissue loss where the depth of the wound is hidden by eschar [dead tissue] and slough [yellow/white soft, stringy, thick substance]) pressure ulcer upon admission. The comprehensive care plan, initiated on 11/4/24, documented Resident #10 had pressure ulcers on their left ischium and coccyx related to multiple sclerosis, diabetes mellitus and limited mobility. There were no care plan interventions developed for the pressure ulcers until 12/4/24. Review of the Wound Evaluation and Management Summary noted dated 11/25/24, the Wound Consultant documented that Resident #10 had chronic wounds on their sacrum and left ischium with history of osteomyelitis (a serious bone infection). It was documented that Resident #10 had a stage IV (full thickness skin and tissue loss that exposes bone, muscle, tendon, ligament, or cartilage) pressure ulcer to their sacrum and left ischium with moderate serous drainage (clear/yellow drainage from a wound). During an interview on 12/6/24 at 12:41 PM, the Director of Nursing stated that they added care plan interventions on 12/4/24 to Resident #10's comprehensive care plan for pressure ulcers after the surveyor requested a copy of the care plan. The Director of Nursing stated they added the care plan interventions because the care plan did not have any and they felt Resident #10 needed them. 2.Resident #25 had diagnoses including unspecified dementia, stroke, and lower back pain. The Minimum Data Set (a resident assessment tool) dated 10/17/24, documented Resident #25 was moderately cognitively impaired, and always understood and understands. Resident #25 required partial/moderate assistance with oral hygiene. The comprehensive care plan last revised 10/25/24, documented Resident #25 had an ADL self-care performance deficit related to muscle weakness, and limited physical mobility related to weakness. The care plan also documented the resident had oral/dental health issues related to poor oral hygiene, and to provide mouth care as per ADL personal hygiene. There was no documentation that the resident had dentures or how to care for them. Review of the Closet Care Plan (used by staff to guide care) updated on 11/25/24, revealed the area labeled personal care had blank boxes where upper and lower dentures should have been checked and there were no instructions for denture care. During an interview on 12/5/24 at 8:58 AM, Licensed Practical Nurse #1 stated that if a resident wore dentures, it should be documented on their care plan, so the staff knew to clean them. During an interview on 12/5/24 at 9:24 AM, Unit Manager, Licensed Practical Nurse #2 stated that the care plan should reflect if a resident wore dentures so the certified nurse aides would know to clean them. They stated it was important for dentures to be removed at night and soaked for proper hygiene, because bacteria could grow underneath them. They were not aware that Resident #25's dentures were not documented on their care plan. Unit Manager, licensed Practical Nurse # 2 stated that care plans had not been updated recently. They stated that care plans should be reviewed, at least annually if not quarterly, by the entire interdisciplinary team and involve the resident and/or their family. They stated they only worked in the facility for a few weeks, so they had not updated care plans yet. During an interview on 12/6/24 at 10:52 AM, the Director of Nursing stated that nursing care plans should be reviewed/updated quarterly, by the unit managers and the interdisciplinary team. Dentures should be documented on the care plan, so staff know to properly clean them. 3. Resident #36 had diagnoses including diabetes mellitus type 2, chronic obstructive pulmonary disease, and bipolar disorder. The Minimum Data Set, dated [DATE], documented Resident #36 was cognitively intact, and always understood and understands. The assessment tool documented that the resident did not have any behaviors. Resident #41 had diagnoses including diabetes mellitus type 2, end stage renal disease, and bipolar disorder. The Minimum Data Set, dated [DATE], documented Resident #41 was cognitively intact, and always understood and understands. The assessment tool documented that the resident did not have any behaviors. Review of a facility investigation summary dated 7/11/24, the Former Administrator documented that on 7/11/24 Resident #36 alleged that Resident #41 rolled up to them in their wheelchair in the lobby area of the facility. Resident #36 alleged that they told Resident #41 you are supposed to stay away from me (due to a previous allegation's intervention) and Resident #41 responded by hitting them in the arm. Resident #36 had no injuries and Resident #41 denied the accusation. The investigation documented the interventions included that both residents were re-educated and reminded to stay away from each other. The comprehensive care plan, date initiated 2/6/24, documented Resident #36 had impaired self-care skills related to muscle weakness. Interventions included that resident was independent with personal powered wheelchair. The care plan documented that Resident #36 had potential for alteration in mood related to diagnosis of bipolar, manipulation with staff and had accusatory behavior at times. There was no care plan development for the allegation of a resident-to-resident interaction including interventions to keep away from Resident #41. The comprehensive care plan, date initiated 9/16/22, documented Resident #41 had limited self-care skills related to weakness. Interventions included that Resident #41 was independent with standard wheelchair. The care plan documented that Resident #41 had a behavior problem related to non-compliance and poor safety awareness as they had a history of refusing therapies, medication, treatments, and care. There was no care plan development for the allegation of a resident-to-resident interaction with intervention to keep away from Resident #36. During a telephone interview on 12/5/24 at 1:26 PM, Previous Unit Manager, Licensed Practical Nurse #3 stated that they did not witness nor had knowledge about the alleged resident to resident incident that occurred on 7/11/24 between Resident #36 and Resident #41. Licensed Practical Nurse #3 stated that development and revision of a resident's comprehensive care plan was the responsibility of the unit manager along with the Director of Nursing. Licensed Practical Nurse #3 stated that prior to end of their employment at the facility, they were behind on their development and revisions of the comprehensive care planning because they would have to work as a floor nurse two to three times a week and did not have a working computer. Licensed Practical Nurse #3 stated that Residents #36 and #41 should have had the alleged resident to resident altercations with interventions added to their comprehensive care plans. During an interview on 12/6/24 at 12:41 PM, the Director of Nursing stated that Licensed Practical Nurse #3 would have been responsible for care plan development and was unsure why they did not develop a comprehensive care plan with interventions for the alleged resident to resident altercation between Resident #36 and #41 on 7/11/24. The Director of Nursing stated they would have expected a care plan to be developed and it was important so staff would know how to take care and maintain the safety of both residents. 4. Resident #43 had diagnoses including major depressive disorder, ileostomy, and gastro-esophageal reflux disease. The Minimum Data Set, dated [DATE] documented the resident was understood, understands, was cognitively intact and had active diagnoses including hypertension, wound infection, hyponatremia (define), hyperlipidemia (define), cerebrovascular accident, malnutrition, depression, and respiratory disorder. Physician order recap report for Resident #43 dated 10/1/24 through 12/31/24 documented the following: -Clean abdominal incision with normal saline pat dry cover with dry clean dressing -Nystatin- Triamcinolone external cream around abdominal incision for skin irritation -Atorvastatin Calcium 20 mg every day for Hyperlipidemia (elevated fat levels in the blood) -Azelastine HCL nasal solution 1 spray in each nostril two times a day for dry nasal passages -Claritin 10 mg daily for allergies -Vitamin B 12 500 micrograms twice a day as supplement -Vitamin D 25 micrograms twice a day as supplement -Gen Teal Tears Moderate Ophthalmic solution 0.3% 1 drop each eye for dry eyes -Isosorbide Mononitrate extended release 30 milligrams every day for angina (chest pain) -Magnesium Oxide 800 milligrams every day for supplement -Metamucil fiber oral packet every day for supplement -Olanzapine 10 milligrams at bedtime for behavior -Omeprazole 20 milligrams every day for gastro-esophageal reflux -PreserVision Multi vitamin every day for supplement -Sennosides-Docusate Sodium 8.6-50 milligram twice a day for constipation -Sertraline Hydrochloride 100 milligrams every day for depression -Silodosin 1 capsule every day for benign prostatic hyperplasia (enlarged prostate gland) -Sodium Chloride 1 Gram four times a day for supplement The comprehensive care plan for Resident #43 dated 10/24/24 identified as current by the Director of Nursing did not have care plan focus areas, goals or interventions for the diagnoses, medications and treatments identified in the physician orders above. In addition, there were no documented focus, goals or interventions for skin integrity, oral care, urinary incontinence, Enhanced Barrier Precautions (interventions designed to reduce transmission of multi-drug resistant organisms including gown and glove use during high contact resident care activities), and discharge planning. During an interview on 10/6/24 at 10:42 AM, Nursing Supervisor/Unit Manager Licensed Practical Nurse #5 stated the comprehensive care plan for Resident #43 should have been completed by November 7, 2024, and they were responsible to ensure the comprehensive care plan was completed to include diagnoses, medications, treatments, skin integrity, incontinence care, oral care, enhanced barrier precautions, advanced directives and discharge planning for continuity of nursing care and it wasn't done. During an interview on 12/6/24 at 12:11 PM, the Director of Nursing stated the comprehensive care plan for Resident #43 should have been developed by the 14th day after admission [DATE]) and there was no care plan development with goals and interventions for the diagnoses, medications and treatments identified in the physician orders above. The Director of Nursing stated there were no documented focus, goals or interventions for skin integrity, oral care, urinary incontinence, enhanced barrier precautions, advanced directives and discharge planning and there should have been. The Director of Nursing stated they would have expected Unit Manager Licensed Practical Nurse #5 to have developed the comprehensive care plan by 11/7/24, and updated it as needed with changes. 5. Resident #65 had diagnoses that included dementia, protein-calorie malnutrition, and macular degeneration left eye (loss of the central field of vision because of deposits of the retina). The Minimum Data Set, dated [DATE] documented Resident #65 had severe cognitive impairment, was sometimes understood, and sometimes understands. Resident #65 was occasionally incontinent of urine and bowel, had a fall with major injury since admission, and was administered high-risk (antianxiety, antidepressant and opioid) medications. The comprehensive care plan for Resident #65, date initiated 7/3/24, identified as current by the Director of Nursing, did not have care plan focus areas, goals or interventions for bladder incontinence and falls until 12/4/24. There were no documented focus, goals or interventions for skin integrity, oral care, bowel incontinence, preferences, advanced directives, diagnoses, medications, and discharge planning. The closet care plan last updated on 10/2/24, documented the resident needed extensive assist of one person for toileting on the commode or bathroom, had an incontinence/toileting schedule, briefs were not indicated. No safety or behavior monitoring was indicated. During an interview on 12/6/24 at 9:13 AM, Certified Nurse Aide #7 stated they weren't responsible for changing or updating the residents care plans. They stated therapy and nursing were responsible. During an interview on 12/6/24 at 9:56 AM, Licensed Practical Nurse #7 stated a resident's care plan was important, so staff knew how to care for the residents. They stated the unit nurse manager was responsible to complete. During an interview on 12/6/24 at 10:18 AM, Unit 5 Nurse Manager, Licensed Practical Nurse #2 stated the interdisciplinary team collectively build a resident's comprehensive care plan. They stated assessments in the electronic record that are in red indicate that they were incomplete/overdue and there hadn't been a care plan meeting for residents since they started at the facility in November. They stated there was no structure or schedule to inform them when the resident's care plans were due for completion and review. Licensed Practical Nurse #2 reviewed Resident #65's care plan and stated that it was incomplete, outdated, or overdue. During an interview on 12/6/24 at 1:45 PM, the Director of Nursing stated every single discipline was responsible to complete the resident's comprehensive care plan within 14 days of admission and should be reviewed and updated as needed. They stated the interdisciplinary team should meet and review the comprehensive care plan at least on a quarterly basis. The Director of Nursing stated the unit managers were responsible for completing the nursing sections of the comprehensive care plan. The Director of Nursing reviewed Resident #65's care plan and stated their care plan was absolutely incomplete and wasn't aware until 12/4/24. The Director of Nursing stated they updated Resident #65's care plan on 12/4/24 after they discovered it wasn't completed. They documented that they added bladder incontinence and falls to Resident #65's care plan on 12/4/24. The Director of Nursing stated it was important that the comprehensive care plan was completed, updated timely for the entire interdisciplinary team to see, so quality of care, continuation of care and safety can be provided to the residents. 10NYCRR 415.11(c)(1)

Based on observation, interview and record review conducted during a Standard survey, completed on 12/6/24, the facility did not ensure information on how to file a grievance or complaint was available to the residents and that they had an established grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights. Specifically, Resident Council was unaware of the process and policy on how to file a grievance or a compliant. The facility did not have a policy to ensure prompt resolution of all grievances regarding resident rights that included all required information. The findings are: During a Resident Council meeting on 12/3/24 at 10:30 AM, 7 of 7 Resident Council attendees stated they did not know how to file a grievance or who acted as the Grievance Officer. The residents stated the facility does not always respond to concerns voiced (staffing concerns, and customer service issues). This involved Resident's #17, 34, 36, 61, 70, 82 and 96. During an interview on 12/6/24 at 11:18 AM, Activities Department Director stated they were not aware if the facility had of a Grievance Officer. They stated when concerns, grievances were expressed during Resident Council meetings, they believed the Social Worker addressed them. They stated some concerns go to a specific department or the Administrator. They stated they weren't aware of a grievance policy or where the grievance forms were kept. During an interview on 12/6/24 at 1:45 PM, the Director of Nursing stated it was important for residents to know how to file a grievance. They stated residents always need to be advocated for, so they feel comfortable while in the facility and that their concerns were addressed. The Director of Nursing stated blank grievance forms were kept at the receptionist desk and maintained by the Social Worker. During an interview on 12/6/24 at 2:25 PM, the Administrator stated Social Worker terminated their employment at the facility (12/2/24). During an interview on 12/6/24 at 3:01 PM, the Receptionist stated they had not had any blank grievance forms available in a long time. They stated no families or residents had asked for a form but they should have them available if needed. During an interview on 12/6/24 at 4:18 PM, the Administrator stated they didn't have a specific Grievance Officer and the Social Worker would be responsible for grievances. They stated grievance forms should be available at the reception so anybody can have access to them. The Administrator stated grievances provide a paper trail and allows for facility follow up. The Administrator stated grievances should be reviewed during morning meeting and they should have ensured grievances were followed up on. Additionally, they stated they hadn't changed the grievance process. During an interview on 12/6/24 at 4:40 PM, the Director of Nursing stated the facility did not have a grievance policy and procedure. During an interview on 12/6/24 at 5:26 PM, the Administrator provided a grievance binder that included filed grievance forms. Review of grievance forms within the binder revealed there was no department head follow up or signatures. The Administrator stated grievances were not being reviewed and process was not being followed. 10 NYCRR 415.3 (d)(1)(i)

