Based on interview, and record review conducted during an Abbreviated survey (Complaint #NY00374712), the facility did not ensure that pharmaceutical services (including procedures that assure the accurate administering of all drugs) met the needs of each resident for one (Resident #1) of three residents reviewed. Specifically, the facility did not ensure nursing staff administered Resident #1's anticonvulsant medications within the allowed administration timeframe and/or that the medication was signed for at the time of administration. Additionally, the Medical Provider was not notified.The finding is: The policy titled Liberalized and Standardized Medication Administration Schedules dated 5/29/25 documented medications will be delivered in a manner that was least restrictive and intrusive while allowing for optimal therapeutic effect of medications. Standard time schedules are medications scheduled at a specific time by a provider and are considered timely if they are administered within one hour before or after the defined time period. The policy documented that if any reason the medication was not administered within the scheduled time limits, the nursing supervisor and medical provider would be notified. An order to administer the medication at the current time may be considered. The policy documented that time-sensitive medications are medications that have a narrow therapeutic index or medications that require specific times for clinical safety and efficacy. Resident #1 had diagnoses that included obstructive hydrocephalus (buildup of fluid in cavities within the brain), dependence on a respirator (ventilator) and epilepsy (seizures). The Minimum Data Set (a resident assessment tool) dated 6/5/25 documented Resident #1 was severely cognitively impaired, sometimes understands, sometimes understood and took anticonvulsant medications. The comprehensive care plan dated 7/5/24, documented Resident #1 had a seizure disorder with episodes of seizure activity. Interventions included to administer medications as ordered by the medical doctor or nurse practitioner, monitor and document for seizure activity and update the medical doctor or nurse practitioner on the resident's status as indicated. During an interview on 7/11/25 at 1:24 PM, Resident #1's family member stated that Resident #1 medications, at times, were administered late and, at times, up to three hours late. The family member stated, last month (unknown day) Resident #1's hallway was staffed with an agency nurse, and they were still passing their dinner medications at 9:00 PM. Review of the Order Listing Report (medical provider orders) dated 7/15/25 documented Resident #1 had the following orders:-Valproic acid 450 milligrams every six hours with start date of 1/14/25-Vimpat 100 milligrams every twelve hours from 2/13/25 until 4/21/25-Vimpat 50 milligrams every twelve hours started on 4/22/25 Review of the Medication Administration Audit Reports revealed the following: -the report dated 7/14/25 documented for 3/1/25-3/31/25, Valproic Acid 450 milligrams and Vimpat 50 milligrams were administered six times past the allowed administration time frame (1 hour before and 1 hour after the time ordered). Additionally, there were multiple days in which the medications were documented as administered two (2) or more hours late.-the report dated 7/16/25 documented for 6/1/25-6/30/25, Valproic Acid 450 milligrams was administered three times past the allowed administration time frame and Vimpat 50 milligrams was administered four times past the allowed administration time. There were at least two (2) days the medications were documented as administered two (2) or more hours late.-the report dated 7/15/25 documented for 7/1/25-7/15/25, Valproic Acid 450 milligrams was administered twice past the allowed administration time frame and Vimpat 50 milligrams was administered four times past the allowed administration time; in which at least one day it was documented as more than two hours late. Review of the progress notes dated 3/6/25-7/16/25 revealed no documented evidence that the supervisor and/or medical provider were notified when the Valproic Acid and Vimpat medications were administered outside of the allowed time frame. During a telephone interview on 7/15/25 at 12:01 PM, Medical Doctor #1 stated they would expect Resident #1's anticonvulsant medications to be given within an hour or two of the medication being ordered and any time after that would be too late. They stated Vimpat and Valproic Acid were significant medications, and it was important to administer the medication within an hour or two of it being ordered to maintain the thresh hold of the medication in the resident's blood stream. Medical Doctor #1 added, one does not want to administer the dosing too close together because that could cause an issue. During a telephone interview on 7/15/25 at 12:33 PM, Registered Nurse #4 stated they usually were responsible for Resident #1's care from 7:00 AM - 7:00 PM three times a week and would be responsible for the 6:00 PM medication pass. Registered Nurse #4 stated they signed off their medications in the electronic medical record at the time of administration and the