Based on observation, interview and record review conducted during the Recertification survey completed on 12/6/24, the facility did not ensure a Quality Assurance and Performance Improvement program (QAPI) developed, implemented, monitored, maintained effective systems, and used feedback to develop an appropriate plan of action to correct identified deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements. Specifically, the facility did not maintain effective systems to maintain compliance and had repeated deficiencies from the previous Recertification Survey 4/21/23 and Post Survey Revisit 7/12/23. In addition to identified systematic problems regarding grievances and functional/usable bathtubs. The findings are: Repeated Citations Refer to the following citations cited 4/21/23: F 584 Safe/Clean/Comfortable/Home Like Environment F 656 Develop/Implement Comprehensive Care Plan F 677 ADL (activities of daily living) Care Provided for Dependent Residents F 812 Food Procurement, Store/Prepare/Serve Sanitary F 880 Infection Prevention and Control F867 Quality Assurance and Performance Improvement Activities (7/12/23). Additionally, Refer to F 585 Resident Rights/Grievances Refer to F 561 Resident Rights/Self-determination. Review of the policy and procedure titled Quality Assurance/Performance Improvement revised 8/16, documented the facility will conduct quality assurance/improvement and assessment committee meeting at least quarterly to identify area of service that are non-complaint, or with potential for improvement. The facility will ensure that there is an effective, facility-wide performance improvement program to evaluate resident care and performance of the organization. The policy documented that the facility would have an ongoing plan, consistent with available community and facility resources, to provide or make available services that meet the medically related needs of its residents. Review of an undated facility document titled Quality Assurance Improvement Plan, provided by the Administrator during the entrance conference process documented that a dashboard for individual performance improvement projects were used to communicate progress and outcomes of individual QAPI (Quality Assurance Improvement Plan) projects. The QAPI (Quality Assurance Improvement Plan) lead is responsible for maintaining documentation of the minutes of all meetings. The plan documented that the QAPI (Quality Assurance Improvement) committee monitors progress to ensure that interventions or actions were implemented and effective in making and sustaining improvements. Once the performance improvement program goals have been met, it will be placed on a permanent tracking log for ongoing measurement to assure the performance improvement project doesn't get forgotten. Review of Recertification Survey Statement of Deficiencies (form 2567) issued by the New York State Department of Health with an exit date of 4/21/23 revealed the facility was cited for the following: -F 656 the lack of development of comprehensive care plans for residents. The facilities corrective action plan included that the Assistant Director of Nursing would report monthly to the QAPI committee to determine if any further process changes or approaches were needed. This would happen for three months or longer depending on compliance outcomes. -F 677 the lack of chin hair removal and long fingernails. The facilities corrective action plan included the floor charge nurse along with the Assistant Director of Nursing would report their finding for three months and corrective action will be taken as necessary by the QAPI committee. -F 812 foods unlabeled/outdated in the refrigerators. The facilities corrective action plan included the Food Service Director along with the QAPI committee will submit weekly audit findings for three months or until problems were resolved. -F 584 the facility did not ensure that housekeeping and maintenance services were adequate to maintain a sanitary, orderly, and comfortable interior. The facilities corrective action plan included the audit results will be reported to the Quality Assurance and Performance Improvement committee for monthly for three months and the frequency of on-going audits will be determined based on the audit results. - F 880 issues involved transmission-based precautions and adequate hand hygiene. The facilities corrective action plan included audit results would be reported to the Quality Assurance and Performance Improvement committee monthly for three months and frequency of on-going audits will be determined based on the audit results. Review of Post Recertification Survey Revisit Statement of Deficiencies (form 2567) issued by the New York State Department of Health with an exit date of 7/12/23 revealed the facility was cited for the following (includes but not limited to): -F 812 the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service. System implemented to ensure continued compliance included: the administrator will meet with the Director of Food Service and Director of Maintenance daily to review any kitchen/food service-related repairs and assign priority tasks. Audits will be performed by the Director of Food service daily for 1 month then weekly for 2 months. The Consultant will also conduct random onsite audits of the above areas for three months and report findings to the QA&A Committee. Frequency of on-going audits will be determined by the Committee based on audit results. -F 867 the Quality Assurance and Performance Improvement Committee the facility did not institute and follow corrective actions that were to put in place to ensure that the following deficiencies would not reoccur. An audit tool was to be developed to track completion of all audits; audits will be submitted to the administrator/designee for review weekly for 12 months to ensure compliance; Audit results will be reported to the QA&A Committee monthly. Frequency of on-going audits will be determined by the Committee based on the results; the Consultant will also conduct random onsite audits of the cited areas for three months and attend the meeting monthly for 3 months. Review of the Quality Assurance and Performance Improvement Meeting Minutes dated 10/25/23 documented that all staff were educated and aware of the importance of a clean and sanitized kitchen and weekly plan of correction audits were ongoing. The meeting minutes documented that infection control, quality assurance and discharge records were reported upon at the meeting. The minutes did not include if the plan was effective. Review of the Quality Assurance/Performance Improvement Meeting Agenda date 10/16/24 documented that infection prevention and control, dietary, environmental services, plant operations and medical record review were reported upon at the meeting. The minutes did not include if the plan was effective. During the QAPI/Quality Assessment and Assurance (QAA) interview on 12/6/24 at 2:25 PM with the Administrator and Director of Nursing, the Administrator stated they could not provide any further documents (QAPI items- meeting agendas, minutes, meeting attendance records or PIP's (performance improvement projects) from the previous Administration other then what was presented (10/25/23, 1/24/24 and 2/28/24). They stated they became the Administrator of record in August 2024 and since they started the committee had conducted a PIP (performance improvement project) on Enhanced Barrier Precautions. The Administrator stated there was continued noncompliance with infection control practices and their performance improvement project was ineffective. The Director of Nursing stated their PIP (performance improvement project) for nail care and facial hair removal remained ineffective as noncompliance continues. The Director of Nursing stated the facility no longer had a Nurse Educator or an Assistant Director of Nursing and there was great turnover of the staff. This made it hard to continue to audit and educate the new staff. The Director of Nursing stated their PIP (performance improvement project) for developing comprehensive care plans was ineffective and the entire care process needed to be revised. The Administrator added there was a lack of staffing resources (employees) available in the facility making it difficult to keep the comprehensive care plans up to date. The Director of Nursing stated the PIP (performance improvement project) for outdated and unlabeled food in the kitchen was ineffective because of continued issues identified. The Director of Nursing stated that there had been a massive staff turnover in the kitchen and education needed to provide to those new staff members. The Administrator stated even though the plan of correction phase was over from previous surveys; constant/or at least as needed auditing and oversite needed to be continued. The Administrator stated new employees needed to be audited and educated on previous deficiencies issue to ensure the same errors/issues are not occurring over and over. The Administrator stated they felt there was sufficient staff to provide efficient and quality of care to the residents, however the facility lacked regional staff oversight and support at a higher level and the day-to-day support of the extra corporate managerial support was lacking. 2a. During an interview on 12/5/24 at 4:51 PM, the Director of Nursing stated the facility did not have functioning bathtubs in the shower rooms on the resident units and the bathtubs in the private rooms were too low and would pose as a safety hazard for residents. They stated the facility should have a functioning tub and believed the last functioning tub in the facility broke approximately 2 years ago. During an interview on 12/5/24 at 5:00 PM, the Administrator stated they were not aware the facility did not have a functioning bathtub. b. During an interview on 12/6/24 at 2:25 PM, the Administrator stated Social Worker terminated their employment at the facility (12/2/24). During an interview on 12/6/24 at 4:18 PM, the Administrator stated they didn't have a specific Grievance Officer and the Social Worker would be responsible for grievances. During an interview on 12/6/24 at 2:25 PM, the Administrator stated Social Worker terminated their employment at the facility (12/2/24). During an interview on 12/6/24 at 4:40 PM, the Director of Nursing stated the facility did not have a grievance policy and procedure. During an interview on 12/6/24 at 5:26 PM, the Administrator stated resident grievances were not being reviewed and process was not being followed. 10 NYCRR 415.27 (c)(1)(2)(3)(iv)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint Investigation (Complaint #NY00321583) during an Abbreviated survey completed on 8/14/23, the facility did not maintain complete and accurately documented medical records for three (Resident #1, #2, and #3) of three residents reviewed. Specifically, the bowel and bladder (B&B) elimination task was not documented as completed daily and/ or each shift. The findings are: The policy and procedure titled Bowel Management dated 7/2017 documented if no bowel movement (BM) for 2 days (6 shift), give Milk of Magnesia (MOM- a laxative used to treat constipation) 30 cc (cubic centimeters) at bedtime and monitor BM. If no BM by the following shift (7 shift), give one Dulcolax suppository (laxative stimulant to relieve occasional constipation) rectally and monitor BM. If no BM by next shift (8 shift), give fleet enema (liquid medicine used to help you have a bowel movement) at bedtime. Per physician's order. If steps 1-3 are not successful, contact Physician for further intervention/ orders. 1. Resident #1 had diagnoses which included hypertension (HTN- high blood pressure), anxiety disorder, and major depressive disorder. The Minimum Data Set (MDS- a resident assessment tool) dated 6/12/23 documented Resident #1 was understood, understands, and cognitively intact. Review of the Closet Care Plan (guide used by staff to provide care) last updated 7/12/23 revealed Resident #1 was an extensive assist with toileting. Review of the Order Recap Report dated 6/1/23- 8/31/23 revealed an order for bowel routine as per policy, document BMs every shift for maintenance with start a date 6/5/23 and no end date. Review of the Medication Administration Record dated 7/1/23 to 8/6/23 revealed an order for bowel routine as per policy, document BMs every shift for maintenance. There was a check for every day, every shift (except for one) indicating administered. The undated document titled Care Profile printed 8/9/23 by the Director of Nursing (DON) documented under task description B&B- Bowel and Bladder Elimination for position Certified Nurse Aide (CNA) with a frequency to document every shift revealed between 7/12/23 to 8/6/23, out of 78 shifts only 45 were marked. 2. Resident #2 had diagnoses which included chronic obstructive pulmonary disease (COPD), gastro-esophageal reflux disorder (GERD- backflow of gastric fluids into the esophagus) and constipation. The MDS dated [DATE] documented Resident #2 was understood, understands, and is moderately cognitively impaired. Always continent of bowels. Review of the document titled POC (Point of Care) Response History dated 8/10/23 revealed under task B&B- Bowel and Bladder Elimination between 7/12/23 to 8/10/23, out of 90 shifts only 50 were marked. 3. Resident #3 had diagnoses which include hypothyroidism, dementia, and hypertension (HTN-high blood pressure). The MDS dated [DATE] documented Resident #3 was always incontinent of bowels. There was no cognitive status indicated. Review of the document titled POC (Point of Care) Response History dated 8/10/23 revealed under task B&B- Bowel and Bladder Elimination between 7/12/23 to 8/10/23, out of 90 shifts only 32 were marked. During an interview on 8/9/23 at 3:12 PM, the DON stated the order for bowel routine as per policy, document BMs every shift for maintenance meant that the nurses were checking to make sure the CNAs were documenting the residents' bowel movements every day and every shift. The nurses should be looking under the POC B&B task to make sure the CNAs were completing. They stated they did not know why the CNAs were not filling them in correctly, but they should be. On 8/10/23 at 9:05 AM, the DON stated they received clinical alerts from the dashboard that indicated if the resident did not have a BM within 3 days. They were not sure that if there was a miss in a day or shift on the POC B&B task if it would affect the alert from the dashboard. During an interview on 8/10/23 10:39 AM, CNA #1 stated we document the BMs on the CNA Worksheet and then we place them in POC for each resident. We are to document them every shift, every day. During an interview on 8/10/23 at 10: 40 AM, CNA #2 stated we track the residents BM on the CNA worksheet. We will then document it in the POC in the computer. If the resident does not wear briefs, we asked the resident themselves if they had a BM. If they do not have a BM, we tell the nurse. This documentation should be done every day, every shift. During an interview on 8/10/23 at 10:43 AM, Licensed Practical Nurse (LPN) #1 stated the CNAs document bowel movements. The CNAs tell the nurses at the end of shift if someone hasn't had BM. If there was no BM for 3 days on every shift the nurse would give the resident MOM, then if they do not have a BM on the next shift the resident would get a suppository, if still no BM by the next shift the resident would get a enema, and the physician would be notified if still no results. The CNAs write on the CNA work sheets but they need to record the BMs in the POC as the piece of paper was not a legal document. Those sheets can get lost, and the nurses go by what was documented in the computer. If it is not in the computer to me, it didn't happen. During an interview on 8/10/23 at 10:54, LPN #2 stated the CNAs were to track the BMs on their assignment sheets and then place it in the computer under the POC. They should be documenting all residents' BMs every day every shift. I look at the computer every day because if the resident doesn't move their bowels in 3 days, we would initiate the bowel regimen. 10 NYCRR 415.22(a)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during complaint investigations (Complaint NY00314500 and NY00308655) during the Standard survey completed on 4/21/23,the facility did provide a safe, clean, comfortable, and homelike environment. The facility did not ensure that housekeeping and maintenance services were adequate, to maintain a sanitary, orderly, and comfortable interior. Specifically, two (Units 5 and 6) of four resident units reviewed for the environment had issues as follows; unlabeled resident urinals and graduated cylinders in shared bathrooms; fall mat in disrepair; brown liquid splatters with drips on a wall; hand rail in resident shower room loose and broken; a rusty commode; a fly paper strips (fly-killing device made of paper coated with a sweetly fragrant, but extremely sticky and sometimes poisonous substance that traps flies and other flying insects when they land upon it) in resident rooms and in a nourishment room; a shower chair in disrepair; and dried brown stains on a resident's closet, wall, and door, and a missing ceiling tile in a resident room. The findings are: A policy and procedure titled Safe, Homelike Environment dated 1/1/2018 documented that the resident has a right to safe, clean, and homelike environment. 1) Intermittent observations on 4/17/23 between 9:00 AM to 4:00 PM on Unit 5 revealed: Resident room [ROOM NUMBER] - unlabeled urinals were stored in the shared bathroom, on a towel bar by the door. Resident room [ROOM NUMBER] - unlabeled urinals and an unlabeled graduated measuring cylinder was stored in a shared bathroom, on a towel bar by the door. Additional intermittent observations on 4/18/23 between 8:00 AM to 12:00 PM on Unit revealed room [ROOM NUMBER] had unlabeled urinals and an unlabeled graduated measuring cylinder in a shared bathroom on a towel bar by the door During an interview on 4/20/23 at 9:02 AM Certified Nurse Aide (CNA) #1, t stated that resident use equipment should be labeled with the resident's name and room number. During an interview on 4/20/23 at 9:08 AM, Licensed Practical Nurse (LPN) #1, stated that resident care equipment should be labeled with the resident's name and room number. LPN #1 stated that the unlabeled equipment should be thrown away. During an interview on 4/21/23 at 11:24 AM with the Director of Nursing (DON), they stated that all resident equipment should be labeled and stored in the residents' area, like a nightstand. During an interview on 4/21/23 at 10:42AM with the per diem Infection Preventionist (IP), the IP stated that resident care equipment should be labeled with the resident's name, room number and put away in the resident's nightstand again to prevent cross contamination. 2) During intermittent observations from 4/17/23 through 4/19/23 between 9:00 AM and 1:30PM, on Unit 6 revealed: Resident room [ROOM NUMBER] - sticky fly paper secured to wall by flat headed pin between dressers in room, above trash can with multiple small dead flying insects. Additionally, on 4/18/23 at 9:37 AM and 2:43 PM an insect trap was observed hanging from privacy curtain track between beds in Resident room [ROOM NUMBER] with appearance of small dead insects present. Resident room [ROOM NUMBER]W - a fly strip hanging from the ceiling sprinkler with approximately 13 black insects stuck to it. Unit 6 Nourishment Room - a fly strip with approximately 30 black insects stuck to it hanging on the wall. Observed on the wall, five inches away from the fly strip, was a sticky, amber colored substance approximately 12 inches long with black debris on it. This substance was 18 inches from the nourishment refrigerator. Further observations on 4/19/23 between 12:00 PM and 2:00 PM revealed the Unit 6 Nourishment Room fly strip had been removed, but the sticky, amber colored substance with the black debris was still on the wall. During an interview on 4/19/23 at 12:15PM, Resident #5, stated that the fly strip in the resident room was gross, and they try not to look at that side of the residents' room, so they don't see it. During an interview on 4/20/23 at 9:31 AM the Director of Housekeeping and Laundry, stated that there should no fly paper strips in the building, and they need to be removed. During an additional interview on 4/21/23 at 8:28 AM, the Director of Housekeeping and Laundry stated resident rooms should not contain fly paper/traps. They were not sure where they came from, when they were put up or by whom. Their expectation would be for staff to inform them if found and remove them because they shouldn't be up. Director of Housekeeping and Laundry stated fly paper, traps are nasty, contaminated with bugs and are not homelike. During an interview on 4/21/23 at 10:42 with the per diem Infection Preventionist (IP), the IP stated that the fly paper strips hanging from walls or ceilings could cause cross contamination especially in a nourishment room. During an interview on 4/21/23 at 11:24 AM, the Director of Nursing (DON), they stated that there should be no fly strips in any area of the facility. The DON stated, that's what we have an exterminator for. 3) Intermittent observations on 4/17/23 between 9:00 AM to 4:00 PM on Unit 5 revealed: Resident room [ROOM NUMBER] had a fall floor mat with tears approximately six to eight inches long, along the corners of the mat. During an interview on 4/20/23 at 9:02 AM CNA #1 stated that resident floor mats that have tears in them should be replaced. During an interview on 4/20/23 at 9:08 AM Licensed Practical Nurse (LPN) #1 stated a fall mat with exposed foam should be replaced. During an interview on 4/20/23 at 9:31 AM with the Director of Housekeeping and Laundry, they stated that they did an audit of fall mats and removed all the ones in disrepair. They stated that they must have missed that fall mat, but they will replace it immediately. 4) During an interview on 4/17/23 at 8:59 AM Resident #65 stated they refuse to take a shower because the shower chair is wobbly and unsafe and had reported it to the nursing staff. During an interview on 4/17/23 at 12:07 PM CNA # 5 stated they were aware Resident #65 expressed they were afraid of the shower chair tipping over and reported it to a nurse but was unable to recall whom they reported it too. During an interview on 4/17/23 at 12:17 PM LPN #6 stated they were aware Resident #65 was afraid the shower chair would tip over and reported it to the Unit Manager (UM) RN #2. Additionally, LPN #6 stated the shower chair looks like it functions, but it does wobble when residents are in it. During an interview on 4/19/23 at 12:24 PM UM RN # 2 stated they do not recall any concerns with the shower chair. During an observation on 4/19/23 at 12:37 PM of Unit 5 shower chair all four wheels do not swivel while maneuvering the chair, three of the wheels are locked in a forward rolling position and the left back wheel is locked in an angled position preventing chair from rolling forward and turning smoothly. During an interview and observation on 4/19/23 at 2:10 PM Maintenance #2 stated the Unit 5 shower chair's wheels are frozen in place not allowing any of the wheels to swivel and the left back is frozen in an angled position. Additionally, Maintenance #2 stated it would be very difficult for staff to push or pull a resident in this shower chair and it needs to be taken out of service and repaired or replaced because it is unsafe. During an interview on 4/20/23 at 1:28 PM the DON stated they would have expected the shower chair to have been reported that it was not working properly and fixed or replaced for resident use and safety. 5) Intermittent observations on 4/18/23 between 8:00 AM to 12:00 PM on Unit 5 and Unit 6 revealed: Resident room [ROOM NUMBER] - three brown liquid, circular shaped splatters approximately two inches in diameter, with 14 drips on the wall approximately ½ inch to eight inches long underneath the splatters; privacy curtain with approximately eight white debris spots approximately ½ inch in diameter. Resident room [ROOM NUMBER] - floor sticky with footprints leading to the resident's bed. Resident room [ROOM NUMBER] - floor had multiple amounts of debris and dust on it; edges and corners had black debris build-up; cobwebs hanging from the ceiling behind the door, by the window and in the corners; a dead spider hanging from the cobweb behind the door; and blackish/ brown color splatters on the wall across from the bed and on the wall next to the bed by the door, and the commode in room [ROOM NUMBER] was rusted. During an interview on 4/20/23 at 1:24 PM Registered Nurse (RN) #2, Charge Nurse acknowledge the commode in room [ROOM NUMBER] was rusted. They stated they will need to get a new commode for room [ROOM NUMBER] as it should not be rusted and if the resident were to scratch themselves on it, they could get injured Resident room [ROOM NUMBER] - no paper towel dispenser in the bathroom. Above the toilet there were small holes in the wall which appeared to have been where a paper towel dispenser used to be. During an interview on 4/20/23 at 1:24 PM Registered Nurse (RN) #2, Charge Nurse stated maintenance will need to replace the paper towel dispenser because if the resident is unable to wash their hands it could be an infection control issue. During an interview on 4/20/23 at 9:31 AM with the Director of Housekeeping and Laundry, stated that any wall splatters and the cleanliness of the rooms are the responsibility of the housekeeper. If the housekeepers cannot remove a stain or debris in a resident's room, they need to report to them. 6) Observations made in Resident room [ROOM NUMBER] on 4/19/23 at 12:26 PM, 4/20/23 at 8:39 AM, 4/20/23 at 4:49 PM, and on 4/21/23 at 8:16 AM revealed, #628W's closet doors and closet door handles had dried, brown debris splattered on them, approximately two feet wide by four feet high. The bed closest to the door had issues with the wall and bathroom covered in brown debris approximately ¼ inch to one inch in diameter with oval shaped areas that were ¼ inch to three inches long from the floor to approximately three feet up the wall. During an interview on 4/20/23 at 8:52AM, Housekeeper #1 stated that daily cleaning of resident rooms involved sweeping the room, emptying the trash, mopping the floor, pulling the dressers away from the wall and cleaning behind them, wiping walls and doorknobs, and adding extra bags to the trash cans for the day. Housekeeper #1 also stated that tray tables and dresser tops were to be wiped daily. Housekeeper #1 accompanied the surveyors to the resident's room to look at the closet. Housekeeper #1 stated the closet door, sides, and handled were unclean and had been like that before they came to work at this facility. They stated they did not have the proper utensils to clean the closet and this job required a scraper. Housekeeper #1 then stated they had not noticed the state of the closet doors, handles and sides before, but should have noticed. Housekeeper #1 stated that they were not able to remove any debris from the wall or bathroom door. Housekeeper #1 then stated they should be reporting any areas they are not able to clean to the Director of Housekeeping and Laundry. During an interview on 4/21/23 at 8:28 AM, the Director of Housekeeping and Laundry, stated the closet doors, sides, and handles in Resident room [ROOM NUMBER] needed to be wiped down. They stated the brown debris on the walls required a wipe down to be clean. The Director of Housekeeping and Laundry stated that they expected housekeeping staff to see them if they are unable to clean a certain area. They stated that the brown debris issues were not reported to them. 7) Intermittent observations on 4/18/23 between 8:00 AM to 12:00 PM on Unit 5 revealed: The Unit 5 Spa Room - the third shower stall had a loose and broken handrail. During an interview on 4/20/23 at 1:24 PM Registered Nurse (RN) #2, Charge Nurse acknowledge the broken handrail in the spa room on Unit 5and stated maintenance will need to fix the hand bar in the shower room because if it were to break off a resident could injure themselves. 8) Intermittent observations from 4/17/23 through 4/21/23 between 7:54 AM and 5:04 PM revealed a missing ceiling tile in Resident room [ROOM NUMBER]W (window). During an interview on 4/21/23 at 7:54 AM, the Resident in the room stated the ceiling tile has been missing for a while. During an interview on 4/21/23 at 7:56 AM, CNA (certified nursing assistant) #8 stated they did not know why there was a missing ceiling tile and wasn't sure if maintenance was aware. CNA #8 stated something could drop down onto the resident and that ceiling tiles shouldn't be missing. During an interview on 4/21/23 at 9:09 AM, LPN (Licensed Practical Nurse) #10 stated Resident room [ROOM NUMBER]W should not be missing ceiling tile as it was a safety concern and did not make the room homelike. LPN #10 stated if maintenance wasn't aware they would put in a request to have it replaced. 10 NYCRR 415.5(h)(2)

Based on observation, interview, and record review conducted during a Complaint investigation (Complaint # NY00314500) during the Standard survey completed on 4/21/23, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. Specifically, one (Resident #46) of four residents reviewed for pressure ulcers did not have a comprehensive care plan developed for a resident with multiple pressure ulcers with measurable goals and interventions. The finding is: 1. Resident #46 had diagnoses included type 2 diabetes mellitus with diabetic neuropathy (disorder affecting nervous system), unspecified open wound left foot, and anemia due to stage 4 chronic kidney disease. The Minimum Data Set (MDS- a resident assessment tool) dated 2/10/23 documented Resident #46 had moderate cognitive impairment. The resident was a risk for developing pressure ulcers and had one unhealed pressure ulcer (PU) stage 3 present on admission. The Comprehensive Care Plan (CCP) identified as current last revised 4/5/23 revealed there was no documented evidence a comprehensive care plan was developed with measurable goals and interventions to address Resident #46 pressure ulcers. Resident #46's Comprehensive Closet Care Plan (used by staff to provide care) dated 8/9/22 and last updated on 4/5/23, did not document interventions for skin care and positioning devices. The resident was non ambulatory and required 2 extensive assist for transfers and positioning in bed. Review of a hospital Wound & Skin Nurse Clinical Note-Initial Consult dated 2/3/23 documented a Stage 3 (full thickness skin loss potentially extending into the subcutaneous tissue layer) sacral pressure ulcer that was present on admission, a left foot diabetic ulcer to the left ankle and a hard dry callous to left planter (bottom) heel. Review of a progress note dated 2/7/23 by the facility Nurse Practitioner #1 documented, left foot wound: will consult wound care specialist for further evaluation and continue treatment per recommendations by hospital. Review of a Wound Evaluation & Management Summary dated 2/20/23 documented Resident #46 had a Stage 3 pressure ulcer of the left, lateral ankle that measured 0.5 x 0.9 x 0.2 cm (centimeters) and a Stage 4 (full thickness skin loss potentially exposing muscle, tendon and even bone) pressure ulcer to the sacrum with a duration greater than 221days. Review of a Wound Evaluation & Management Summary dated 4/10/23, documented the resident's Stage 4 sacral pressure ulcer had improved and the documented duration of the ulcer was greater than 268 days. During an observation on 4/17/23 at 1:09 PM, 4/18/23 at 3:21 PM and 4/19/23 at 9:07 AM, Resident #46 was lying in bed and had a white gauze wrap around left ankle and heel. Additionally, Resident #46 was wearing a pressure relieving soft bootie on left their heel. During an observation on 4/20/23 at 11:03 AM, Resident #46 was out of bed sitting in wheelchair wearing a yellow non-skid sock over gauze bandage on left foot. The resident did not have on a pressure relieving soft bootie. During an observation of treatment to left ankle on 4/20/23 at 12:40 PM, LPN #7 removed wrapped white gauze dressing and large gauze pad covering from Resident #46's left ankle and heel. The gauze pad covering ulcer had a small amount of tannish drainage from medial aspect of left foot/heel. A Stage 2 (partial-thickness skin loss) pressure ulcer approximately the size of a quarter was observed with macerated (wet, moist wrinkly) skin to medial (inside) aspect of left foot/heel. Left lateral (outer) ankle was observed with an unstageable (unable to stage) dime sized raised soft dark tan scab, with surrounding erythema (redness). During an interview on 4/20/23 at 1:07 PM, Certified Nursing Assistant (CNA) #8 stated they believed Resident #46 was supposed to wear a boot to their left leg and it would be on the resident's closet care plan (CP). CNA #8 viewed Resident #46 closet care plan posted on the resident's closet and stated the bootie wasn't on there. CNA #8 stated staff wouldn't know Resident #46 was to wear a boot on their left leg if it wasn't on the closet CP. During an interview on 4/21/23 at 8:39 AM, Registered Nurse Supervisor (RN) #1 stated the unit managers initiate and update the resident care plans for pressure ulcers. During an observation and interview with the Assistant Director of Nursing (ADON) of a treatment to Resident #46's left ankle on 4/21/23 at 8:47 AM, revealed a Stage 2 pressure ulcer to the medial aspect of left foot/heel with skin maceration and surrounding erythema (redness). The left lateral ankle with dime size dark tan scab present with erythema surrounding scab. ADON stated when there was a scab like that it is considered an unstageable pressure ulcer. During an interview on 4/21/23 at 10:19 AM, the Director of Nursing (DON) stated the team, all disciplines, were responsible to ensure resident comprehensive care plans (CCP) were completed. DON stated it was important for residents to have a CCP to show specific clinical pathways, individual needs of the residents. After review of Resident #46 CCP in electronic record, DON stated their CCP was not done, and it should've been. 10NYCRR 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a Standard survey completed on 4/21/23, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for three (Residents #63, #65 and #78) of eleven residents reviewed. Specifically, Resident #63 had multiple long ¼ inch whiskers on their chin, Resident #65 had unkempt, oily disheveled hair, had not received hair washing for greater than 2 months and wanted their hair washed; and Resident #78 had long fingernails greater than ¼ inch beyond their fingertips. The findings are: The facility policy and procedure (P&P) titled Routine Care (AM/PM) dated 2/2015, documented routine care rendered by the nursing staff included attention to the physical preference to the patient/resident in the assessment, planning and provision of care. Total bath (bed, shower or tub) washes the resident in sequence (face, chest, abdomen, arms, hands, anterior perineum (area between anus and genitalia), change water, back, legs feet, posterior perineum). In addition, the policy documented, assess facial hair and remove; assess nails and clean, clip or trim. The P&P titled Fingernail and Toenail Care dated 7/3/12 documented, Residents hands and fingernails will be monitored during weekly skin assessments or on resident's bath days. 1. Resident #63 had diagnoses which included dementia, anorexia (an eating disorder characterized by restriction of food intake leading to low body weight) and malaise (a general feeling of discomfort, illness or uneasiness). Review of a Minimum Data Set (MDS - a resident assessment tool) dated 4/3/23 documented the resident had severe cognitive impairment and required extensive assistance of one for personal hygiene. Review of Resident #63's comprehensive care plan (CCP) with initiated date of 4/18/22 documented resident had an ADL self-care performance deficit, interventions included extensive assistance was required for grooming. Review of Resident #63's undated Closet Care Plan (a guide for staff to provide care) identified as current by the Director of Nursing (DON), documented the resident required extensive assistance for personal care including grooming. Review of Resident #63's Progress Notes dated 1/6/23 - 4/19/23 revealed no evidence that the resident refused to have the whiskers shaved from their chin. During intermittent observations on 4/17/23 at 12:12 PM, 4/18/23 at 3:59 PM, 4/19/23 at 10:18 AM, and 4/20/23 at 7:47 AM and 10:15 AM with multiple ¼ long whiskers on their chin. During an interview on 4/20/23 at 11:34 AM, Certified Nurse Aide (CNA) #6 stated they were familiar with Resident #63 and was responsible for their care and did not offer to shave the resident's whiskers from their chin this morning and should have. During another interview and observation on 4/20/23 at 11:42 AM, CNA #6 provided facial hair removal from Resident #63's chin, and Resident #63 was observed to be sitting calmly in their wheelchair (w/c) and positioned their chin in a manner for CNA #6 to easily shave their whiskers from their chin. CNA #6 stated the resident should have been shaved this morning during care. During an interview on 4/20/23 at 1:13 PM, the DON stated they would have expected the CNAs to have shaved Resident #63's chin whiskers on their shower day or as needed for dignity. 2. Resident #65 had diagnoses which included anxiety, major depressive disorder and cerebral infarction (a stroke). Review of a MDS dated [DATE] documented the resident was cognitively intact and required extensive assistance of 2 for personal hygiene. Review of Resident #65's CCP with initiated date of 12/15/21 documented the resident was supposed to have a shower/bed bath twice weekly and as needed. The resident had an ADL self-care performance deficit related to generalized weakness; interventions included extensive assistance with bathing. Review of Resident #65's undated Closet Care Plan (identified as current by the Director of Nursing (DON)) documented the resident required extensive assistance of one with bathing. During an observation and interview on 4/17/23 at 9:07 AM, Resident #65 stated it's been months since they had their hair washed because they are provided a bed bath and the staff don't offer to wash their hair while in bed and they want their hair washed. The resident's hair was oily and unkempt. During intermittent observations on 4/18/23 at 3:26 PM and 4/19/23 at 8:49 AM Resident #65's hair was oily and unkempt. During an interview on 4/19/23 at 12:01 PM, CNA #7 stated they were familiar with Resident #65 and had provided care to the resident but had not provided hair washing because the resident was provided a bed bath and the facility did not have any equipment to wash a resident's hair while in bed; such as dry shampoo, hair washing cap or bed hair washing trays. CNA #7 stated they had not told the nurses that the resident needed their hair washed and should have. During an interview on 4/19/23 at 12:07 PM, CNA # 5 stated they were familiar with Resident #65 and had provided care to them in the past and the resident needed their hair washed because it was oily, and all knotted up in the back of their head and probably needed to be cut. CNA #5 stated the resident received a bed bath and the facility did not have any equipment to wash a resident's hair in bed. During an interview on 4/19/23 at 12:17 PM, Licensed Practical Nurse (LPN) #6 stated they were familiar with Resident #65 and stated the resident was provided bed baths and they didn't think the facility had any equipment such as dry shampoo, shower caps or bed hair washing trays to wash the resident's hair. During an interview on 4/19/23 at 12:24 PM, Unit Manager (UM) Registered Nurse (RN) #2 stated Resident #65 was provided a bed bath and was unable to have their hair washed unless the resident was provided a shower because the facility did not have any equipment to wash the resident's hair while in bed. During an interview on 4/20/23 at 1:28 PM, the DON stated Resident #65 should have had their hair washed even if they were in bed, during their bed bath on the scheduled shower day. The DON stated they believed the facility had dry shampoo and shower caps available but was not certain and would have expected the nursing staff to have notified them if they did not have equipment to wash the resident's hair. The DON stated they expected the nursing staff to ensure the resident's hair was washed for cleanliness and dignity. 3. Resident #78 had diagnoses which included right side hemiplegia (paralysis of one side of the body), Parkinson's Disease (a disorder of the central nervous system that affects movement) and gastro-esophageal reflux disease. Review of the MDS dated [DATE] documented the resident usually understands and sometimes is understood and was unable to complete a cognitive interview. The MDS further documented the resident required extensive assistance of one person for personal hygiene. Review of Resident #78's CCP dated 12/23/21, documented the resident had decreased self-care skills, interventions included extensive assist was required for grooming, and shower/bed bath twice weekly and as needed. Review of Resident #78's undated Closet Care Plan (identified as current by the DON) documented the resident required extensive assistance of one with grooming. During intermittent observations on 4/18/23 at 9:07 AM and 3:48 PM, on 4/19/23 at 10:38 AM and 12:58 PM, Resident #78's fingernails on their left hand (thumb, index finger and fifth finger) were long-greater than a ¼ inch beyond the fingertip pad and on their right hand all fingernails were long- greater than a ¼ inch beyond the fingertip and curving downward towards the palm of the hand. During an interview and observation on 4/19/23 at 1:11 PM, CNA #4 stated they had provided care to Resident #78 today and they were responsible to trim resident's fingernails and did not notice the length of the resident's fingernails today. CNA #4 observed Resident #78's fingers and stated the resident's left-hand thumb, index and fifth fingernails were very long and the resident's right hand all fingernails were very long and curving downward toward the palm of the hand and they all need to be trimmed. CNA #4 stated the resident's fingernails should be trimmed during shower day and as needed and she should have noticed the length of the resident's fingernails this morning during care and trimmed them. During an interview on 4/19/23 at 1:25 PM, LPN #5 stated resident's receive fingernail care weekly on shower days and is documented on the Shower/Skin Check form. LPN #5 reviewed the electronic medical record (EMR) for Resident #78 and stated the last documented weekly skin check was on 8/2/22. During an observation and interview on 4/19/23 at 1:46 PM, LPN #5 stated Resident #78's fingernails were very long and should have been trimmed. LPN #5 stated the fingernails were approximately 1 inch in length on the left-hand thumb, index and 5th finger and all fingernails on the right hand. LPN #5 stated Resident #78 did not have a diagnosis of diabetes therefore it was the CNAs responsibility to trim the resident's fingernails. During an interview on 4/19/23 at 1:46 PM, Assistant Director of Nursing (ADON) RN #3 stated the CNAs were responsible to trim resident's fingernails on shower days and as needed unless the resident had a diagnosis of diabetes, and the nurses should be documenting if nails were trimmed on the Shower/Skin Check weekly. ADON RN # 3 reviewed the EMR and stated the last documented Shower/Skin Check form was completed on 8/2/22 and documented nails trimmed - yes. The ADON RN #3 stated they believed the Shower/Skin Check form should have been completed twice weekly indicating if nail care was provided and it wasn't. During an interview on 4/20/23 at 1:19 PM, the DON stated they would have expected the CNAs to have trimmed the resident's fingernails on shower days and as needed and the nurses should be ensuring the fingernails were trimmed, there is not a regularly scheduled unit manager on the unit at this time. Fingernails were to be trimmed for hygiene, skin integrity, comfort, and infection control purposes. The DON further stated the facility did not enforce the use of the Shower/Skin Check form and expected the CNAs and nurses to be aware of the length of resident's fingernails and trim them as needed during daily care. 10NYCRR 415.12 (a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 4/21/23, the facility did not provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident encouraging both independence and interaction in the community for one (Resident #78) of one resident reviewed for activities. Specifically, Resident #78 was not in attendance of activities according to their preference and comprehensive assessment due to the lack of being not gotten up and out of bed and not being asked if they wanted to attend activities. The finding is: The facility undated policy and procedure (P/P) titled Activities Protocol identified as current by the Administrator, documented the facility will provide an ongoing program of activities to meet in accordance with the resident assessment, the interests and physical, mental and psychosocial well -being of each resident. To promote and maintain the resident's sense of usefulness to self and others, make his or her life more meaningful, stimulate and support the desire to use his or her physical and mental capabilities to the fullest extent and enable the resident to maintain a sense of usefulness and self-respect. To provide an ongoing program of activities to meet the interests, physical, mental, and psychological needs of each resident. The P/P titled Resident Rights Policy dated 10/2016 documented the Resident Rights were developed to ensure that each resident's rights were protected and promoted. That each resident be encouraged and assisted in the fullest exercise of these rights and are afforded their right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration and privacy. Review of the document Your Rights as a Nursing Home Resident in New York State provided by the Administrator of the facility dated 2022 revealed Self-Determination is having the right to be offered choices and allowed to make decisions important to you and receive services with reasonable accommodations for individual needs and preferences. Resident #78 had diagnoses including right side hemiplegia (paralysis of one side of the body), Parkinson's Disease (a disorder of the central nervous system that affects movement) and gastro-esophageal reflux disease. The Minimum Data Set (MDS - a resident assessment tool) dated 2/1/2023 documented Resident #78 usually understands, sometimes understood and was unable to complete a cognitive interview. In addition, the resident did not exhibit rejection of care. The MDS dated [DATE] documented the Activity Preferences for Resident #78 were somewhat important to do things with groups of people, to do favorite activities, and go outside. Review of the untitled comprehensive care plan (CCP) identified as current by the Director of Nursing (DON) with initiated date 12/23/21 revealed Resident #78 was dependent on staff etc., for meeting emotional, intellectual, physical and social needs, resident will maintain involvement in cognitive stimulation, social activities as desired. Interventions included: invite resident to scheduled activities, provide activities calendar, notify resident of any changes to the calendar of activities. The resident's preferred activities are BINGO, jeopardy, uno, and word search. Review of the Closet Care Plan revealed Resident #78's Activities was blank with no documented interventions. Review of the Progress Notes dated 3/2/23 through 4/19/23 revealed there was no documented evidence Resident #78 was offered to attend activity programs and refused. In addition, there was no documented evidence resident refused to get out of bed. During intermittent observations on 4/18/23 at 8:49 AM and 3:48 PM and 4/19/23 at 10:38 AM, 12:58 PM and 1:40 PM Resident #78 was in the bed with facility gown on. No activities provided in the room noted. Television noted to be on. During an interview and observation on 4/18/23 at 3:48 PM and 4/19/23 at 10:38 AM Resident #78 stated Yes when asked if they would like to go to an activity and stated No when asked if staff had asked them to attend activity programs. Observation of Resident #78's room revealed no Activity Calendar present. Review of the April 2023 Activities Calendar revealed BINGO and games were offered on April 17 and April 18. In addition, various other activities were offered such as make overs, movie, arts and crafts on April 17, 18, and 19 with no specific times. During an interview on 4/19/23 at 2:19 PM the Activities Director (AD) stated Resident #78 wants to attend activities and they have informed the nursing staff when the resident indicates they want to attend, but often the resident is not out of bed in time for the activity. The AD stated they had not reported the resident was not able to attend and should have reported it to the Assistant Director of Nursing (ADON) or Director of Nursing (DON) because there is no Unit Manager (UM) on the resident's unit. They stated Resident #78's son always tells them the resident wants to attend and when the resident does come to the activity, they stay approximately 30 minutes. The last time the resident attended an activity program was approximately 4 weeks ago because the resident was out of bed in time. The AD stated they do not provide an Activity Calendar to each resident as indicated on the CCP. They had not developed an Activity Calendar in January 2023, February 2023 and has no evidence a calendar was developed for March 2023, as they believe they had thrown out the calendar for March. Additionally, the AD stated the April Activity Calendar does not indicate the times of the activities because they have activities all day long. Upon request to review the attendance records the AD stated they do not document resident attendance to activities. The AD stated they have not asked Resident #78 to attend any activities this week because they were too busy. During an interview on 4/20/23 at 10:12 AM Certified Nursing Assistant (CNA) #6 stated the resident was pleased to be out of bed and had fun in BINGO today. CNA #6 stated they do not know if the resident had been offered activity programs in the past but believe activities are important to promote a quality of life, and physical and mental exercise to the residents. During an interview on 4/20/23 at 1:14 PM the DON stated activities are important and would expect the resident to attend activities per their preferences. 10 NYCRR 415.5(f)(1)

Based on observation, interview, and record review conducted during a Standard survey completed on 4/21/23, the facility did not ensure that the residents' environment remained as free from accident hazards as possible, and each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #404) of two residents reviewed. Specifically, the facility did not ensure Resident #404 had a call device to request assistance and the resident fell on the floor in their room which resulted in bruising to their left forehead. The finding is: 1. Resident #404 had diagnoses including anxiety disorder, Parkinson's Disease, and chronic obstructive pulmonary disease (COPD). The Minimum Data Set (MDS, a resident assessment tool) dated 3/24/23 documented Resident #404 was cognitively intact, understood, and understands. The resident required extensive assist of one with bed mobility and supervision of one assist for transfers. The Comprehensive Care Plan (CCP) initiated on 3/31/23 documented Resident #404 is at risk for falls related to deconditioning, gait/balance problems. Interventions included: anticipate and meet resident needs, be sure the resident's call light was within reach and encouraged the resident to use it for assistance as needed; the resident needed prompt response to all requests for assistance, and the resident needed a safe environment with a working and reachable call light. Review of the un-witnessed incident report dated 4/16/23 at 1:49 AM, documented Resident #404 complained of transferring themselves without assist. Resident #404 obtained a bruise post fall to their forehead measuring 2 centimeters by 1 centimeter. Immediate action taken included a PT (physical therapy) referral and encouraged to call staff for assist. During an observation and interview on 4/17/23 at 9:24 AM, Resident #404 stated they currently don't have a call bell and haven't had one since they moved into this room three days ago. The resident stated they had no means to call for help when they fell the other day trying to stand up to go to the bathroom from their bed. Resident #404 stated they had to physically get themselves up off the floor, get in their wheelchair and go get help. Resident #404 stated they hit their head on the metal frame of the tray table. The resident's left upper forehead above their left eye was observed with a raised area and fading bruise. Additionally, Resident #404 stated they absolutely would have used a call device if they had one. The resident had no functional call bell or tap bell in their room at this time. Observation on 4/18/23 at 9:02 AM, revealed the resident had no functional nurse call bell or tap bell in their room. The call bell cord and call bell station cover were observed unattached from the wall, sitting at the foot of the bed. During a telephone interview on 4/19/23 at 1:39 PM, Licensed Practical Nurse (LPN) #11 stated they didn't pay any attention to whether Resident #404 had a call bell on the night of their reported fall. LPN #11 stated they observed last night that resident #404 did not have a call bell and but had a tap bell. Additionally, LPN #10 stated all residents should have a call bell so they can get help when they need it. During a telephone interview on 4/19/23 at 1:52 PM, Registered Nurse Supervisor (RN) #6 stated staff had reported to them that Resident #404 fell out of bed on 4/16/23. RN #6 stated resident #404 stated they called out but didn't mention anything about their call bell not working to them. RN #6 stated they did not check the resident's call bell because Resident #404 was brought down to see them. RN #6 stated they weren't aware of any missing call bells and didn't know why they didn't check for one when completing the incident report. RN #6 stated Resident #404 should have had a call bell so they could get in touch with the staff. During an interview on 4/20/23 at 5:39 PM, the Director of Nursing (DON), stated they were not aware Resident #404 had gotten themselves up off the floor on 4/16/23. The DON stated if a resident's call bell was not working, a tap bell can be given, and if they were unable to use a tap bell the resident should be placed on 30-minute checks. The DON stated resident #404 should have had a call bell. 10 NYCRR 415.12(h)(2)