time documented in the electronic medical record would be the time they administered Resident #1's anticonvulsant medications. Registered Nurse #4 stated if the anticonvulsant medications were late for Resident #1 it was because they prioritized their morning medication pass to administer narcotics first as they did not want to administer the next narcotic dose too close together. Registered Nurse #4 stated they did not notify anyone that they were having difficulty passing Resident #1's medications on time because the management team should have already been aware as they were always hustling and bustling during their shifts. During a further telephone interview on 7/16/25 at 2:01 PM, Registered Nurse #4 stated they were unsure why they did not administer Resident #1's Valproic Acid medication at 6:00 PM on 3/8/25, 3/9/25, 3/11/25 and 3/20/25 because they always signed off their dispensed medications at the time of administration. Registered Nurse #4 stated they did not notify the medical provider that they could not always administer Resident #1's anticonvulsants timely, and they did not know they could do that. During an interview on 7/15/25 at 3:08 PM, Registered Nurse #1, Unit Manager, reviewed Resident #1's medical providers orders and stated Resident #1 was to receive Vimpat at 8:00 AM and 8:00 PM and Valproic Acid at midnight, 6:00 AM, noon and 6:00 PM. They stated staff would have an hour before and an hour after the medication was ordered to administer the medications. Registered Nurse #1 reviewed the Medication Administration Audit Report and stated it appeared that Vimpat and Valproic Acid were administered late at times. Registered Nurse #1 stated it would be important to administer Resident #1's anticonvulsant medications within the allowable time frame because Resident #1 had a history of seizures, and those medications kept them at baseline. They stated they did not know why the medications were administered late and they were not aware staff was having difficulty passing medications on time. During an interview on 7/15/25 at 3:41 PM, the Director of Nursing stated upon review of Resident #1's orders, Vimpat was ordered every twelve hours at 8:00 AM and 8:00 PM. They stated the Valproic Acid was ordered every 6 hours at midnight, 6:00 AM, noon and 6:00 PM. The Director of Nursing stated those medications were to be administered one hour before and up to one hour after. The Director of Nursing stated they expected the medications to be signed off in the electronic medical record at the time of administration. The Director of Nursing reviewed the Medication Administration Audit Report and stated the medications, at times, were not administrated timely and would be considered a medication error. They stated anticonvulsants needed to be administered timely to keep a therapeutic level to prevent a seizure. They stated they were unaware of late administration and was unsure why Resident #1 anticonvulsants were administered late at times. During a telephone interview on 7/15/25 at 4:05 PM, the Consultant Pharmacist stated that anticonvulsant medications needed to be ordered for a standardized time to maintain a constant blood level. The Consultant Pharmacist stated their expectation would be staff would document in the electronic medical record if a medication was being administered late with reasoning for it being late. They stated they would have expected the medical provider to be notified for a possible different administration time if the anticonvulsant medications were being administered late. During a telephone interview on 7/15/25 at 8:42 PM, Licensed Practical Nurse #1 stated they worked the 7:00 PM - 7:00 AM shift. They stated on 3/8/25 and 3/9/25 Resident #1's 6:00 PM Valproic Acid medication was administered late. Licensed Practical Nurse #1 stated when they administered Resident #1 bedtime medications, they observed the Valproic Acid medication was in red in the electronic medical record (red meaning the medication was late), so they administered the medication at that time. They stated Resident #1's 6:00 PM Valproic Acid would have been the responsibility of the day shift 12-hour nurse to administer it prior to leaving their shift. Licensed Practical Nurse #1 stated they did not notify the nursing supervisor and/or the medical provider that Resident #1's anticonvulsant medications were administered late but they should have. During a telephone interview on 7/15/25 at 11:54 PM, Licensed Practical Nurse #3 stated they were usually responsible for Resident #1's care 5 days a week from 11:00 PM-7:00 AM. Licensed Practical Nurse #3 stated Resident #1 was ordered Valproic Acid for seizures, and it was ordered to be given at midnight and 6:00 AM. Licensed Practical Nurse #3 stated they knew Resident #1 got a midnight dose of Valproic Acid, and at times, they would just administer the medication without signing it off as given. They stated they would go back hours later and sign it out but knew that was not appropriate. Licensed Practical Nurse #3 stated they knew they should be signing out medications at the time of administration for accurate documentation. During a telephone interview on 7/22/25 at 10:35 AM, Medical Doctor #1 stated they expected the facility to notify them if staff were having difficulty administering Resident #1's anticonvulsants within one or hour two hours of being ordered and they would have adjusted the medication times. During a telephone interview on 7/22/25 at 10:39 AM, the Director of Nursing stated they expected the nursing staff to notify the supervisor or unit manager if they were having issues with medications not being administered on time. They stated the medical provider should have been made aware of Resident #1's untimely administration of their anticonvulsant medication because it could have been medication errors if they were not given timely. 