Based on interview and record review conducted during the Standard survey completed on 4/21/23, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director and the Director of Nursing (DON), and these reports must be acted upon for one (Resident #34) of five residents reviewed for drug regimen reviews. Specifically, Resident #34 was ordered Haldol (antipsychotic medication) prn (as needed) for agitation from 1/30/23 to 2/28/23. The Consultant Pharmacist did not identify and recommend the discontinuation of the prn antipsychotic medication after 14 days. The finding is: 1.Resident #34 had diagnoses including bipolar disorder, major depressive disorder, and schizophrenia. The Minimum Data Set (MDS- a resident assessment tool) dated 1/8/23 documented Resident #34 was understood, understands and cognitively intact. Antipsychotic medication was being used over the past seven days. The untitled comprehensive care plan dated 7/2/19, documented Resident #34 used psychotropic medications related to behavior management for diagnoses of bipolar disorder and schizophrenia. The Order Recap Report dated 1/1/23- 4/20/23 documented an order for Haldol Injection Solution (Haloperidol Lactate) inject 2 mg intramuscularly every 24 hours as needed for agitation with start date of 1/30/23 and end date of 2/28/23. The Medication Regimen Review (MRR) dated February 2023 and completed by the Consultant Pharmacist documented Resident #34 was reviewed on 2/15/23 with No Irregularities Noted. The Physician Progress Note dated 1/30/23 documented Resident #34 would be started on Haldol 2 mg IM as needed once a day due to bipolar and manic episodes and paranoid behavior and recurrent ER (emergency room) visits. The Physician Progress Note dated 3/2/23 documented Resident #34 was on Haldol 2 mg IM as needed once a day. Staff reported Haldol had not been utilized. Will discontinue Haldol for now. During a telephone interview on 4/20/23 at 9:14 AM, the Medical Director stated Resident #34 was having bad behaviors since Christmas time and felt they needed a prn antipsychotic medication. The Medical Director stated, I was not aware that a prn antipsychotic medication needed to be reordered after 14 days and documentation for justification for the use of the antipsychotic medication. They stated they stopped the medication because the resident was not using it. During a telephone interview on 4/20/23 at 9:26 AM, the Consultant Pharmacist stated prn antipsychotic medications should not be ordered more than 14 days. After 14 days the medication needs to be re-ordered and the physician needs to document the reason for the need of the medication and how this medication will benefit the resident. The Consultant Pharmacist stated, they should have caught the order for Haldol 2 mg IM as needed once a day during their MRR review on 2/15/23 and should have written a note to the physician regarding this. The Consultant Pharmacist stated, I do not know how or why I missed this order. During an interview on 4/20/23 at 10:06 AM, the Director of Nursing (DON) stated the prn orders for antipsychotic medications needed to be stopped after 14 days at which time they need to be re-ordered with a documented justification for the continued use. The DON stated, they would have expected the Consultant Pharmacist to have caught this order as they are better at the medication regulations than anyone else. A policy and procedure for Medication Regime Review and Consultant Pharmacist were requested on 4/20/23. The facility did not provide any policy and procedure regarding this. 10 NYCRR 415.18(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed 4/21/23, the facility did not store all drugs and biologicals in locked compartments and under proper temperature for one of one floor used by residents and one (Unit 6) of two medication storage rooms. Specifically, a box of medications that contained 61 medications for 20 residents was left unattended, unsecured on the floor outside an office in the hallway where residents, staff and visitors had access. This involved Resident #'s 7, 16, 62, 82, 84, 88, 92, 104, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, 215, and 216. In addition, the medication Retacrit (epoetin, injectable medication used to treat anemia) was not stored in the refrigerator as required upon receiving from the pharmacy (#405). The findings are: The policy and procedure (P/P) titled Medication Storage dated 2/2015 documented medications are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is assessable only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medications requiring refrigeration or temperatures between 2°C (36°F) (degrees Celsius/ Fahrenheit) and 8°C (46°F) are kept in a refrigerator with a thermometer to allow temperature monitoring. 1. During an observation on 4/18/23 at approximately 7:50 AM revealed a large box of medications sitting with 3 clear plastic bags of garbage on the floor in the hallway between the nursing supervisor's office and the elevator on the first floor of the facility. At that time the Director of Nursing (DON) walked over and glanced towards the box of medications and bags of garbage and walked into the opened nursing supervisor's office. At approximately 8:10 AM the box of medication and garbage bags were still sitting in the same area. At this time the door to the supervisor's office was closed shut. At approximately 8:15 AM Registered Nurse (RN) #1, Supervisor went to the office door to unlock it and stated they had no idea why the medications in the box were sitting there. They stated they shouldn't be and should be locked up. At that time the box of medications was brought into the supervisor's office. The box contained the following medications for Resident #'s 7, 16, 62, 82, 84, 88, 92, 104, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, 215, and 216: - 27 tablets of Buspirone (use to treat anxiety) 15 mg (milligrams) - 2 tablets of Jardiance (used to treat diabetes)10 mg - 6 tablets of Rosuvastatin (used to treat high cholesterol) 10 mg - 26 capsules of Tamsulosin (used to treat enlarged prostate) 0.4 mg - 56 tablets of Allopurinol (used to treat gout) 100 mg - 9 tablets of Carvedilol (used to treat heart failure) 25 mg - 4 tablets of Levothyroxine (used to treat thyroid disease)112 mcg (microgram) - 65 tablets of Metformin (used to treat diabetes)1000 mg - 6 tablets of Entresto (used to treat heart failure) 24-26 mg - 8 tablets of Jardiance 10 mg - 27 capsules of Vancomycin (antibiotic) 125 mg - 30 tablets of Ondansetron (used to prevent nausea) 4 mg - 8 tablets of Buspirone 30 mg - 30 tablets of Prednisone (steroid)10 mg - 88 tablets of Diltiazem (used to treat high blood pressure) 30 mg - 10 capsules of Hydroxyz [NAME] (used to treat allergies) 25 mg - 110 tablets of Buspirone 10 mg - 2 tablets of Prednisone 20 mg - 48 tablets of Acetazolamide (diuretic) 250 mg - 18 tablets of Midodrine (used to treat low blood pressure) 5 mg - 25 tablets of Colchicine (used to treat gout) 0.6 mg - 4.5 tablets of Metoprolol Succinate (used to treat heart disease) 25 mg - 46 tablets of Vitamin D3 (supplement) 25 mcg - 3 tablets of Prednisone 5 mg - 1 capsule of Gabapentin (anticonvulsant) 100 mg - 24 tablets of Famotidine (used to treat gastritis) 20 mg - 7 tablets of Vitamin A 300 mcg - 8 tablets of Naproxen (used to treat pain) 250 mg - 15 tablets of Pantoprazole (used to treat heartburn) 40 mg - 32 tablets of Amiodarone (used to treat irregular heartbeat) 200 mg - 6 tablets of Furosemide (diuretic) 20mg - 91 tablets of Metoprolol Tartrate 25 mg - 2 tablets of Sertraline (anti-depressant) 50 mg - 20 tablets of Mirtazapine (anti-depressant) 15 mg - 6.4 of Enoxaparin Injection (prevent blood clots) 80/0.8 ml (milliliter) - 3 tablets of Atorvastatin (used to treat high cholesterol)10 mg - 50 tablets of Cyclobenzaprine (muscle relaxant) 5 mg - 7 tablets of Levothyroxine 200 mcg - 14 tablets of Venlafaxine (used to treat depression)150 mcg - 18 capsules of Diltiazem 240 mg - 40 ml of Enoxaparin Injection 120/0.8 ml - 60 capsule of Gabapentin 400 mg - 16 tablets of Eliquis (used to prevent blood clots) 5 mg - 400 ml of Sucralfate [NAME] (anti-ulcer drug)1 gm (gram)/ 10 ml - 1 Atropine Sul Solution (treat multiple problems) 1% OP - 3 Insulin Lispro Injection (treat diabetes) 100/ml - 16 tablets of Molnupiravir (anti-viral) 200 mg - 75 ml of Ipratropium/ Albuterol (help control symptoms of lung disease) Solution 0.5/2.5 ml - 60 tablets of Budesonide (steroid) [NAME] 0.5mg/2 mg - 2.5 Latanoprost Solution (used to treat glaucoma) 0.005% - 90 tablets of Bumetanide (diuretic)0.5 mg - 2 Albuterol AER HFA (help control symptoms of lung disease) - 3 Insulin Glargine Injection (used to treat diabetes) Solution 100 - 60 tablets of Methocarbamol (muscle relaxant) 500 mg - 30 tablets of Clopidogrel (anti-platelet medication)75 mg - 30 tablets of Rosuvastatin 10 mg - 60 tablets Xarelto (used to treat blood clots) 2.5 mg - 60 tablets of Oxybutynin (used to treat overactive bladder) 5 mg - 120 tablets of Hydralazine (used to treat high blood pressure)100 mg Review of the pharmacy Return Receipt dated 4/18/23 and 4/20/23 verified the medications listed above were in the box returned to the pharmacy. During an interview on 4/18/23 at approximately 8:35 AM, the DON stated When I came in today, I saw the box sitting there, but I thought it was garbage and did not realize there were medications in the box. I am not sure why they were put there but they should have been locked up in the supervisor's office. They were the medications that needed to be returned to the pharmacy. The medications should have not been in an open area like they were because everyone had access to them including the residents. During a telephone interview on 4/19/23 at approximately 3:45 PM Pharmacist #1 stated medications should be locked up, like in a medication room because a resident could walk up and take them or get into them if they were left in an open area. 2. During an observation of Unit 6 medication storage room on 4/20/23 at 5:08 PM, revealed on top of the medication refrigerator there was a bubble wrapped package with a bright florescent green label that documented refrigerate upon arrival. The package contained a warm ice pack and a small clear plastic bag that contained two unopened vials of Retacrit. The label on clear plastic bag documented it was dispensed from pharmacy on 4/5/23 for Resident #405. During an interview on 4/20/23 at 5:08 PM, Licensed Practical Nurse (LPN) #12 stated Resident #405 had an order to receive Retacrit three times a week, and they would notify the supervisor of medication not being stored in refrigerator as indicated. During an interview on 4/21/23 at 9:25 AM, the Pharmacist Consultant stated the Retacrit should have been refrigerated until use per the manufacture's recommendations. The medication can lose potency and wouldn't work as well if it was not refrigerated. During an interview on 4/21/23 at 10:19 AM, the Director of Nursing (DON) stated they expected that when a nurse received a medication requiring refrigeration, they would place the medication in the refrigerator, to maintain the effectiveness of the medication. 10 NYCRR 415.18(e)(1-4)

Based on observation, interview and record review conducted during the Standard survey completed on 4/21/23 the facility did not dispose of garbage and refuse properly for two of two dumpsters. Specifically, waste was not properly contained within dumpsters and the lids on the top were not closed shut. There were open bags of garbage and debris on the ground surrounding the dumpster with birds and squirrels picking at the garbage. The finding is: The policy and procedure (P/P) titled Sewage disposal- Medical Waste Disposal- Dumpster Maintenance and Holding of Waste last revised 12/1/2019 documented the dumpster and surrounding area shall be clear and free of debris. Individuals disposing of refuse will ensure all refuse ends inside the dumpster, the dumpster lids are properly closed and the dumpster sliding doors are properly closed. The environmental team shall be responsible for ensuring the surrounding area is clear from debris-in the event the items are too large the maintenance team shall assist in removing items properly. Observation on the exterior of the building on 4/17/23 at 8:15 AM revealed the facility had two trash dumpsters located in the parking lot and the covers were not closed. There were two crows were picking at an open white colored plastic bag of trash that was lying on the ground next to one of the facility's two trash dumpsters on the right side. Observation on the exterior of the building on 4/18/23 at 7:30 AM revealed the covers on the facility's two trash dumpsters were not closed. A crow was picking at an open white colored plastic bag of trash that was lying on the ground next to one of the facility's two trash dumpsters on the right side. Observation on the exterior of the building on 4/18/23 at 3:50 PM revealed the covers on the facility's two trash dumpsters were not closed. There were three white colored plastic bags of trash lying on the ground near the two dumpsters. One bag was between the dumpsters and two bags were on the outside of the dumpsters. All three bags were ripped open. There was a substantial amount of debris and garbage spread approximately 200 to 300 feet on the grass and in the trees directly behind the two dumpsters. There were three white plastic bags hanging in the tree branches. Observation on the exterior of the building on 4/19/23 at 10:16 AM revealed the covers on the facility's two trash dumpsters were not closed. There were two broken over the bed tray tables and an office style type chair lying on the ground next to one of the dumpsters. There were multiple open white plastic bags of garbage lying between and next to the two dumpsters. There was a significant amount of debris still spread across the approximate 200 to 300 feet of grass and tree area behind the dumpsters. The three white plastic trash bags were hanging in the trees. Several small birds were flying into the dumpsters and landing on the trash on the ground, picking at the trash and flying away. During an interview on 4/19/23 at 10:16 AM, the Food Service Director (FSD) stated the dumpsters were being used by multiple departments. Housekeeping tosses the trash they gather throughout the day on the units into these dumpsters. Dietary after collecting their trash from the kitchen, gets tossed in the dumpsters. The FSD stated the trash should be placed through the sliding doors on the side and the doors and the lids should always remain closed. The FSD was not sure how the lids on the top get open. The FSD stated the trash that is lying around the dumpster and the area behind the dumpster should not be there as this can be an infection control issue. Animals could come and get in the garbage and spread it. The FSD stated, I have seen birds sitting on top of the dumpsters. The FSD stated, We think that the company that picks up the trash, when dumping it into their truck, does not all fall into the truck but falls on the ground. We did talk to the garbage company about this issue as this has been on-going. The Director of Housekeeping and I come out here with our staff often to try to keep the area clean. During an interview on 4/19/23 at 11:53 AM, the Director of Housekeeping stated, the dumpster area to my knowledge is to be taken care of by maintenance, but because they have been short staffed, housekeeping has been taking care of it. They stated the housekeeping staff is out there around the clock. They believe the garbage that is being left outside the dumpsters is from the company that comes and picks up the garbage as the staff is pretty good with getting the trash in the dumpster. They stated they did not know why the top covers to the dumpsters are open as they do not throw the garbage in that way. They stated the lids and doors to the dumpsters should always be closed. The Director of Housekeeping stated the garbage that was spread out behind the dumpsters was not there yesterday and they believe the wind blew the garbage out there that morning as their staff is out there all the time cleaning the area up. Observation on the exterior of the building on 4/20/23 at 7:32 AM revealed the covers on the two dumpsters were not closed. [NAME] plastic bags of garbage were still lying next to the dumpsters. The approximate 200 to 300 feet grass area and trees behind the dumpster still had a significant amount of debris and garbage spread out. Three white plastic bags were still hanging in the trees. Observation on the exterior of the building on 4/21/23 at 8:31 AM revealed the covers on the two dumpsters were not closed. There were two squirrels running around and crawling in and out of the facility's two trash dumpsters. At this time revealed two squirrels crawled down the right dumpster and began gnawing at an open white colored plastic bag of trash that was lying on the ground next to the right side of this dumpster. 10 NYCRR 415.14(h) 14-1.150(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Onsite Post Survey Revisit completed on 7/12/23, the facility did not ensure that the Quality Assurance Performance Improvement Program (QAPI) Committee developed and implemented appropriate plans of action to correct identified quality deficiencies and regularly reviewed, analyzed, and acted on available data to make improvements. Specifically, the QAPI Committee did not have documentation of audits or documentation of review of audits to ensure deficiencies identified during the Recertification Survey completed on 4/21/23, were corrected, and the facility did not institute and follow corrective actions that were to put in place to ensure that the following deficiencies would not reoccur. The findings are: Refer to: F 812- Food Procurement, Store/Prepare/Serve - Sanitary - Scope and Severity D F 908- Essential Equipment, Safe Operating Condition - Scope and Severity D K 200- Means of Egress Requirements - Other - Scope and Severity D K 222- Egress Doors - Scope and Severity E K 225- Stairways and Smokeproof Enclosures - Scope and Severity E K 281- Illumination of Means of Egress - Scope and Severity E K 293- Exit Signage - Scope and Severity E K 321- Hazardous Areas - Enclosure - Scope and Severity E K 324- Cooking Facilities - Scope and Severity E K 345- Fire Alarm System - Testing and Maintenance - Scope and Severity E K 353- Sprinkler System - Maintenance and Testing - Scope and Severity E K 362- Corridors - Construction of Walls - Scope and Severity E K 363- Corridor - Doors - Scope and Severity E K 911- Electrical Systems - Other - Scope and Severity E K 918- Electrical Systems - Essential Electric System Maintenance and Testing - Scope and Severity E K 920- Electrical Equipment - Power Cords and Extension Cords - Scope and Severity E K 921- Electrical Equipment - Testing and Maintenance Requirements - Scope and Severity E K 923- Gas Equipment - Cylinder and Container Storage - Scope and Severity E The facility's policy and procedure (P&P) titled Quality Assurance/Performance Improvement dated 8/2016 documented the facility will develop and implement plans for improvement to address deficiencies identified and will document the outcome of the remedial action. Review of the approved POC for the Recertification Survey completed on 4/21/23, documented the facility identified a correction date of 6/20/23 for the deficient practices cited under F Tag 812, F Tag 908; and K Tags 200, 222, 225, 281, 293, 321, 324, 345, 353, 362, 363, 911, 918, 920, 921, and 923. The following corrective actions were identified by the facility in their Plan of Correction, for the Recertification Survey completed on 4/21/23: -For F 812, the hand sinks and towel dispensers in the dietary department will be repaired by 6/20/23. FSD will submit weekly findings in a monthly summary for 3-months or until problems are resolved. QAPI Committee will assist FSD to ensure timely compliance. -For F 908, the ten-inch-wide section of the sewer pipe was to be sealed and the dark standing liquid in the pit was flushed by 5/31/23. Audit results will be reported to the QA&A Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results. -For K 200, the Maintenance Shop's door lock requiring more than one releasing operation will be replaced by 6/20/23. The Maintenance Director/Tech will report completion of lock changes to the QAPI Committee to ensure compliance with K 200. An audit will be completed monthly by the Maintenance Director/Tech to ensure this issue is no longer present in the facility. The QAPI Committee will review completion and determine any further changes needed. -For K 222, all exit doors with delayed egress features will be audited to ensure proper operation by 6/20/23. The Maintenance Director/Tech will submit this audit monthly to the QAPI Committee. The QAPI Committee will determine additional process change needed based on findings. -For K 225, First Floor Rectory Door: self-closing mechanism was installed, door adjusted to latch into frame and fire resistance label was affixed, Chapel door to the Rear Chapel Stairway: latch was installed, and fire resistance label was affixed, Door separating center stairway and basement corridor: latch was attached. Door to rear kitchen stairway: fire resistance label was affixed, Basement exterior door (#14) in rear laundry stairwell - fire resistance label was replaced, Door separating rear laundry stairwell from attached garage: Gap at bottom was repaired. All to be completed by 6/20/23. Audit results will be reported to the QA&A Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results -For K 281, Light fixtures will be installed at exit doors #14, #15(double bulb), #19 and #24 by 6/20/23. Maintenance Director will report when audits are completed to QAPI Committee for review. The Committee will monitor for compliance. -For K 293, A full audit of exits signs will be completed to ensure proper illumination and legibility. The lightbulbs will be changed on the exit signs located at exit door #24 and resident room [ROOM NUMBER]. The exit sign located at door #5 in the chapel was replace. All corrective measures by 6/20/23. The Maintenance Director will complete the audit tool called Monthly Emergency Exit Doors and Signs and submit to QAPI Committee for review. The QAPI Committee will make additional process changes as required based on compliance. -For K 321, Gap at top of chemical room storage door frame was repaired, Basement Loading dock: supplies were removed and stored. Latch mechanism was repaired, 2nd floor kitchenette door: Latch was repaired all by 6/20/23 .The director of maintenance will provide quarterly reports on any contracted work, cable installation, areas of penetrations, and subsequent inspections to the QAPI committee for the next 12 months. Audit results will be reported to the QA&A Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results -For K 324, The manual pull station in the kitchen was inspected by the Maintenance Director/Tech on 5/15/2023 and will be inspected monthly hereafter. The deep fryer was moved 5/15/2023. The drop down nozzles were repositioned to point at the cooking equipment. All corrective measured to be completed by 6/20/23. FSD will report audit results to QAPI Committee to ensure successful POC. QAPI Committee will ensure POC is complete. -For K 345, The facility's fire inspection vendor will will audit the entire building and the fire alarm system to ensure there are no other issues as those cited in the building. Unit 5 and 6 smoke hatches will be inspected. The electrical wiring for the Fire Alarm Control Panel (FACP) in the Maintenance Shop will be installed in conduit. Smoke detectors that failed sensitivity testing will be replaced at the following locations; Stairwell to Apartment, C Wing Diet Storage room, C Wing Med Storage room. All corrective measures completed by 6/20/23. The Maintenance Director/Designee will report to QAPI Committee when all items herein are completed. The Committee will monitor for completion and take corrective action as needed. Administrator. -For K 353, Sprinkler pipes that are in disrepair will be evaluated and replaced as needed. The sidewall sprinkler head in the elevator shaft will have the hand towel removed. The wire will be removed from the two inch diameter sprinkler piping in the maintenance shop. All corrective measure s by 6/20/2023. The Maintenance Director will also report when all jobs herein are complete to the QAPI Committee. The Committee will ensure compliance. -For K 362, missing lay-in ceiling tiles will be replaced at the following locations; the Basement, Unit 1 corridor, Unit 2 Soiled Utility room, Kitchen, C13 Dietary Storage room, A3 Wheelchair storage room, A5/A7 Therapy Storage room and A10 Storage room. All corrective measures by 6/20/23. They will also report when all the lay-in ceiling tiles are replaced and all other jobs are completed to the QAPI Committee. The Committee will ensure ongoing compliance. - For K 363, Unit 1 corridor door/Housekeeping room - penetration around door knob will be sealed, Unit 2 corridor door/Housekeeping room- penetration around door knob will be sealed, Food Service Director's office door- gaps at the top and length of doors will be repaired, First Floor Dining room double doors gap was repaired. All corrective measures by 6/20/23. Audit results will be reported to the QA&A Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results. - For K 911, duplex outlet will be repaired outside of room [ROOM NUMBER], cover plates will be replaced at; Unit 5 Nurses' Station, Unit 6 Resident Lounge, C13 Dietary Storage Room, Second Floor Minimum Data Set (MDS) Office. Electric panel doors on Unit 1, 2, 4, 5 and 6 will be locked. GFCI outlet will be installed in pit room. All corrective measure s by 6/20/2023. The Maintenance Director/tech will audit monthly for 3-months on related issues cited herein. The Maintenance Director will then inform the QAPI Committee when all items are completed and the Committee will ensure compliance. - For K 918, The facility's emergency generator will be equipped with an emergency manual stop station in an area located remotely from the generator by 6/20/23. The results of audits, inspections and tests will be discussed at QAPI monthly for 3 months to ensure corrective measures are properly implemented. Process changes will be made as needed based on findings. - For K 920, A facility-wide audit for improper electrical adapters, power strips and extension cords will be completed. Extension cords will be removed from the therapy area, the kitchen in 1b herein, the chest freezer inside room C11 and the Medical Records Storage Room. The six-outlet electrical adapter will be removed from the chapel. All corrective measures by 6/20/23. The Maintenance Director/designee will ensure completion of all items herein and will report completion to the QAPI Committee. The Committee will ensure compliance. - For K 921, an audit of all lifts and beds will be conducted by the maintenance director/designee. Lifts will be audited preventatively per the user manual and its preventative maintenance schedule. Resident beds will be inspected by maintenance every six months. All corrective measures by 6/20/23. The maintenance director will share his findings with the QAPI Committee monthly. The Committee will ensure ongoing compliance with both lifts and beds. - For K 923, An oxygen storage audit tool will be developed to ensure oxygen is properly stored by 6/20/2023. Audit results will be reported to the QA&A Committee monthly for three months. Frequency of on-going audits will be determined by the Committee based on audit results. During an interview on 7/12/23 at 10:30 AM the Maintenance Director stated they met daily with the Administrator and discussed the outstanding deficiencies. They planned to have the Maintenance Assistant correct more of the outstanding deficiencies, so the Maintenance Director could complete audits of the corrected deficiencies. The Administrator and the Maintenance Director met with the Maintenance Assistant about the plan and corrective measures were not getting completed. The Maintenance Director stated they were aware of the outstanding deficiencies. The Maintenance Director stated both the Administrator and the Regional Director of Maintenance (corporate), were aware of the outstanding deficiencies. During an interview on 7/12/23 at 11:20 AM, the Administrator stated they had meetings prior to their corrective date with the Maintenance Director, Director Of Nursing, and Food Service Director to discuss their Plan Of Correction (POC). The Administrator stated they thought they had more deficiencies from the POC addressed than what was completed. The Administrator stated they talked about the outstanding items with the Maintenance Director daily and their plan for the outstanding items was to sit down with the Maintenance Assistant to get them on task, then have the Maintenance Director complete the audits. The Administrator stated they didn't think having a full QAPI committee meeting would have helped them to get their outstanding POC items completed by their correction date. During an interview on 7/11/23 at 2:08 PM, the Administrator stated their QAPI team meets monthly and includes: the Administrator, the Director of Nursing (DON), all Managers, the Medical Director attended quarterly, and the Regional Director of Operations attended via telephone. The Administrator stated the QAPI meeting was conducted on 6/28/23, not before their correction date. The Administrator stated they were focused on deficiencies from their survey. The Administrator stated they went down the list of their POC during this QAPI meeting and identified what everyone had to do. Prior to their correction date they had small group meetings, 1:1 meetings, and in morning report they would discuss items in their POC. The Administrator stated they were aware some items weren't fixed yet and the plan was for their maintenance assistant to complete the kitchen sink items, but had trouble with them getting things done. The Administrator stated they sat down with the Maintenance Assistant to discuss what needed to be done, but things weren't getting done. The Administrator stated they contacted their Regional Director of Maintenance, but the Regional Director had not been out to the facility. 10NYCRR 415.27(c)(3)(iv)(v)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the Standard survey completed on 4/21/23, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for two (Residents #78 and 82) of three residents reviewed for transmission-based precautions and incontinence care. Specifically, transmission-based precautions were not implemented for an active infection or reflected on the care plan (Resident #82) and staff did not perform adequate hand hygiene while providing fecal incontinence care (Resident #78). The findings are: The facility policy and procedure (P&P) titled Contact Precautions revised 2/16, documented contact precautions shall be observed by all personnel to prevent transmission of infectious agents, including epidemiologically important organisms, which are spread by direct or indirect contact with the resident or the resident's environment. Contact precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increase potential for extensive environmental contamination and risk of transmission. Personal protective equipment (PPE) will be available to all potentially exposed workers. Resident's requiring contact precautions will be prioritized for private room placement. Common infections included Clostridium difficile (C-diff- bacteria in the bowel that may cause diarrhea). Requirements included a sign stating STOP, please check with the nurse's station before entering this room, acute temporary care plan, and isolation supplies for contact precautions (gloves, gown). Resident rooms will be cleaned and disinfected at least daily with a focus on frequently touched surfaces. The P&P titled Hand Hygiene revised 3/10, documented handwashing was regarded as the single most important means of preventing the spread of infection. All personnel shall wash their hands to prevent the spread of infection and disease to other residents. Handwashing must be performed when hands have been soiled, after having direct contact with resident's skin, after handling linens, after giving incontinence care, and having contact with urine and feces. 1. Resident #78 had diagnoses which included right side hemiplegia (paralysis of one side of the body), Parkinson's Disease (a disorder of the central nervous system that affects movement) and gastro-esophageal reflux disease. Review of a Minimum Data Set (MDS - a resident assessment tool) dated 2/1/23 documented the resident usually understands and sometimes was understood and was unable to complete the cognitive interview. The MDS documented the resident required extensive assistance for personal hygiene, was frequently incontinent of urine, and always incontinent of bowel. The comprehensive care plan (CCP) dated 12/23/21 documented Resident #78 had decreased self-care skills and required extensive assistance with toileting. The undated Closet Care Plan (a tool used by staff to guide care), identified as current by the Director of Nursing (DON), documented the resident was incontinent and required extensive assistance of one for toileting. During an observation on 4/19/23 at 12:58 PM, certified nurse aide (CNA) #4 applied gloves, provided incontinent care to resident and removed a large amount of feces. CNA #4 did not remove gloves and wash their hands prior to applying a clean brief, adjusting clean bed linen, adjusting call light cord and bed control. CNA #4 removed one glove from one hand, gathered the soiled linen and the soiled disposable brief in their gloved hand, removed the items from the resident's room without removing both gloves and washing their hands. CNA #4 entered the soiled work room, applied a glove to the ungloved hand, sorted the soiled disposable items from the soiled linen items, then removed their gloves from both hands and exited the soiled work room without washing their hands. During an interview on 4/19/23 at 1:08 PM, CNA #4 stated they should have removed both gloves and washed their hands after providing incontinence care and before touching clean items, the clean brief, clean linens, call light cord and bed control because of infection control and potentially cross contaminated to the clean items. CNA #4 stated they should have removed both their gloves washed hands and applied a new glove prior to leaving the resident's room with the soiled items and should have washed their hands again prior to leaving the soiled work room after disposing the soiled linens and disposable items. During an interview on 4/19/23 at 1:25 PM, Licensed Practical Nurse (LPN) #5 stated they would have expected the CNA to remove their gloves and wash their hands after providing incontinence care and before touching anything clean in the resident's room, such as the brief, bed linens, call light and bed control to prevent cross contamination to clean items and prior to leaving the resident's room. LPN #5 stated they would have expected the CNA to wash their hands after disposing of items in the soiled work room. During an interview on 4/20/23 at 1:24 PM, the DON stated they expected the CNA to remove their gloves and wash their hands after providing incontinence care, especially incontinence care with feces, and prior to touching any clean items such as bed linen, call light and bed control; and removed their gloves, wash their hands, and apply a clean glove to gather all soiled linens and disposable items prior to exiting the resident's room. The DON stated they expected the CNA to wash their hands prior to exiting the soiled work room because they sorted the soiled items. The DON stated this was a breach of infection control practices. 2. Resident #82 had diagnoses which included C-diff colitis, diabetes, and anemia. The MDS dated [DATE], documented the resident was cognitively intact and frequently incontinent of bowel. Review of Resident #82's Hospital Discharge summary dated [DATE] revealed a discharge diagnosis of C-diff colitis and they had diarrhea for several days. Despite having a seven-day course of oral vancomycin (antibiotic) they continued to have diarrhea and stool incontinence. Discharge medications included fidamoxocin (Dificid) 200 mgs (milligrams) one tablet twice daily for two more days, then take one tablet by mouth every other day for 10 doses, starting on 4/16/23. The admission and readmission Care Plan Checklist dated 4/13/23, documented Resident #82 was incontinent of stools and did not document the C-diff infection. The CCP revised 4/13/23 did not document the resident had an active C-diff infection. The Closet Care Plan revised 4/14/23, documented the resident required extensive assistance from one staff member for toileting. The Closet Care Plan did not document the resident was on contact precautions. Review of the facility's Resident Matrix (used to identify pertinent care categories for residents) provided on 4/17/23, revealed there were currently no residents on transmission-based precautions or that Resident #82 had an infection. Review of the Medication Review Report dated 4/20/23 revealed a physician's order for fidaxomicin 200mg one tablet by mouth one time a day in the morning and at bedtime with a start date of 4/13/23 until 4/15/23, then on 4/16/23 take one tablet by mouth every other morning for C-diff for 10 administrations. The nursing Progress Notes from 4/13/23 through 4/20/23 revealed no documented evidence Resident #82 was on contact precautions, had C-diff, or was monitored for bowel movements. The bowel and bladder elimination POC Response History dated 4/13/23 through 4/20/23 revealed Resident #82 was incontinent of stool on 4/14/23. Review of the facility documentation identified by Registered Nurse (RN) Assistant Director of Nursing (ADON) as the twenty-four-hour reports for Units one and two dated 4/13/23 to 4/20/23, revealed no documentation that Resident #82 had C-diff, received fidaxomicin, or was on contact precautions. The Physician's Progress Notes dated 4/17/23, documented Resident #82 had C. difficile colitis and was started on vancomycin and discharged on fidaxomicin every other day for ten days due to unresponsiveness to vancomycin. There was no documentation the resident was on contact precautions. During intermittent observations from 4/17/23 to 4/20/23 between 8:00 AM and 3:00 PM, revealed Resident #82 was in a semi-private room and had a roommate. Staff entered and exited Resident #82's room without any gowns or gloves. There were no signs posted, PPE, or disposal receptacles for soiled linens and trash upon entering Resident #82's room. During an interview on 4/19/23 at 10:06 AM, LPN #2 stated no residents were currently on precautions. LPN #2 stated precautions would be implemented for MRSA (Methicillin-resistant Staphylococcus aureus - bacteria infection), VRE (Vancomycin resistant enterococci-bacterial infection), and C-diff. LPN #2 stated there were no infections on Unit one or Unit two. During an observation and interview on 4/19/23 at 10:34 AM, CNA # 2 stated when a resident was on precautions there would be a sign on the door indicating what type of PPE was required to enter the room and no one was currently on precautions. CNA # 2 observed Resident #82's room and verified that no signs, PPE, or receptacles were present. During an interview on 4/20/23 at 10:41 AM, the Medical Director stated fidaxomicin was used to treat C-diff. C-diff was a bacteria that produced spores that landed on surfaces and could be directly touched by staff members and if they were not properly protected with PPE, may spread the infection to other residents. The Medical Director was aware of the C-diff infection and saw Resident #82 on 4/17/23 in which loose stools were reported. The Medical Director didn't realize contact precautions were not implemented. During an interview on 4/20/23 at 10:45 AM, CNA #3 stated they set up Resident #82 with the wash basin in the bathroom and collected the soiled linens. CNA #3 stated they did not wear gloves and disposed of the soiled linens into the soiled utility room receptacles. CNA #3 reviewed Resident #82's closet care plan and stated C-diff was not listed. During observation and interview on 4/20/23 at 10:46 AM, the RN ADON stated the hospital Discharge summary dated [DATE] documented C-diff was listed as a discharge diagnoses. Resident #82 should have been on contact precautions since admission and was not. LPN #3 was responsible and should have implemented contact precautions. Contact precautions included a private room, a posted sign on the door, a yellow precaution packet which included sleeves where gloves, gowns and goggles were stored on the door, and trash and linen receptacles. LPN #3 should have documented on the twenty-four-hour report for oncoming staff. During a medication administration observation on 4/20/23 at 11:54 AM, LPN #4 entered Resident #82's room and administered medications. LPN # 4 did not wear PPE. LPN #4 was unaware Resident #82 had C-diff and stated there was no sign on the door or contact precautions in place. Resident # 82 should have been in a private room to reduce the risk of infecting the roommate. LPN #4 stated precautions protected staff and other residents from the spread of infection. A telephone interview on 4/20/23 at 4:08 PM, with RN #4 revealed LPN #3 completed the admission and RN #4 co-signed the admission paperwork. RN #4 verified the paperwork had been completed and never reviewed the medications or hospital discharge summary. During an interview on 4/21/23 at 10:13 AM, LPN #3 stated contact precautions were not implemented upon admission for Resident #82. Yellow precaution packets were available and kept in the clean utility room to stock with PPE and hung on the resident's door with a sign to report to the nurse's station prior to entering the room. Linen and trash receptacles should have been placed in the room for contaminated linens and trash. Resident #82's clothing should have been washed separately for the protection of other residents. LPN #3 stated, I dropped the ball on this one. During a telephone interview on 4/21/23 at 11:02 AM, the RN Infection Preventionist (IP) stated Unit Managers were responsible for tracking infections. The RN IP reviewed the infections monthly and was unaware of the C-diff. Resident #82 should have been in a private room, and contact precautions implemented. Exposure to the roommate and unprotected staff could have caused the infection to spread. During an interview on 4/21/23 at 11:15 AM, the DON stated LPN #3 or RN #4 should have identified the infection and contact precautions should have been in place and addressed on the plan of care, so staff were able to properly take care of the resident. LPN #3 and RN #4 should have read the hospital discharge summary. Resident #82 should have been in a private room to prevent cross contamination to other residents and staff. PPE should have been worn before entering the room. 10 NYCCR 415.19(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed 4/21/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Kitchen had issues: metal frame holding ceiling tiles were curling/ peeling white paint, hoods over the ovens had a copious amount of grease stains flowing down the back of hood and wall, hand washing sinks had no soap and paper towel dispensers, one hand sink was broken with water not draining, chest freezer in basement had broken seal with ice build-up inside around the seal area, reach in refrigerator in basement was freezing items, sticky fly tape hanging from pipe in dry storage with dead flies on it, and foods either unlabeled or outdated in the refrigerators In addition, two (Unit 1/2 and Unit 5) of three unit nourishment kitchen refrigerators contained unlabeled, undated, and outdated foods. Unit 5 freezer had a 1 to 2-inch ice build-up, outside of refrigerator had a greasy substance build-up, and paper towel dispenser was broken. The findings are: The policy and procedure (P/P) titled Food Storage Refrigerator/ Freezer dated 1/2022 documented purpose is to ensure foods are stored properly to minimize spoilage and contamination, and to ensure taste and quality of food. All refrigerated foods should be labeled/ dated and discarded after three (3) days. Reach-in freezers should be defrosted as frequently as necessary to maintain efficiency according to the manufacturer's recommendations. The undated P/P titled Cleaning of Food Storage Areas documented the purpose is to ensure proper maintenance and cleanliness to storage areas. All kitchens, kitchens areas, and dining areas shall be kept clean, free from litter, rubbish, rodents, and insects. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair 1. During an observation of the main kitchen on 4/17/23 between 8:40 AM and 9:25 AM and 4/19/23 at 8:10 AM revealed the following: -The hoods over the ovens/ stoves had a copious amount of grease flowing down the back of the hood. -The two hand washing stations had no soap/ soap dispenser and no paper towels/ paper towel dispensers. One hand sink was broken as the water would not drain down leaving standing water in the sink. -The reach in chest freezer in the basement had a broken seal. There was a thick buildup of ice in the freezer. -The dry storage area in the basement had a sticky fly tape hanging from the ceiling with a multiple number of dead insects attached. -The reach in refrigerator in the basement was freezing foods close to the top of the unit. -The reach in refrigerator across from the walk-in refrigerators had three plastic containers one labeled egg salad dated 4/12/23, one unlabeled with a creamy like substance dated 4/12/23 and one labeled deli ham dated 4/12/23. -The paint of the metal frames holding the ceiling tiles in place was peeling/ curling off through the entire ceiling in the kitchen. This included the area above where food was being prepped and served. During an interview on 4/17/23 at 9:30 AM, the Food Service Director (FSD) stated the hoods over the stoves/ ovens had recently been cleaned. The FSD stated they are supposed to be getting new soap and paper dispensers in the kitchen as they have been ordered. They stated the hand sink that was backing up has been looked at by maintenance and needs to be fixed. They stated they have been using the two-compartment sink near the food prep area to wash their hands. The FSD stated the chest freezer in the basement needs to be defrosted about once a month or as needed and stated it needed to be defrosted. They stated they know the seal was broken but still feels they can use it as long as they defrost it often. They stated they do have a new chest freezer in the kitchen. The FSD stated they needed to take the fly strip down and at times had flying insects down in the basement because the delivery door gets opened a lot. They stated they know the refrigerator freezes at the top and they tend to like it that way but knows the dial needs to be turned down and will get maintenance to fix. The FSD stated protein like foods in the refrigerator should be thrown away after three days. The FSD stated they know about the paint peeling from the metal frame on the ceiling and with maintenance, they are planning on scraping the paint off the metal frames in the kitchen once maintenance was available. The FSD stated the paint could potentially fall in the food either while being prepped and served which is definitely an infection control issue. 2. Observation in the Unit 1/ 2 Nourishment Room on 4/17/23 at 9:32 AM revealed the refrigerator contained the following items: -A container of store-prepared rosemary chicken, four pieces, with no resident name or date opened, but store label stated, sell by 4/15. -A container of store-prepared pineapple chunks, about one pint, a hand-written label stated a resident room number and 4/1. -A box of commercially prepared mini tacos labeled with a resident name, box instructions include keep frozen, food was thawed. Observation in the Unit 5 Nourishment Room on 4/17/23 at 10:40 AM revealed the refrigerator contained the following items: -An opened bag of potato chips with no resident name. -An opened eight-ounce bag of sliced Swiss cheese, with no resident name or date opened, but manufacturer stamp stated, [DATE]. -An opened twelve-ounce container of French onion dip, with no resident name or date opened, but manufacturer stamp stated, sell by May 28 23. -Two opened 46-ounce containers of thickened juices with no date opened. -A commercially prepared frozen dinner, no resident name, box instructions include keep frozen, food was thawed. -Freezer had ice build- up around it 1 to 2 thick. -Paper towel dispenser was not working. During an interview on 4/17/23 at 10:50 AM, the FSD stated the dietary department was responsible for the maintenance of Nourishment Room refrigerators and a Dietary Aide checked them three times per day. They further stated Nourishment Room refrigerators were for resident food only and resident names must be on all items and items must be discarded three days after opening. At this time, the FSD was pushing a cart that contained the rosemary chicken and pineapple from the Unit 1/ 2 Nourishment Room refrigerator and stated these items, along with the Swiss cheese, French onion dip, and thickened juices from the Unit 5 Nourishment Room refrigerator must be discarded because they were not labeled with a resident's name, or a date opened. The FSD also stated they were personally doing the Nourishment Room refrigerator checks at this time because the dietary department was staff-challenged, and the unlabeled and undated items should have been caught and removed. 10 NYCRR 415.14(h) 14-1.43(e), 14-1.171(a), 14-1.143(c)