10 NYCRR 415.18(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Complaint investigation (#NY00358228) completed during the Standard survey on 1/21/25, the facility did not ensure that each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two (Resident #46 and #81) of eight residents reviewed for dignity. Residents #46 and #81 were treated in an undignified manner. Specifically, Certified Nurse Aide #10 pushed Resident #81 while they were in their wheelchair on the back two wheels lifting the front two wheels and pedals off the floor (in a wheelie type of motion). Certified Nurse Aide #10 also made a fist and a boxing jab motion toward Resident #46 and wheeled them into the corner facing the wall in a common area. The findings are: The policy and procedure titled Dignity, date modified 8/19, documented each resident had the right to be treated with dignity and respect. All activities and interactions with residents by any staff must focus on assisting the resident in maintaining and enhancing self-esteem and self-worth and incorporate the resident's goals, preferences, and choices. The policy documented when providing care and services, staff must respect each resident's individuality, as well as honor and value their input. 1. Resident #46 had diagnoses which included cerebral infarction (stroke), benign neoplasm of the meninges (noncancerous tumor on the covering of the brain) and dementia. The Minimum Data Set (an assessment tool) dated 10/6/24 documented Resident #46 was usually understood, usually understands, and had severe cognitive impairment. The assessment documented Resident #46 was dependent on staff for wheelchair mobility. The comprehensive care plan revised 8/13/24, documented Resident #46 had a deficit in activities of daily living function and mobility. Interventions included that Resident #46 was a total assist of one staff member for wheelchair mobility. The comprehensive care plan documented Resident #46 had the potential for alteration in mood/behavior related to dementia. Interventions included to approach resident from the front in a calm gentle manner, explain all expects of care and provide support and reassurance. 2. Resident #81 had diagnoses that included dementia, Parkinson's disease, and hypotension (low blood pressure). The Minimum Data Set, dated [DATE] documented Resident #81 was sometimes understood, sometimes understands, and had severe cognitive impairment. The assessment tool documented that Resident #81 was a moderate assist for wheelchair mobility. Review of the comprehensive care plan revised 10/9/24, documented that Resident #81 had a deficit in activities of daily living function and mobility. Interventions included that Resident #81 was a moderate assist of one staff member for wheelchair mobility. The comprehensive care plan documented Resident #81 was moderately impaired with decisions making related to dementia. The comprehensive care plan documented Resident #81 had the potential for alteration in mood/behavior related to dementia. Interventions included to provide support and reassurance. The Administrative Services Investigation Summary Guide dated 10/23/24 signed by the Assistant Director of Nursing and the Administrator documented that on 10/21/24 during the 2:00 PM and 10:00 PM shift, video camera footage revealed that Certified Nurse Aide #10 pushed Resident #81 in their wheelchair with the front wheels off the ground doing a wheelie. It was also documented that Certified Nurse Aide #10 was observed to make a fist punching motion toward Resident #46. It was documented that the Assistant Administrator then started an investigation that included staff and resident interviews. The Incident Investigation Accused Party's Statement obtained by the Human Resource Manager and Former Director of Nursing on 10/23/24 at 10:31 AM documented that Certified Nurse Aide #10 stated that they wheeled Resident #81 with the wheels in the air because Resident #81 had these things on the bottom and it be hard to push the wheelchair (referring to the mounted anti-tippers). It was documented that Certified Nursing Aide #10 stated that they did not push anyone into a corner and that they did not know if Resident #46 was competent enough to know that throwing a fist movement was playing around and they stopped themselves because they did not know that Resident #46 would flinch. The statement documented that Certified Nurse Aide #10 stated it was in the moment; I play around too much. Resident #46 was talking junk. In the