Based on observation and interview during the Standard survey started on 4/17/23 and completed on 4/21/23, the facility did not maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Issues included a sewer pipe was open and unsealed, a pit containing a sewer pipe was partially full of standing water, a toilet waste line was open and unsealed, and drains leaked from First Floor into the Basement. This affected one (First Floor) of one resident use floor and one of one Basement. The findings are: 1. Observation in the Basement A Wing on 4/18/23 at 12:25 PM revealed the building's main sewer pipe ran horizontally below Storage Room #A11 inside of a four-foot-long by four-foot-wide by five-foot-deep concrete pit. A ten-inch-wide section of the sewer pipe was open and unsealed. Continued observation through the open, unsealed section of the pipe revealed liquid was flowing through the pipe. The pit contained dark standing liquid of unknown depth. Additional observation revealed the vertical four-inch diameter PVC (polyvinyl chloride - a type of plastic) pipe and the four-inch diameter opening on the floor adjacent to the pit were also open and unsealed. 2. Observation on 4/17/23 at 11:12 AM in the First Floor unoccupied apartment at the end of the Unit 5 on 4/17/23 at 11:12 AM revealed an open and unsealed four-inch diameter toilet waste line. During an interview at the time of this observation, the Therapy Assistant stated this drain line was clogged and was successfully snaked and cleared less than one year ago, and the toilet should be put back on. 3. Observation in the Basement on 4/18/23 at 1:35 PM revealed the unnumbered room across from room #A1 measured approximately twelve feet long by six feet wide and had standing liquid covering approximately 75 percent of the floor. Further observation revealed liquid was leaking from the ceiling onto the floor and the standing liquid appeared to be one and a half inches deep at the center of the room. During an interview at the time of the observation, the Therapy Assistant stated they were not aware of this leak and they were not sure of the origin of this leak. Additionally, at this time, the Director of Maintenance from a Related Sister Facility stated either the toilet or sink drain line form above, was leaking into this room. At this time, both the Therapy Assistant and the Director of Maintenance at a Related Facility stated the room had a mildew odor. 4. Observation in the Basement on 4/18/23 at 12:15 PM revealed liquid was leaking from the ceiling area onto a wheelchair in Storage Room #A5/ A7. Continued observation revealed one ceiling tile was water-damaged and partially broken off at the location of the leak. During an interview at the time of the observation, the Therapy Assistant stated they were not aware of the leak. Additionally, at this time, the Director of Maintenance from a Related Sister Facility stated the leak appeared to be coming from a four-inch diameter toilet drain line, which was likely from a resident's bathroom above. 10NYCRR: 415.29(b)(d)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Complaint investigation (#NY00314500) during the Standard survey completed 4/21/23, the facility was not adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. Specifically, the facility did not maintain the resident call bell system in working order for three (Unit 2, Unit 5, Unit 6) of three resident care units. The findings are but not limited to: 1. The following observations and interviews were made on Unit 2: During an interview on 4/18/23 at 8:40 AM, the resident residing in #210D (door) stated the call bell had stopped working yesterday or the day before, and they can't call to get their oxygen tank replaced. The surveyor reported the non- functioning call bell concern to the floor nurse, who was not aware, and stated they would get a tap bell for the resident. 4/19/23 at 9:57 AM the call bell in room [ROOM NUMBER]D was still non- functioning. 2. The following observations and interviews were made on Unit 5: 4/17/23 at 12:34 PM in Resident room [ROOM NUMBER] (window) revealed the nurse call light cover was off the wall hanging by the wires and was continuously lit outside above the door and was continuously lit and ringing up at the nurse's station. This was observed throughout the survey on 4/18/23, 4/19/23 and 4/20/23 between 8:00 AM and 3:00 PM. During an interview on 4/18/23 at 10:30 AM, the Unit Clerk on Unit 5 stated the call light in Resident room [ROOM NUMBER] had been broken for a few weeks and it constantly rings. They stated if another call bell goes off it makes the same sound, but a different light was lit on the master board. 4/17/23 at 10:36 AM in Resident room [ROOM NUMBER]D revealed the nurse call bell cover was missing and the call light was unable to be used. A tap bell was on the over the bed tray table. During an interview on 4/17/23 at 10:28 AM, the resident that resided in #520D stated the call bell on the wall was broken for about 4 months. They stated they were given a tap bell to use but felt it was not very loud and the staff would not be able to hear it. 4/18/23 at 9:41 AM Resident room [ROOM NUMBER]W revealed the nurse call bell station cover was off the wall and wires were hanging. There was no tap bell in the room. During an interview on 4/18/23 at 9:44 AM, Registered Nurse (RN) #2 went into room [ROOM NUMBER]W and stated, you are correct the call light system is not working and that they will get them a tap bell. At 10:00 AM RN #2, stated they did not have any more tap bells. 4/17/23 at 10:49 AM Resident room [ROOM NUMBER] the call bell was non -functioning and there was a tap bell noted in the room. During an interview on 4/17/23 at 10:49 AM, the resident that resided in room [ROOM NUMBER] stated they have to use a tap bell to call for staff assist. In addition, Resident Room #s 508W, 514D and 514W had not functioning call bells. 3. The following observations and interviews were made on Unit 6: 4/19/23 at 11:30 AM the nurse call bell station for Resident room [ROOM NUMBER]W was non- functioning and no longer attached to the wall, leaving wires exposed. 4/19/23 at 11:50 AM the nurse call bell stations for Resident room [ROOM NUMBER] W and 613 D were non-functioning and no longer attached to the wall leaving exposed wires. 4/17/23 at 3:27 PM revealed the nurse call bell station in Resident room [ROOM NUMBER] was non- functioning with exposed wires and no available call cord. 4/17/23 at 3:33 PM Licensed Practical Nurse (LPN) #5 stated they have reported to maintenance the call bell in Resident room [ROOM NUMBER] was non-functioning as well as others and was told the parts were on order. 4/17/23 at 9:14 AM Resident room [ROOM NUMBER]W revealed the nurse call bell station was missing and a hole was present in the wall with exposed wires. There was no tap bell. During an observation on 4/17/23 at 12:31 PM, the call bell station cover, and call bell cord were observed on the floor behind the head of bed. During an interview on 4/17/23 at 9:14 AM, the resident who resided in room [ROOM NUMBER]W stated they call out excuse me to staff walking by to get help. Additionally, at 12:31 PM the resident stated they have reported to staff that their call bell was missing. 4/17/23 at 9:58 AM revealed the nurse call bell stations in Resident room [ROOM NUMBER]D, door side and window side, were not attached to the wall and wires were exposed. There was no tap bell noted. During an interview on 4/17/23 at 9:24 AM, the resident who resided in room [ROOM NUMBER]D stated they have not had a call light or tap bell since they were moved into the room three days ago. 4/17/23 at 12:54 PM in Resident room [ROOM NUMBER]W the nurse call bell cover was off the wall and wires were exposed coming out of wall. The cover to call bell station was observed in top drawer of nightstand. There was no tap bell available. During an interview on 4/17/23 at 12:56 PM, the resident that resided in room [ROOM NUMBER]W stated it had been a while, at least two months, since they have had a functioning call bell. During an interview on 4/17/23 at 1:40 PM, LPN #8 stated maintenance was aware of the broken call bells and were told parts were on order. Surveyor notified LPN #8 of Resident Room #s: 619W, 626W, and 628D/W, were without functioning call bells and/or tap bells. 4/18/23 at 8:43 AM and 2:42 PM, revealed Resident room [ROOM NUMBER]W remained without nurse call bell or tap bell. During an interview on 4/18/23 at 8:49 AM, Certified Nursing Assistant (CNA) #6 stated the call bell for #619W hasn't worked since they started working at the facility in March 2023. CNA #6 stated it was important for residents to have a call bell to make their needs known and for emergencies. 4/18/23 at 9:02 AM, revealed Resident room [ROOM NUMBER]D remained without a nurse call bell or tap bell. The call bell cord and call bell station cover were observed unattached from wall sitting, amongst personal belongings, at foot of the resident's bed. During an interview on 4/18/23 at 2:56 PM, LPN #5 stated they were informed by the Director of Nursing to initiate thirty-minute checks on residents without call bells at 9:00 AM today. LPN #5 stated the call bell was used by residents to communicate their needs and that all residents should have access to a call bell or tap bell. LPN #5 stated tap bells were usually available, but currently they were out of them in central supply. During an interview on 4/18/23 at 3:21 PM, CNA #10 stated the resident in #619W will use their grabber to tap on the tray table to call for assistance because they don't have a functioning call bell. During an interview on 4/18/23 at 3:29 PM, Registered Nurse Supervisor (RNS) #1 RNS #1 stated call bells were necessary for resident safety, and so prompt care can be provided. RNS #1 stated they were not aware Room #s 626W, 628 D and W call bells were not functioning and did not have a tap bell. During an interview on 4/21/23 at 11:29 AM, The Maintenance assistant stated there was no tracking system in place for routine maintenance of the call system. Mounting plates were ordered last month. When call lights weren't functioning, nursing staff verbally communicated to the maintenance department. When maintenance was unavailable or it was over the weekend, the receptionist was notified. During an interview on 4/21/23 at 11:54 AM, the Administrator stated multiple call lights were identified on Unit 5 and Unit 6 as nonfunctioning on 3/3/23. Mounting plates were ordered and they were still waiting on additional parts. Residents with nonfunctioning call lights were supplied with tap bells. The Administrator expected the CNA to report a broken call light to the nurse. The nurse verbally reported the broken call light to maintenance. When maintenance was unavailable the receptionist was notified and notified the maintenance assistant would be notified. There was no written means of communication between the nursing staff and maintenance. The Administrator stated there was no policy and procedure for maintaining the call bell system. 10 NYCRR 415.29

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during an Abbreviated Survey (Complaint NY#00263124) completed on 8/27/21, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident 58) of 21 reviewed for plan of care (POC). Specifically, the facility did not ensure Resident #58 had their abdominal (ABD) binder on as they have a history of dislodging their percutaneous endoscopic gastrostomy tube (PEG/ G-tube- feeding tube inserted into the stomach) and were not wearing heel booties, at all times (AAT), per doctors' orders plan of care. The findings are: Resident #58 had diagnoses including cerebral vascular accident (CVA-stroke) with right sided hemiplegia (paralysis of one side of body), diabetes, and hypertension (HTN-high blood pressure). The Minimum Data Set (MDS-a resident assessment tool) dated 7/16/21 documented the resident had severe cognitive impairment, usually understood, and sometimes understands. In addition, resident noted to have a feeding tube. Intermittent observations from 8/24/21 through 8/27/21 revealed the following: -8/24/21 at 12:36 PM the resident was lying in bed with the top sheet pushed off to the side. Bilateral lower extremities (BLE) were bent at the knee, resting to the left side, with heels of feet resting up near the resident's buttocks. The resident was not wearing abdominal binder or heel booties. Heel booties were observed on top of the resident's closet. There was no abdominal binder observed in the room. -8/25/21 at 11:12 AM the resident was out of bed (OOB) sitting in Broda chair. BLE as observed on 8/24/21. The resident was not wearing abdominal binder or heels booties. Heel booties were observed on top of the resident's closet. There was no abdominal binder observed in the room. -8/27/21 at 7:28 AM the resident was lying in bed as observed on 8/24/21. The resident was not wearing abdominal binder or heel booties. Abdominal binder and heel booties were not observed in the resident's room. -Additionally, intermittent observations on 8/24/21, 8/25/21, and 8/27/21 between the hours of 8:00 AM and 4:00 PM revealed the resident did not have abdominal binder or heel booties in place as per the plan of care. 1a. Review of the facility policy and procedure titled Interdisciplinary Care Plan revised 6/2017 documented the following: -The Registered Nurse (RN)/Licensed Practical Nurse (LPN) charge nurse is responsible to ensure that the POC is being followed as written. -All licensed nurses are responsible for ensuring that the care plan (CP) is carried out in the resident's daily routine. -The CP will be individualized in an easily readable guide to care -The closet CP will be a shortened version of the comprehensive care plan (CCP). This will be located at the nursing station to facilitate care by direct care givers on a daily basis and in all resident rooms. -All direct care staff will have access to the closet CP. Review of the CCP with a print date of 8/27/21 documented the following: Date initiated 9/9/20- the resident has an alteration in gastro-intestinal status related to (r/t) disease process (NPO- nothing by mouth status), resident has a G-Tube. Interventions include abdominal binder AAT except hygiene. Review of physician Order Summary Report print date of 8/27/21 revealed the following: Start date 7/2021 ABD binder AATs may remove when soiled, for bed bath/ shower, and peg tube dressing changes every shift for preventative measures. Review of Treatment Administration Record (TAR) dated 7/1/21 through 7/31/21 and 8/1/21 through 8/31/21 documented ABD binder AAT's may remove when soiled, for bed bath/shower and peg tube dressing changes every shift for preventative measure. -Between 7/1/21 through 7/31/21 revealed 26 entries of 89 were not signed out as administered. 7 entries signed out and coded with #9=Other/See Progress Notes. 1 entry signed out code #5=Hold/See Progress Notes, per the chart codes indicated on the last page of the TAR. -Between 8/1/21 through 8/31/21 revealed 23 entries of 78 not signed out as administered. 11 entries signed out and coded with #9=Other/See Progress Notes. Review of hospital discharge summaries revealed the following: -7/23/2020-PEG placement 7/20/2020 -8/06/2020-resident agitated at the facility and pulled out her PEG tube. PEG replaced. Discharge plan included dislodged PEG tube, abdominal binder at all times, PEG replaced by interventional radiology (IR) prior to discharge. -8/19/2020-Resident presents for PEG tube placement. GI consulted and replaced PEG. -6/29/21-Schedule appointment within the next day to have a PEG tube placed as a temporary catheter was inserted, this may be used until the PEG is put in. Should use abdominal binder as this well prevent recurrent dislodgement of the PEG tube. Review of EMR nursing Progress Notes dated 7/23/2020 through 9/29/2020 and 7/6/2021 through 8/27/21 documented the following: -8/5/20 at 12:30 PM-Resident sent to hospital today after they pulled their PEG tube out. -8/7/20 at 11:43 AM-Resident pulled out PEG tube. -8/8/20 at 8:14 AM- PEG tube dislocated from abdomen. Sent to ER for PEG replacement. -8/11/20 at 1:32 PM-Resident pulled out PEG tube this AM. -8/26/20 at 2:44 PM- Resident pulls at PEG tube and [NAME] all over the bed. -9/4/20 at 2:08 PM- Resident very restless, pulled out PEG tube. -9/6/20 at 3:17 PM- Resident pulled out PEG tube. -9/7/20 at 10:02 AM-PEG tube dislodged. MD updated; resident sent to ER for replacement of tube for feeding. -9/27/20-Resident resting in bed. No abdominal binder found this shift. The Progress Notes lacked documented evidence of the abdominal binder or heel booties be soiled, misplaced, or re-ordered. Review of provider Progress Notes documented the following: -7/28/2020-Resident combative at times during care and tries to pull their PEG tube. -8/5/2020-Resident pulled PEG tube out. Will send to ER for replacement. -8/7/2020-Resident has significant agitation and anxiety and has been pulling out their PEG tube. Just hospitalized for replacement of PEG and came back to facility yesterday. Today resident pulled out PEG tube again. Will send to ER for replacement. Resident would need abdominal binder. -9/4/2020- Resident has recurrent ER visits for PEG tube dislodgment and replacement multiple times with recurrent ER visits. Pulled out PEG tube again today. -9/6/2020- Resident is non -compliant with treatment and pulled PEG tube out again. -9/8/2020-Significant past medical history of non-compliance with PEG tube and is pulling out PEG tube. Has multiple hospitalization for PEG tube replacement. -10/30/2020-Resident keeps pulling her PEG tube and is intermittently combative during care. -6/28/21-Resident sent to ER due to PEG tube came out. -6/29/21-Resident pulled their PEG tube out today. Recently had replacement by ER despite resident pulled PEG tube out today. Will send to ER for replacement and continue to monitor. 7/1/21-Catheter dislodged and not functioning today. Does require PEG tube will send to hospital for further evaluation. 1b. Review of electronic medical record (EMR) Orders revealed a physician order, dated 1/27/21, bilateral heel booties, AAT's, except for hygiene every shift (QS) for support to pressure points. Review of Treatment Administration Record (TAR) dated 7/1/21 through 7/31/21 and 8/1/21 through 8/31/21 documented heel booties bilateral, AAT's, except for hygiene QS for support to pressure points. -Between 7/1/21 through 7/31/21 revealed 26 entries out of 93 not signed out as administered. -Between 8/1/21 through 8/31/21 revealed 15 entries of 78 not signed out as administered. During an interview on 8/26/21 at 8:00 AM, CNA #16 stated they have worked at the facility for about one month and have never seen an abdominal binder on the resident. If the resident had one the CNA providing care would be responsible for applying. Additionally, CNA #6 stated the resident usually has heel booties on. During an interview on 8/26/21 at 8:03 AM, LPN #8 stated Resident #58 has not had an abdominal binder in about a week. I told a Nursing Supervisor and the Director of Medical Records. Director of Medical Records does the ordering for medical devices like that. The resident gets soiled, often, so it probably went to laundry, but we need more. During an interview on 8/26/21 at 11:05 AM, the former Assistant Director of Nursing (ADON) stated Resident #58 had a history of pulling out her PEG tube frequently, that is why they have an order to wear the abdominal binder AAT's. During an interview on 8/26/21 at 12:00 PM, CNA # 6 stated they were familiar with Resident #58 CP and has provided care for the resident. They stated the resident has an abdominal binder and wears heel booties in addition to other positioning devices. CNA #6 stated CNAs are responsible for applying splints, heel booties & positioning pillows as directed on the plan of care. If we can't, for whatever reason, we should tell the nurse. During an observation of care on 8/27/21 at 8:12 AM, CNA #4 had just completed AM care. The resident was dressed and lying-in bed. Right upper extremities were bent at elbow, resting on chest, hand towards head with fingers of right hand rolled into palm. BLE were bent at the knee, resting to the left side, with heels of feet resting up near the resident's buttocks. The resident was not wearing an abdominal binder or heel booties. The CNA stated the resident will often grab at caregiver's arms during care, but is accepting of abdominal binder, heel booties and other positioning devices. CNA #4 stated the resident normally wears an abdominal binder and heel booties. They looked around the room in dresser and closet and unable to locate either. CNA #4 stated I don't see them, but the resident should have them on. I think I saw the resident wearing them yesterday, I think they had them on. I told the nurse the resident was missing their abdominal binder and heel booties. During an interview on 8/27/21 at 11:09 AM, CNA # 5 stated they were assigned and cared for Resident #58 yesterday. They stated they had just started at the facility and was just getting familiarized with the facility process. CNA #5 stated they were aware the resident is supposed to wear abdominal binder and heel booties. The CNA stated they were unable to locate the items in the resident's room, yesterday, and that is why they were not put on the resident. The CNA could not recall if they informed anyone that the binder and heel booties were not available for the resident. During an interview on 8/27/21 at 12:27 PM, CNA # 4 stated Resident #58 didn't have their abdominal binder or heel booties when I changed them. I am pretty sure the nurse is aware. During an interview on 8/27/21 at 12:30 PM, LPN #8 stated nurses are responsible to make sure the abdominal binder and heel booties are in place because that is signed off on the TAR. LPN #8 stated they were not sure why the resident was not wearing them. Maybe they got soiled and had to go to laundry, but we could always call laundry or get replacements from therapy. I told the ADON and Director of Medical Records we needed an abdominal binder and heel booties. During an interview on 8/27/21 at 2:00 PM, the Director of Medical Records stated they were not aware Resident #58 needed an abdominal binder, but they would check with the staff and order, if required. During an interview on 8/27/21 at 2:53 PM, the ADON stated they would expect the resident's CP to be followed. If something is missing that a resident requires, I tell the CNA's they should notify a nurse, therapy, and follow the chain of command to let people know what they need. The CNA told me the resident was missing some positioning devices, abdominal binder and booties, this morning. I have been working on comparing CCP and updating closet care plans to make sure they are all up to date and match. The Director of Nursing (DON) and I have a board with items that we are working on called our focus. We have a lot of issues that we need to work on, but we both just started. It is our goal to get it all done. During an interview on 8/27/21 at 3:11 PM, the DON stated she would expect staff to be familiar with a resident's CP before providing care and that interventions on the CP be implemented. I would expect staff to get items that they need to provide care. If items for care are unable to be located, I would expect the staff to let someone know, or call/walk to therapy or whatever department you needed to get what you need to provide care. Additionally, the DON stated Resident #58 should definitely have an abdominal binder, with the history of pulling the PEG, and heel booties if that is what is ordered and on the plan of care. If the items were soiled and went to laundry, I would expect the resident to have more than one, so they had the items AATs as ordered. 415.12

Based on observation, interview, and record review conducted during a Standard survey completed on 8/27/21, it was determined that the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene for one (Resident #29) of two residents reviewed for incontinence care. Specifically, the Certified Nurse Aide (CNA) provided incomplete AM (morning) and incontinence care. The finding is: 1. Resident #29 had diagnoses which include major depressive disorder, peripheral vascular disease (poor circulation) and sacral (area between base of spine and tailbone) pressure ulcer. The Minimum Data Set (MDS- a resident assessment tool) dated 6/15/21 documented the resident was cognitively intact, required extensive assistance of one person for personal hygiene, and did not exhibit behaviors or refuse care. The facility policy and procedure (P&P) titled Incontinent Care dated 2/2015 documented to keep the resident who is incontinent clean, dry, and comfortable; equipment included wash cloth, towel, soap and water or peri-wash product; procedure included wash hands, don gloves, wipe buttocks removing all feces with toilet paper, place in bedpan, place bath towel on bed alongside of back and buttocks, wash, rinse and dry soiled body areas, remove gloves and wash hands. The facility P&P titled Hand Hygiene dated 3/2/2010 documented: all personnel shall wash their hands to prevent the spread of infection and disease, appropriate 15 second handwashing must be performed after and in some cases before the following conditions: after giving incontinence care, after handling items potentially contaminated with blood, urine, feces, the use of gloves does not replaced handwashing. During an observation of AM care on 8/26/21 at 9:31 AM, CNA #16 gathered one towel and one wash cloth, wet half of the towel with water from the bathroom sink, added soap to the towel and cleansed the resident's peri (genital) area. CNA #16 did not rinse or dry the peri area. CNA #16 used the same end of the wet towel and cleansed the resident's buttocks, removed feces, and did not rinse or dry the resident's buttocks. Wearing the same gloves, CNA #16 readjusted the resident's clean clothing, bedding and moved the tray table. CNA #16 was then observed to remove gloves, wash hands, applied a new pair of gloves, used gloved hands and separated the soiled brief from the soiled linen. Wearing the same gloves, CNA #16 moved the resident's tray table, opened the drawer of the nightstand, and applied lotion to the resident's legs. CNA #16 did not use a basin of water or clean the resident's chest, armpits, or back during AM care. During an interview on 8/26/21 at 9:44 AM, CNA #16 stated AM care included washing the resident's peri area and buttocks and they don't offer to clean under the resident's breasts or arms, back and other areas of the body unless the resident had an odor. CNA #16 stated they only used a basin with water when providing a complete bed bath. CNA #16 stated they did not rinse or dry the resident's skin and used a towel to wash the resident although the facility had enough linens. CNA #16 stated they would change gloves and wash hands when visibly soiled and had no knowledge if gloves were to be changed and hands washed between soiled and clean areas. CNA #16 stated they have not had any incontinent care or AM care training at the facility. During an interview on 8/26/21 at 1:56 PM, Resident #29 stated it bothered them that CNA #16 didn't wash beneath their breast and armpit area or use washcloths, a basin and rinse and dry their skin. During an interview on 8/26/21 at 2:19 PM, the Administrator stated they expected the staff to use appropriate linens, wash cloths, towels and basins while providing care, ensuring the resident's skin was washed, rinsed and dried. The Administrator also stated at a minimum staff should be changing gloves and washing hands after providing incontinent care before proceeding to a clean area of a resident or environment. During an interview at 8/26/21 at 4:25 PM, the Director of Nursing (DON) stated AM care consisted of the staff washing the resident's entire body, not just the peri area or buttocks and supplies included washcloths, towels, soap, and a basin with water. The DON stated at a minimum CNA #16 should have used a basin with water, towels and washcloths; washed the resident's entire body, rinsed and dried the resident's skin and after removing the feces CNA #16 should have changed gloves and washed their hands before touching anything clean for infection control purposes. The DON stated agency staff were educated and competencies were completed upon hire for AM care and incontinence care. Upon review of CNA #16's education file, DON stated there were no incontinence care or AM care education documents and competencies. The DON stated the facility does not have a policy specifically related to AM care. 415.12 (a)(3)

Based on observation, interview, and record review conducted during the Standard survey completed on 8/27/21, the facility did not ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for one (Resident #34) of one resident reviewed for respiratory care. Specifically, oxygen (O2) was not administered in accordance with the physician's order, oxygen concentrator filter was dirty and covered with white debris, and the oxygen tubing was not dated and documented when changed. The finding is: The facility's undated policy and procedure (P&P) titled Oxygen Supplies and Concentrator documented that the facility will maintain an adequate supply of oxygen concentrators, nebulizers, tanks, and supplies. The policy did not include the care and maintenance of the concentrator and tubing. 1. Resident #34 was admitted to the facility with diagnoses which included chronic obstructive pulmonary disease (COPD), anxiety disorder and unspecified heart failure. The Minimum Data Set (MDS- a resident assessment tool) dated 6/23/21 documented Resident #34 was cognitively intact. Review of the Comprehensive Care Plan (CCP, identified as current) dated 8/12/20 documented Resident #34 had an alteration in their respiratory status related to a diagnosis of COPD and used oxygen. Interventions included to monitor for difficulty breathing, signs and symptoms of acute respiratory insufficiency, and monitor for signs and symptoms of respiratory infection. The CCP did not address oxygen administration and equipment maintenance. Review of an Order Summary Report dated 8/26/21 revealed an active order to administer oxygen as needed (PRN) for shortness of breath (SOB) via nasal cannula (NC) at 2 liters. There were no physician orders to address oxygen tubing changes or concentrator filter cleaning. Review of the Medication Administration Records (MARs) and the Treatment Administration Records (TARs) for Resident #34 dated 7/1/21 to 7/31/21 and 8/1/21 to 8/31/21 revealed that the oxygen administration order was not transcribed or signed as administered by staff. In addition, the MAR and TAR did not address the oxygen tubing changes and concentrator filter cleaning. During observations on 8/23/21 at 10:44 AM, 8/25/21 at 10:52 AM, 8/25/21 at 1:28 PM, 8/26/21 at 8:30 AM and 8/27/21 at 8:13 AM revealed Resident #34 received oxygen at 3 liters via nasal cannula by an oxygen concentrator. In addition, the O2 concentrator filter was dirty and covered with white debris, and the O2 tubing was undated. During interview on 8/26/21 at 8:24 AM, Licensed Practical Nurse (LPN) #1 reviewed Resident #34 physician's orders and stated Resident #34 had an order for oxygen PRN at 2 liters via nasal canula. LPN #1 then reviewed Resident #34's MARs/TARs and stated they could not locate the information regarding oxygen administration, oxygen tubing changes and concentrator care. LPN #1 stated stated oxygen administration and tubing changes should be documented on the MAR or TAR. LPN #1 stated it was the nurse's responsibility to change the oxygen tubing but did not know how often the tubing should be changed. Additionally, LPN #1 stated they were unsure but thought that maintenance handled O2 concentrator care. At the time of the interview 8/26/21 at 8:24 AM, LPN#1 observed Resident #34's oxygen liter flow and stated Resident #34 was receiving oxygen at 3 liters via nasal cannula around the clock because this was the resident's preference. LPN #1 stated they were aware Resident #34 was receiving 3 liters of oxygen and that the order was for 2 liters. LPN #1 also stated the expectation with a discrepancy would be to notify the nurse manager or supervisor to get the order changed because we can't give oxygen without an order. During an observation and interview on 8/26/21 at 8:52 AM, Registered Nurse Supervisor (RN) #1 observed Resident #34's oxygen flow rate and stated the resident was receiving oxygen at 3.5 liters via nasal canula and that the oxygen concentrator was filthy. RN #1 reviewed the physician's orders and stated the oxygen order was for 2 liters via nasal canula PRN for SOB and that the resident was not receiving the proper liter flow of oxygen. RN #1 stated that oxygen tubing was to be changed every Sunday on the night shift and the information should be on the TAR. In addition, RN #1 stated that they have never seen an order for concentrator filer cleaning. During an interview on 8/26/21 at 10:12 AM, the Assistant Director of Nurses (ADON) stated they were unsure who was responsible for oxygen concentrator care. There should be an order for O2 tubing changes, and the tubing should be changed by the nurses. The ADON stated they were not sure of the time frame tubing should be changed but thought it was once a week. In addition, the ADON stated that O2 tubing should be labeled, dated, timed, and signed in TAR. During an interview on 8/27/21 at 12:17 PM, the Maintenance Director stated oxygen concentrators in use were the nursing departments responsibility and that they have not changed filters since being employed by the facility. The Director stated that they had no logs or tracking system in place but believed that the therapy assistant handled the tracking. During an interview on 8/27/21 at 12:20 PM, the Director of Nurses (DON) stated the nursing staff were expected to follow the physician's orders for oxygen. If a discrepancy was found, the order should be checked and clarified with MD if needed. The DON stated staff should only adjust a resident's oxygen liter flow in an emergent situation, and if staff did adjust the O2 liter flow; the expectation would be to call provider and assess the resident's respiratory status. If a resident with COPD oxygen is adjusted, they can retain carbon dioxide which could cause lethargy and confusion. The DON stated O2 concentrator filter care was completed by the therapy assistant and maintenance but did not know how often the filter should be changed/cleaned or how the facility tracked. The DON stated it was important to change the O2 concentrator filter because dirt and debris could cause possible infections. The DON stated oxygen tubing was to be changed every week on Sunday nights and should be documented in the MAR/ TAR and. O2 tubing should be labeled with date and time. An attempted was made to interview the therapy assistant on 8/27/21 at 1:30 PM without success. During an interview on 8/27/21 at 3:30 PM, the Assistant Administrator stated there was no facility policy available to address oxygen use and care of the respiratory equipment (tubing, concentrator). 415.12(k)(6)

Based on observation and interview during the Standard survey completed on 8/27/21, the facility did not dispose of garbage and refuse properly. Specifically, waste was not properly contained outside of the facility in closed dumpsters, and torn bags of garbage and loose debris were observed on the ground behind the dumpsters, which created potential feeding and harborage areas for pests. The finding is: Observation on 8/23/21 at 9:40 AM revealed two cardboard dumpsters and two garbage dumpsters were located behind the facility. Further observation revealed one torn garbage bag on the ground outside of the garbage dumpsters, and garbage items from this torn bag, which included food debris and dirty food plates, were strewn around the surrounding grass in a 20-foot diameter area. A bee trap was observed hanging on one of the garbage dumpsters and many live bees were observed in the vicinity. On the ground to the right of the garbage dumpsters were an intact garbage bag under a pile of dried brush, a broken tent, a bed frame, three air conditioning units, a vacuum, and several chairs. Additionally, at this time, a 45-gallon uncovered garbage can was observed across the driveway from the garbage dumpsters and it was filled with food wrappers and packaging. A second observation and interview of the exterior garbage storage area on 8/26/21 at 8:10 AM with Dietary Aide #2 revealed four dumpsters with the side doors open on each, garbage observed on the ground near the dumpsters and on the lawn behind the dumpsters. Dietary Aide #2 stated the birds take the garbage out of the dumpsters and does not know who is responsible to ensure the dumpsters' doors are closed and who is responsible to clean up around and behind the dumpsters. A third observation of the exterior garbage storage area on 8/26/21 at 8:20 AM revealed a woodchuck on the lawn near garbage that was spread out, including three large clear plastic bags against the tree line on the lawn, gloves, Styrofoam plates, cups and bowls, and a plastic bleach bottle spread out in over a 50 foot long by 50-foot-wide area. A fourth observation of the exterior garbage storage area on 8/26/21 at 9:00 AM revealed multiple torn garbage bags on the ground behind the dumpsters and milk cartons, dirty food plates, food debris, and juice containers were strewn around the surrounding grass. Additionally, the intact garbage bag under the pile of dried brush and the other items on the ground to the right of the garbage dumpsters remained. During an interview at the time of the fourth observation, the Director of Housekeeping stated every department uses these garbage dumpsters and it is a team effort to maintain the area. The Director of Housekeeping also stated the torn garbage bags on the ground must have just happened because someone from Housekeeping or Dietary should pick this up when they see it. The Director of Housekeeping further stated the dumpsters' lids and sliding doors must be kept closed because woodchucks are around the area and they can get into the dumpsters, and the bees are a recent issue, but did not know a specific length of time. During an additional interview at the time of the fourth observation, the Maintenance Assistant stated the Housekeeping, Maintenance, and Dietary departments maintain the dumpster area and the lids and sliding doors on the dumpsters are supposed to be kept closed. The Maintenance Assistant further stated there is at least one raccoon in the area and raccoons might be able to drag garbage out of the dumpster, but they could not say for sure because they are not here to know what happens at night. The Maintenance Assistant also stated the Maintenance department cleans the area behind the dumpsters to the property line, they last cut the lawn in this area on 8/22/21, and they were unsure how long the garbage bag had been on the ground under the pile of dried brush. During an interview on 8/26/21 at 2:15 PM, the Administrator stated the dumpsters should be closed at all times when not in use and it is the responsibility of all the departments that place garbage in the dumpsters to ensure that the doors are closed and the garbage is picked up; Dietary, Maintenance, and Housekeeping. The Administrator further stated; there are wild animals close by because the property is located next to protected land and the dumpsters should always be closed when not in use. During an interview on 8/26/21 at 5:25 PM, the Assistant Administrator stated the facility did not have a policy on garbage storage. 415.14(h) 14-1.150

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 8/27/21, the facility did not maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19 for one (Resident #289) of three residents reviewed for transmission based precautions (TBP). Specifically, the facility did not ensure a newly admitted , unvaccinated resident was placed on TBP (including appropriate room signage) and staff did not wear required Personal Protective Equipment (PPE) when in direct contact with the resident. The finding is: CDC (The Centers for Disease Control and Prevention) guidelines titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes updated 3/29/21 documented all unvaccinated residents who are new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. CDC guidance titled Transmission-Based Precautions (undated), documented: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal Protective Equipment (PPE) upon room entry and properly discarding before exiting the patient room is done to contain pathogens. Review of a facility policy titled Admissions during a pandemic Social leaves/appointments/visitation/for COVID-19 revised 6/2021 documented: admitted residents required a negative test result within the last 72 hours - unless proof of vaccine, if no vaccine must quarantine for 10 days. 1. Resident #289 was admitted to the facility on [DATE] with diagnoses including dementia, hypertension, and major depressive disorder. The Brief Interview for Mental Status (BIMS, a resident assessment tool) dated 8/17/21 documented the resident was severely cognitively impaired. During an observation on 8/23/21 at 11:02 AM, Resident #289 was not wearing a surgical mask and was sitting in the dining room. The resident's room door did not have a sign that indicated the resident was on TBP and there was no PPE set up on the door. Review of the Resident's progress notes dated 8/17/21 through 8/23/21 revealed there was no documented evidence the resident was placed on TBP. Review of the comprehensive care plan dated 8/17/21 and the undated Closet Care Plan revealed there was no documented evidence the resident was placed on TBP. Review of the 24 hour shift report dated 8/17/21 through 8/23/21 revealed there was no documented evidence the resident was placed on TBP. During an interview on 8/24/21 at 9:07 AM, Certified Nursing Assistant (CNA) #1 stated they had provided care to Resident #289 on 8/19/21 and 8/20/21 and did not wear PPE because the resident was not on precautions. During an interview on 8/24/21 at 9:31 AM, Physical Therapist (PT) #1 stated Resident #289 was not on precautions on 8/18/21 when the resident was evaluated in their room. PT #1 also stated the resident was not on precautions on 8/19/21 and 8/20/21 when therapy was provided in the therapy room and staff were not wearing PPE. PT #1 stated they knew when a resident was on precautions when the room had a precaution sign and a PPE set up on the door; this resident didn't have either. PT #1 stated if the resident was on precautions, they would have provided therapy in the resident's room and worn a gown, gloves, eye protection and a surgical mask in the resident's room. During an interview on 8/23/21 at 11:17 AM, the Assistant Director of Nursing (ADON) acting Nurse Manger for Unit 6, stated she didn't know if new admission residents were to be placed on precautions and would need to ask the DON. During an observation on 8/23/21 at 11:21 AM, Occupational Therapist (OT) #2 transported Resident #289 from the dining room down the hallway and was over-heard stating they were taking the resident to therapy. During further interview on 8/23/21 at 11:22 AM, the ADON stated she spoke to the Director of Nursing (DON) who said newly admitted residents were to be on TBP and quarantined in their room for 10 days from admission date. The ADON stated the Occupational Therapist (OT #2) was stopped in the hallway and directed to transport Resident #289 to the resident's room because they should be on precautions and treated in their room. During an observation and interview on 8/23/21 at 11:27 AM, OT #2 was in Resident #289's room, wearing a surgical mask and no other PPE while in direct contact with the resident. OT #2 stated, they were uncertain of the facility protocols for unvaccinated, newly admitted residents and didn't know if the resident was on precautions. OT #2 stated they were not informed Resident #289 was on precautions and were directed by ADON to take the resident to their room. During an observation of Resident #289's room on 8/23/21 at 11:33 AM, the ADON stated the room needed to have a TBP sign and a set up was needed in the doorway to ensure staff were aware the resident was on precautions. The ADON stated she had not informed OT #2 the resident was on precautions. During an interview on 8/23/21 at 3:21 PM, the DON stated Resident #289 was not vaccinated and should have been on precautions since admission date of 8/17/21. The DON stated therapy should have been provided at bedside and the resident should not have been out of their room. The DON stated the ADON should have immediately informed the therapist the resident was on precautions to prevent OT #2 from initiating therapy in the room without proper PPE. During an interview on 8/23/21 at 3:26 PM, the Administrator stated the nursing staff should have ensured Resident #289 was placed on precautions. During an interview on 8/26/21 at 10:41 AM, the DON stated staff should have been wearing PPE while providing direct care and therapy should have been provided in the resident's room. 10 NYCRR 415.19(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview completed during the Standard survey completed 8/27/21, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, one (Resident #58) of two residents reviewed for range of motion (ROM-normal range of motion for a joint) services was not provided with an air carrot (assistive device that positions the fingers away from the palm) to their right hand, and pillows for leg positioning as recommended by Occupational Therapy (OT) and Physical Therapy (PT). The finding is: Review of the facility policy and procedure (P&P) titled Range of Motion and Assistive Devices with Activities of Daily Living revised 11/13/18 documented every effort will be made to ensure that residents do no lose ROM of activities of daily living (ADL) abilities unless the loss is unavoidable. Additionally, it documented the following: -Therapy staff will work with nursing staff to identify the most reasonable and attainable plan for ADL and ROM assistance. -Information on the ADL/ROM assistance plan will be included in the Comprehensive Care Plan (CCP) and Certified Nurse Aide (CNA) Closet Care Plan. -CNAs are expected to assist with ADLs and ROM at all times (AAT) in accordance with the care plan (CP). -If the residents CP for ADL and ROM assistance cannot be carried out for any reason the Nurse Manager (NM)/designee will be notified immediately. -A nurse will discuss CNA concerns with the CNA and may observe and document on the provision of ADL and ROM assistance if appropriate. Review of the facility P&P titled Interdisciplinary Care Plan revised 6/2017 documented the following: -The Registered Nurse (RN)/Licensed Practical Nurse (LPN) charge nurse is responsible to ensure that the POC is being followed as written. -All licensed nurses are responsible for ensuring that the CP is carried out in the resident's daily routine. -The CP will be individualized in an easily readable guide to care -The closet CP will be a shortened version of the CCP. This will be located at the nursing station to facilitate care by direct care givers on a daily basis and in all resident rooms. -All direct care staff will have access to the closet CP. 1. Resident #58 had diagnoses including cerebral vascular accident (CVA-stroke) with right sided hemiplegia (paralysis of one side of body), diabetes, and hypertension (HTN-high blood pressure). The Minimum Data Set (MDS-a resident assessment tool) dated 7/16/21 documented severe cognitive impairment. Resident is usually understood and sometimes understands. Section G documented no impairment of upper extremity and lower extremity impairment on both sides. The MDS dated [DATE] documented upper extremity impairment on one side and no impairment of lower extremity. Review of CCP with a print date of 8/27/21, documented the following: Date initiated of 9/2/20- Limited self-care skills related to (r/t) weakness with intervention: right upper extremity (RUE) air carrot guard AATs remove, hygiene, ROM, and hour of sleep (HS). Date initiated 11/18/20- Limited physical mobility r/t stroke with interventions including place positioning device behind bilateral (B) knees in bed and in Broda Chair (tilt-in-space positioning chair). ROM/stretching may need to be provided to optimize lower extremity (LE) positioning prior to device placement. AAT except hygiene. Reposition as needed (prn). Review of the undated Closet Care Plan (guide used by staff to provide care), identified by staff as current, documented daily reminders: right upper extremity (RUE) air carrot guard AATs, remove for meals, hygiene, ROM, and hour of sleep (HS). Additionally, positioning device behind bilateral lower extremity (BLE-knees). ROM/stretching may need to be provided to optimize LE positioning prior to device placement. AAT except hygiene. Reposition prn. Review of the OT-Therapist Progress & Discharge summary dated [DATE] documented the resident was discharged from skilled OT treatment demonstrating improvement in ROM of RUE allowing for an upgrade in splint option previously utilizing a palm guard (assistive device that positions the fingers away from the palm) in R hand to an air carrot which encourages increased web space, with good response from resident. The summary documented in-service training completed with care givers/staff for donning (putting on)/doffing (removing) of splint, as well as wear scheduled. The discharge summary included documentation of verbal and visual demo dated 6/10/21, presented by the OT, for the care giver to be able to don/doff R air carrot scheduled for AATs except for ROM, hygiene, HS. Review of the PT-Therapist Progress & Discharge summary dated [DATE] documented the resident was see in skilled PT to improve ROM. The resident was discharged with plan to continue to use positioning pillows to optimize leg positioning. The summary documented caregivers were informed on the use of pillows to improve leg positioning. Intermittent observations from 8/24/21 through 8/27/21 revealed the following: -8/24/21 at 12:36 PM the resident was lying in bed with the top sheet pushed off to the side. RUE was bent at elbow, resting on chest, hand towards head with fingers of right hand rolled into palm. BLE were bent at the knee, resting to the left side, with heels of feet resting up near the resident's buttocks. There was no air carrot in R hand, no positioning pillows in the legs/knees. There were no pillows or air carrot observed in the resident's room. -8/25/21 at 11:12 AM the resident was out of bed (OOB) sitting in Broda chair. RUE and BLE as observed on 8/24/21. The resident did not have air carrot in R hand and no positioning pillows in the legs/knees. There were no pillows or air carrot observed in the resident's room -8/26/21 at 8:03 AM the resident was out of bed sitting in Broda chair. RUE and BLE as observed on 8/25/21. The resident did not have air carrot or positioning pillows in place. There were no pillows or air carrot observed in the resident's room. -8/27/21 at 7:28 AM the resident was lying in bed as observed on 8/24/21. There was no air carrot in R hand and no positioning pillows in the legs/knees. There were no pillows and air carrot observed in the resident's room. -Additionally, intermittent observations on 8/24/21, 8/25/21, and 8/27/21 between the hours of 8:00 AM and 4:00 PM revealed the resident did not have air carrot on r hand and positioning pillows behind legs. During an interview on 8/26/21 at 12:00 PM, CNA # 6 stated they were familiar with Resident #58 CP and has provided care for the resident. They stated the resident wears a splint on the R hand and has used extra pillows for positioning of legs. CNA #6 stated CNAs are responsible for applying splints, heel booties & positioning pillows as directed on the POC. If we can't, for whatever reason, we should tell the nurse. During an observation of care on 8/27/21 at 8:12 AM, CNA #4 had just completed AM care. The resident was dressed and lying-in bed. RUE was bent at elbow, resting on chest, hand towards head with fingers of right hand rolled into palm. BLE were bent at the knee, resting to the left side, with heels of feet resting up near the resident's buttocks. There was no air carrot in R hand and no positioning pillows in the legs/knees. CNA #4 attempted to demonstrate ROM to surveyor, but resident grabbed CNA with their left hand and pushed the CNA #4 arm away. CNA #4 attempted another time and resident grabbed CNA with their left hand and pushed the CNA's arm away. The CNA stated the resident will often grab at caregiver's arms and not allow ROM to be completed but is accepting and will allow placement of splint and positioning pillows. CNA #4 stated the resident normally wears a splint in the R hand and leg pillows. They looked around the room in dresser and closet. There were pictures taped and hanging inside of the closet door demonstrating positioning pillow placement. CNA #4 stated I don't see the resident's splint, but they should have them on. I think I saw the resident wearing them yesterday, I think the resident had them on. I will have to get more pillows. I told the nurse the resident was missing their splint. During an interview on 8/27/21 at 11:09 AM, CNA # 5 stated they were assigned and cared for Resident #58 yesterday. They stated they had just started at the facility and was just getting familiarized with the facility process. CNA #5 stated they were aware the resident is supposed to have a splint and positioning pillows. The CNA stated they were unable to locate the splint or positioning pillows in the resident's room yesterday and that is why they were not put on the resident. During an interview on 8/27/21 at 11:45 AM, OT #1 stated the resident previously had a palm guard but was recently upgraded to an air carrot because it's wider and allows more web space and is more comfortable in the hand. They stated the resident was recently on therapy program and did not have a decline in ROM. The purpose of the air carrot is to maintain ROM from further decline. OT #1 stated the CNAs and nurses were educated on don/doff of the air carrot. It is to be worn AATs except ROM, hygiene, and HS. CNAs would be responsible for applying the air carrot. OT #1 stated they were not aware the resident did not have an air carrot in their room, but staff could come to therapy, at any time, to get an additional or replacement. During an interview on 8/27/21 at 12:02 AM, PT #1, with Physical Therapy Assistant (PTA) present, stated the resident was recently in the therapy program for BLE contracture management. They stated the resident was compliant with keeping the LE pillow positioners in place and the expectation were to have them placed AATs, in bed and OOB. The PTA stated in-service education was provided for staff on placement of pillows and PT stated pictures of placement were posted in the resident's closet for staff to see how/where the pillows are expected to be placed. The PT #1 stated they would expect any issues with positioning pillows to be documented in the progress notes or therapy to be notified so they could follow up for additional interventions, if required. During an interview on 8/27/21 at 12:30 PM, Licensed Practical Nurse (LPN) #8 stated CNAs were responsible for placement of Resident #58 air carrot and positioning pillows as that is not something that is signed off on the TAR. LPN #8 stated they were not sure why the resident was not wearing them or why the air carrot and positioning pillows were not in place. Maybe they got soiled and had to go to laundry, but we could always call laundry or get replacements from therapy. LPN #8 stated they had seen PT placing the positioning devices recently and thought they did it. During an interview on 8/27/21 at 2:53 PM, the Assistant Director of Nursing (ADON) stated they had been working on updating CCPs and closet CPs to make sure they matched. If a resident has recommendations from therapy and is care planned for splints/positioning devices the expectation is that they are to be implemented and in place. I would expect CNAs to follow the chain of command if something is not available or they need assistance with care items. Let the nurse know, me, the Director of Nursing (DON) so we can get what they need for the resident. They could also get assistance with positioning devices from Therapy department. During an interview on 8/27/21 at 3:11 PM, the DON stated they would expect staff to be familiar with a resident's CP before providing care and that interventions on the CP be implemented. I would expect staff to get items that they need to provide care. If items for care are unable to be located, I would expect the staff to let someone know, or call/walk to therapy or whatever department you needed to get what you need to provide care. 415.12(e)(2)