moment I put my fist up, like parents do with their kids when they are playing around. On 1/15/25 at 1:35 PM the video footage was reviewed with the Human Resource Manager present. Video footage observed was of the Unit three common area/nursing station area for 10/21/24 between 7:20 PM - 7:38 PM. The following was observed: -7:20 PM Resident #46 was sitting in a wheelchair in the hallway near the nursing station. -7:29 PM Certified Nurse Aide #11 was standing to Resident #46's right side behind their wheelchair. Certified Nurse Aide #10 ambulated an unidentified resident out of the dining room across the common area. Certified Nurse Aide #10 stopped in front of Resident #46, raised a fist as if they were doing a boxing jab and directed it toward Resident #46. Resident #46 raised their right arm and swatted Certified Nurse Aide #10. Certified Nurse Aide #10 then walked out of camera view. -7:32 PM Certified Nurse Aide #11 touched Resident #46 hand, appeared as if something was said to Resident #46, then walked out of camera view. Activities Leader #1 enters camera view, approaches Resident #46 and appeared to have a conversation with the Resident #46. Resident #46 was not combative, agitated and did not appear to be frightened. -7:36 PM Resident #46 self-propelled their wheelchair toward the left hallway and out of camera view. Certified Nurse Aide #10 can be seen wheeling Resident #81 in their wheelchair from the dining room, across the common area, to the left hallway. Certified Nurse Aide #10 tipped Resident #81's wheelchair backwards lifting the front two wheels off the floor as they pushed the wheelchair on the back wheels only in a wheelie. The resident's feet were suspended in air as they were being propelled. -7:37 PM Certified Nurse Aide #10 with slight force pushed Resident #46 in their wheelchair to the common area; let go of the wheelchair handles while the chair was still in motion in the direction of the corner. Certified Nurse Aide #10 then walked out of camera view. -7:38 PM Resident #46 self-propelled themselves out of the corner. During an interview at 1:49 PM (after the video footage was reviewed), the Human Resource Manager stated they would describe Certified Nurse Aide #10's actions as a dignity concern because they cannot treat residents in that manner. The Human Resource Manager stated that Certified Nurse Aide #10 had stated they were just playing around. The Human Resource Manager stated no one should ever raise a hand to a resident regardless of them playing or not. Residents with cognitive deficits were not capable of interpreting playing around. They also stated residents were not children and the should not be treated like children. During a telephone interview on 1/16/25 at 12:56 PM, Certified Nurse Aide #11 stated on 1/15/25 at the time of the incident they were standing with by Resident #46 at the nursing station; Resident #46 was in their wheelchair. Certified Nurse Aide #10 walked by and started to have a joking/sarcastic conversation with Resident #46. Certified Nurse Aide #10 put their fist in the air and made a boxing jab motion directed toward Resident #46. They stated that even though the situation occurred in a joking manner it still was inappropriate because the unit was a memory care unit and they residents may not understand it was meant in a joking manner. They stated it was the resident's home and staff should want them to feel safe and comfortable in their home. Certified Nurse Aide #11 stated they did not witness Certified Nurse Aide #10 push Resident #81 on only the two back wheelchair wheels but that would be inappropriate behavior because it would be like pushing a baby in a stroller. They stated both situations would be considered dignity concerns towards the residents. During an interview on 1/17/25 at 10:46 AM, Activity Leader #1 stated at the time of the incident they worked on the memory care unit from 12:00 PM - 8:00 PM and witnessed Certified Nurse Aide #10 pushing Resident #81 in their wheelchair in a wheelie motion from the dining room to the first set of bedroom doors in the hallway (approx. 75-100 yards). Activity Leader #1 stated the motion did not appear safe. Activity Leader #1 stated they also witnessed Certified Nurse Aide #10 doing a boxing jam motion toward Resident #46 and laughing it off. They stated they did not feel Certified Nurse Aide #10 actions toward Resident #46 was safe because they did not know Resident #46's past, and it could have triggered them. Activity Leader #1 added that residents on the memory unit could always communicate, and what may seem like a joke to one may not be a joke to another, and the residents should have been treated with the upmost respect. During an interview on 1/21/25 at 9:32 AM, Registered Nurse #5 stated they did not witness the interactions with Certified Nurse Aide #10 and Resident #46 and #81. Registered Nurse #5 stated they did not watch the video footage, but it would be unacceptable behavior for staff to wheel a resident with the front wheels in the air. They stated a resident could have fell backwards, got scared, or jumped out of the wheelchair. Registered Nurse #5 stated making a fist with a jab motion toward a