Based on observation, interview and record review conducted during an Abbreviated survey (Complaint # NY00253925) completed during the Standard survey on 8/27/21, the facility did not ensure that each resident received adequate supervision to prevent accidents for one (Resident #15) of one resident reviewed. Specifically, Resident #15 eloped while out at an appointment at a local hospital on 3/12/20. The finding is: Review of the policy and procedure titled, Wander/Elopement Risk Assessment dated 11/2004 documented once a resident has been identified as being at risk for elopement and preventative interventions have been implemented appropriate documentation from all departments will be checked and be kept in the resident's permanent record. Modes of communication include but are not limited to (a) Resident's care plan; (b) Elopement list; (c) Check in/out logs will be used if and when a resident leaves or returns form the facility to the unit with RP (responsible party). Resident #15 had diagnoses which included schizophrenia, anxiety, multiple substance abuse, aphasia (loss of ability to understand or express speech, caused by brain damage) and a history of traumatic brain injury (TBI) with subdural bleed. The Minimum Data Set (MDS-a resident assessment tool) dated 12/23/19 documented the resident had unclear speech, usually understands, usually understood and has moderately impaired cognitive skills for daily decision making. The MDS documented the resident had physical behavioral symptoms toward others, verbal behavioral symptoms toward others, other behavioral symptoms not directed toward others, rejection of care and wandering occurring daily. Review of the Wandering/Elopement Risk Assessment dated 8/15/2019 documented Resident #15 was at risk to wander. Review of the Comprehensive Care Plan (CCP) initiated date of 8/26/2019 documented Resident #15 is a wanderer related to disoriented to place, impaired safety awareness and wanders aimlessly at times with. Interventions included: distract resident from wandering, identify pattern of wandering and wander guard placed on left wrist. Resident has a behavior problem from recent TBI related to increased agitation, pacing on unit and intermittent verbal outburst. Interventions included: staff to re-approach with a firm tone, redirect and give resident time out to relax. Resident has potential to be verbally aggressive related to mental/emotional illness, diagnosis of Schizophrenia. Interventions included: staff to intervene with agitation before it escalates, guide away from source of distress and engage in calm conversation. Resident #15 noted to be independent with no assistive devices needed for transfers and ambulation. Review of the Progress Notes dated 3/12/20 at 4:36 PM the former Director of Nursing (DON) #1 documented at 11:06 AM writer received a phone call that resident was out of facility on an appointment at hospital and CNA #2 was unable to locate the resident. This writer spoke with the CNA #2 who then proceeded to explain that the resident was on an appointment and became irate with staff including the nurses. When the staff and CNA #2 redirected the resident to calm down, the resident was standing next to the CNA #2 and then the CNA #2 stated they proceeded to ask the hospital staff if the resident needed anything else, attempted to call for transportation to pick them back up. When the CNA #2 turned their back, the resident left and was unable to relocate the resident. Review of the Progress Notes dated 3/13/20 at 10:34 PM the former Assistant Director of Nursing (ADON) documented Resident #15 return to facility around 9:00 AM by a staff member who saw the resident standing on a street corner and picked them up and brought them back to the facility. The resident was unable to clearly state what happened. Resident showered and given a head-to-toe assessment with no open areas, bruising or injury. The resident was fed and laid down. Review of the Progress Note completed by the Nurse Practitioner (NP) dated 3/13/20, revealed that nursing staff requested Resident #15 to be seen due to the resident was out for one day after they became irritated and walked out of room and could not be located in the hospital. The NP note revealed that Resident #15 was alert to self with confusion and their baseline mentation remained stable. Review of the document titled Elopement dated 3/12/20 at 11:30 AM revealed the resident eloped from local area hospital. The resident became irate with staff. CNA #2 redirected the resident to calm down and had the resident stand next to them. CNA #2 completed talking to the hospital staff, called for return transportation and when CNA #2 turned their back to the resident, the resident was no longer standing there. The document revealed the facility Administrator contacted hospital security and when hospital cameras were reviewed it revealed resident was seen leaving hospital at approximately 11:00 AM. During intermittent observations between 8/23/21 through 8/27/21 Resident #15 was noted to walk around the facility's first floor at will. Resident #15 was noted wearing a wander guard bracelet on the left wrist. During an interview on 8/25/21 at 4:24 PM CNA #2 stated that on 3/12/20 they went with Resident #15 on a transport to the local area hospital for an appointment. CNA #2 stated they were an agency CNA and that prior to going on the transport, they knew Resident #15 walked around the facility but was not aware that the resident had a potential for walking away. CNA #2 stated they do not believe that they ever had Resident #15 on their assignment and that the facility did not provide them with a care plan for Resident #15 prior to leaving for the transport. CNA #2 stated that when Resident #15 returned to the waiting area, the hospital staff stated they had paperwork to give to the facility. CNA #2 stated that they toileted Resident #15 and they went up to the staff desk to retrieve the paperwork. CNA #2 stated that Resident #15 was standing about two steps behind them and when they turned back toward the resident, Resident #15 was no longer standing there. CNA #2 stated that they checked the bathroom and went back out the way they came in searching for the resident. CNA #2 stated they called the facility, spoke with the former DON #1, the Administrator, and the hospital security desk. CNA #2 stated within the hour the former DON came to the hospital and they both searched the grounds and local streets around the hospital looking for Resident #15 without success. CNA #2 stated that they were provided counseling/education after the incident in regard to never taking their eyes off a resident while going on an out of facility appointment. During a telephone interview on 8/26/21 at 10:51 AM the former ADON stated they were the Unit Manager of Unit's 1 and 2 in 3/2020. The former ADON stated they completed a head-to-toe assessment upon Resident #15's return to the facility on 3/13/20 with no injuries or distress noted. The former ADON stated that CNA #2 was an agency staff member that worked on and off the unit and should have been aware of Resident #15 having the potential to walk away. The former ADON stated that they were unaware if CNA #2 was given a care plan or education that Resident #15 had the potential of elopement prior to leaving for the transport. During a telephone interview on 8/26/21 at 2:08 PM the former DON #1 stated Resident #15 walked away from CNA #2 while their back was turned while on an escort to an appointment at a local area hospital. The former DON #1 stated Resident #15 returned to the facility in a staff members car the next morning after the staff member saw him standing on a street corner. The former DON #1 stated CNA #2 was an agency staff member, that the CNA was familiar with Resident #15 and CNA #2 was assigned to the resident prior to 3/12/20. The former DON #1 stated CNA #2 was asked to go on the escort because of the gender of CNA #2 and Resident #15 was sometimes hard to redirect. The former DON #1 stated that Resident #15 had no prior history of elopement in the facility and is unsure if CNA #2 was given a care plan prior to transport. During an interview on 8/26/21 at 2:50 PM the Administrator stated that Resident #15 had an appointment at the hospital and walked away from CNA #2 and left the hospital grounds. The Administrator stated they notified the Police Department and the Department of Health per regulations. The facility Administrator stated as a result of the incident, CNA #2 was educated on providing one to one care to residents while on an out of facility transport . The Administrator stated CNA #2 was an agency aide that had worked in the facility prior to the transport and should have been aware of Resident #15 potential to walk away. The Administrator stated that they did not know if CNA #2 had ever had Resident #15 on their assignment and is unaware that if a care plan was given to the staff member prior to the transport. The Administrator stated their expectation is that a staff should read the resident's care plan prior to providing any care and they would consider taking a resident on a transport providing care, therefore it would have been the responsibility of the staff member to look at the care plan prior to taking the resident on an appointment. During a telephone interview on 8/27/21 at 10:57 AM CNA #3 stated that while they were driving to work, they recognized Resident #15 standing on a street corner. CNA #3 stated they called the facility and spoke with a supervisor that they saw the resident. CNA #3 stated they could not recall the location nor the supervisor's name. CNA #3 stated they asked Resident #15 to get into their car and they both went to the facility. CNA #3 stated that Resident #15 was nonverbal, incontinent but that they did not appear in any distress. 415.12(h)(2)

Based on interview and record review conducted during the Standard survey completed on 8/27/21, the facility did not ensure residents who use psychotropic drugs received gradual dose reductions (GDR) in an effort to discontinue these drugs for one (Resident #62) of five residents reviewed for antipsychotic medications. Specifically, there was a lack of documented targeted behaviors and ongoing behaviors to support the use of antipsychotic medication and lack of attempted GDRs as required. Additionally, the resident lacked a comprehensive care plan for antipsychotic medication use. The finding is: The facility policy and procedure (P&P) titled, Monitoring of Psychotherapeutic Medications revised on 9/10, documented residents receiving a psychotherapeutic medication will be observed for therapeutic response to the medication. When a resident starts on a new psychotherapeutic medication the nurse will: document the resident behavior and response; monitor for extra pyramidal effects; notify the physician of resident refusing and/or adverse effects, or omission of the medication. The P&P documented that these events will be reviewed and summarized in the weekly comprehensive behavior note written by the nurse. The facility P&P titled, Interdisciplinary Care Plan revised on 6/2017 documented that all careplans written for the residents of the facility shall contain the following: A place to address the problems triggered by the care area assessments (CAAS). Problems not triggered by the CAAS may be specific disease process that has a significant effect on the resident's wellbeing, or behaviors that may not necessarily have occurred during the assessment look back period, may show up time to time through a quarter. 1.Resident #62 was admitted to the facility with diagnoses including atherosclerotic heart disease, anorexia and dementia without behavioral disturbance. The Minimum Data Set (MDS- a resident assessment tool) dated 7/19/21 documented the resident had severe cognitive impairment and no verbal, physical or other behaviors directed toward others. The MDS documented no rejection of care and the resident received antipsychotic medications. The Order Summary Report dated 8/26/21, documented a physician order for Risperdal (antipsychotic medication) 0.25 mg (milligrams) by mouth at bedtime for mood with an order date of 3/12/20. There was no evidence of an attempted GDR for Risperdal on the Order Summary Report. The Medication Administration Record (MAR) dated 8/1/2021 - 8/31/21 documented Risperdal 0.25 mg was administered to Resident #62 as ordered from 8/1/21 - 8/26/21, except for 8/9/21. Review of the Comprehensive Careplan (CCP) initiated on 3/13/20 revealed Resident #62 did not have a CCP developed for antipsychotic medication use. Review of the Consultant Pharmacist Medication Regimen Review revealed: -on 12/14/20, a GDR was recommended for Risperdal 0.25 mg or to document the clinical rationale that a reduction would likely to impair the resident's function or increase distressed behavior. The Medical Doctor (MD) signed and dated the document on 12/24/20 as disagreed. There was no documented rationale why the MD disagreed with the recommendation. -on 7/13/21, a GDR was recommended for Risperdal 0.25 mg or to document the clinical rationale that a reduction would likely to impair the resident's function or increase distressed behavior. The Medical Doctor (MD) signed and dated the document on 12/24/20 as disagree, Patient failed GDR. Review of MD Progress Notes dated 12/11/20 - 8/6/21 revealed Resident #62's behavior had been stable. There was no documentation the resident had any distressful or psychotic behaviors. Review of the Documentation Survey Report V2 (Electronic Medical Record (EMR) used for Certified Nurse Aide (CNA) documentation) from 5/29/21-8/26/21 revealed no documented behaviorial symptoms except for wandering on 7/1/21 and 7/17/21. Review of nursing Progress Notes from 3/29/21-8/26/21 revealed no documentation of behaviors or psychosis to support the ongoing use of antipsychotic medication. During an interview on 8/27/21 at 10:37 AM, CNA #17 stated that they were familiar with Resident #62 and that the resident was pleasant with no aggressive, combative, or hallucinating behavior and was not disruptive to self or others. During an interview on 8/27/21 at 11:16 AM, CNA #14 stated they work both day and evening shifts and were familiar with Resident #62. CNA #14 stated they had never seen Resident #62 with aggressive behavior and usually kept to themselves. During an interview on 8/27/21 at 11:20 AM, Licensed Practical Nurse (LPN) #5 stated that Resident #62's that the resident was pleasant and easily followed commands. During an interview on 8/27/21 at 12:07 PM, LPN #3 Unit Manager (UM) stated they were familiar with Resident #62, worked on all three shifts, and the resident was pleasant with no aggressive behaviors. LPN #3 UM stated that Resident #62 had no harmful behaviors or aggression toward self or others. LPN #3 UM stated that they were responsible for updating Resident #62's careplan and that there was no care plan in place for antipsychotic medication use but there should be one. LPN #3 UM stated Resident #62 was on an antipsychotic medication and that a GDR should be attempted. After reviewing Resident #62's medication orders, LPN #3 UM stated that the resident has not had a GDR of Risperdal since their admission to the facility (over a year ago). During a telephone interview on 8/27/21 at 12:59 PM, the MD stated they reviewed Resident #62's notes and the resident did not have a GDR of Risperdal since they were admitted (over a year ago). The MD stated that the Risperdal should have been GRD'd but they did not do so. The MD stated that Resident #62 had increased confusion but had not noted any hallucinations during their MD visits. The MD stated that wandering behavior was not an indication for use of an antipsychotic medication, but hallucinations were. During a telephone interview on 8/27/21 at 2:05 PM, the Consultant Pharmacist stated that they make recommendations to the MD for a GDR for antipsychotic medications and ask for a documented reason if the MD disagrees. The Consultant Pharmacist stated that if he did not see any behavioral notes in the medical record from facility staff or from the MD, they would continue to request a GDR for antipsychotic medications. The Consultant Pharmacist stated the purpose of a GDR of medications is for a resident to be on the safest, lowest dose possible. During an interview on 8/27/21 at 1:29 PM, the Assistant Administrator stated an antipsychotic is a medication that prevents psychosis and that they were not aware of the regulations for GDRs of antipsychotic medications. The Assistant Administrator stated that they would expect the regulations to be followed. During an interview on 8/27/21 at 3:26 PM, the Administrator stated there was a GDR committee where medications were reviewed weekly. The Administrator stated that a resident's GDR meeting was scheduled along with their careplan meeting unless an extra review needed to take place. The Administrator stated that they had participated in the meetings and that Resident #62 sounded familiar but could not recall what was discussed at the meeting. The administrator stated they expected an antipsychotic careplan to be in place to ensure that a resident has a person centered careplan. 415.12 (l)(1)(2)(ii)

Based on observation and interview during the Standard survey completed on 8/27/21, the facility did not maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Issues included open and uncapped sewer plumbing, a consistent floor drain leak from First Floor into Basement, and shower plumbing devices and hoses that did not have vacuum breakers installed to prevent backflow. This affected one (Unit 6) of three resident units, one of one Main Kitchen, and one of one Basement. The findings are: 1. Observation on the Basement's A Wing on 8/24/21 at 10:32 AM revealed a portion of the building's main sewer pipe ran horizontally below Storage Room #A11 in a four foot long by four foot wide by five-foot-deep pit. Further observation revealed the pit was covered by a large sheet of wood. When the facility's Director of Maintenance lifted the wood, a ten-inch-wide area of the pipe was open and uncapped. Continued observation through the open uncapped area of the pipe revealed liquid was flowing through the pipe. During an interview at the time of this observation, the Director of Maintenance stated the pipe was kept open in order to see that it was not backed up. 2. Observation on the Basement's C Wing on 8/23/21 at 10:28 AM revealed an area of ceiling damage that measured eight inches in diameter around a three-inch drain in Dietary Storage Room #C7. There was another four-inch diameter area of ceiling damage that was ten inches away from the drain. Continued observation revealed the ceiling damage consisted of cracked and peeled plaster and a black substance that coated the ceiling in the affected area. At this time, a clear liquid was dripping from the affected ceiling area into a bucket below. A metal wall heat register cover was six horizontal inches away from the waste bucket, and had an eight-inch high by five-inch wide area where the metal was rusted through. Additionally, racks of dry food goods were stored on open shelving 24 horizontal inches away from the waste bucket. A second observation in Dietary Storage Room #C7 on 8/24/21 at 12:45 PM revealed a clear liquid was dripping from the same affected ceiling area into a bucket below. During an interview at the time of the second observation, the Director of Maintenance stated this area had been dripping for a while, but couldn't say exactly when. The Director of Maintenance further stated they did not know what was dripping and they would have to take the area apart to find the source. Additionally, the Director of Maintenance stated the drain appeared to have been sealed with fire caulk and the black substance on the surrounding ceiling area appeared to be tar, which they assumed was applied by the Therapy Assistant or the former Director of Maintenance. A third observation in Dietary Storage Room #C7 on 8/25/21 at 7:50 AM revealed a clear liquid was dripping from the same affected ceiling area into a bucket below. During an interview on 8/25/21 at 9:50 AM, the Therapy Assistant stated they did not apply fire caulk or tar to the drain or surrounding ceiling area in Dietary Storage Room #C7, and it was probably done by the former Director of Maintenance but did not know exactly when. A fourth observation in Dietary Storage Room #C7 on 8/25/21 at 11:18 AM revealed a clear liquid was dripping from the same affected ceiling area into a bucket below. During an interview at the time of the fourth observation, the Maintenance Assistant stated the floor drain in the affected ceiling area belonged to the ice machine in the Main Kitchen above. At this time, water was poured down the ice machine's floor drain and the clear liquid continued to drip from the ceiling area around the drain into Dietary Storage Room #C7 at the same pace. The Maintenance Assistant stated the ice machine floor drain in the Main Kitchen needed to be removed, a new floor drain installed and re-sealed, and the plaster surrounding the drain needed to be removed and installed again with new materials. 3. Observation on the First Floor on 8/23/21 at 8:28 AM revealed three showers and three shower wands in the Resident Spa on Unit 6 did not have vacuum breakers. The showers each had shower wands attached to them by hoses that allowed the wands to lie flush with the shower's floor. The length of the hoses allowed the shower wands to be submerged if the showers' floor drains did not drain properly. During an interview on 8/26/21 at 10:50 AM, the Maintenance Assistant was unaware of the status of vacuum breakers on the Unit 6 Resident Spa shower wands or hoses. During a telephone interview on 8/26/21 at 2:15 PM, the Administrator was unaware of the status of vacuum breakers on the Unit 6 Resident Spa shower wands or hoses. 415.29(d)(f)(4)