resident was not acceptable behavior because it could have been interpreted as a gesture of intimidation. Residents should not be afraid of staff. Registered Nurse #5 stated that placing a resident in a corner and letting go of the wheelchair to allow it to roll on its own was not appropriate, as it could have scared a resident that did not have any control. Registered Nurse #5 stated they felt the actions of Certified Nurse Aide #10 towards Resident #46 and Resident #81 would be a dignity issue. During an interview on 1/21/25 at 9:55 AM, the Director of Social Work stated they participated in the investigation into the interactions between Certified Nurse Aide #10 toward Resident #46 and #81. They stated that Certified Nurse Aide #10 pushed Resident #81 in the wheelchair in a wheelie motion and raided a fisted hand to Resident #46. They stated they did not watch the video footage but watched the Assistant Administrator do a reenactment of Certified Nurse Aide #10's actions. They stated they would describe those actions as inappropriate, immature and not dignified. The Director of Social Work stated they interviewed both residents after the incident was reported and neither resident remember the incident nor had any effects from the incident. During an interview on 1/21/25 at 10:09 AM, the Director of Nursing stated that a staff member should never make a fist at a resident or push them into a corner while letting go of the wheelchair as it was moving. They stated staff should always push a wheelchair with all four wheels on the ground. The Director on Nursing stated these situations could be forms of intimidation, abuse, a dignity issue due to the residents being helpless. During an interview on 1/21/25 at 10:17 AM with the Assistant Administrator and the Administrator; the Assistant Administrator stated they were notified by the Director of Activities that Certified Nurse Aide #10 was noted to be making faces at Resident #81 on the memory care unit. They stated they were alarmed when they watched video footage of the memory care unit. They observed Certified Nurse Aide #10 make a fist to Resident #46, push Resident #81 in a wheelie motion while in their wheelchair, and then push Resident #46 into a corner while the resident was in their wheelchair. The Assistant Administrator stated that Resident #46 and Resident #81 both had dementia and all three situations could be viewed as intimation, threating, and was not dignified. The Administrator stated they agree with what the Assistant Administrator had stated. 10NYCRR 415.3(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review conducted during a Complaint investigation (#NY00335735) during a Standard survey completed on 1/21/2025, 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 for one (Resident #51) of two residents reviewed. Specifically, Resident #51 was not ambulated every day as recommended and planned. The finding is: The policy and procedure titled Ambulation Program dated 7/24/2018 documented that residents who need assistance with walking will be placed on a Unit Ambulation Program designed for improving, reinforcing, or maintaining the current status of a resident's ambulation. It also documented that the program is conducted by the unit nursing staff. Resident #51 had diagnoses of lymphedema (chronic condition that causes swelling in the body's tissues due to a buildup of lymph fluid) and chronic pain syndrome. The Minimum Data Set (a resident assessment tool) dated 10/23/2024 documented the resident was cognitively intact, understood and understands others, and required supervision for ambulating 10 feet. The comprehensive care plan dated 12/12/2024 documented Resident #51 was on a nursing rehab ambulation program, required stand by assist of one staff member for 10 to 15 feet with a rolling walker, wheelchair to follow once a day. Review of Resident #51's physical therapy (PT) evaluation and plan of treatment dated 11/8/2024 documented the reason for referral was the resident was an [AGE] year-old resident and was referred to skilled physical therapy for a decline in their transfers and ambulation. The evaluation documented that without skilled physical therapy program, Resident #51 was at risk of further decline with inability to regain independence. Review of Resident #51's physical therapy Discharge summary dated [DATE] documented that physical therapy instructed Resident #51 in a functional maintenance program, proper body mechanics, safety sequencing techniques and use of assistive devices to facilitate improved functional abilities, increase safety and decrease need for assistance, prevent decline from current level of skill performance, increase functional mobility skills and facilitate functional independence in the absence of secondary medical complications. Review of Resident #51's nursing rehab ambulation program stand by assist of one staff member for 10 to 15 feet with rolling walker with a wheelchair follow once a day documented from 12/13/2024 to 1/13/2025 documented that the resident was walked 10 to 75 feet on: 12/17/2024,12/18/2024,12/24/2024,12/25/2024,1/2/2025, and 1/3/2025. During an interview on 1/16/2025 at 3:37 PM, Resident #51 stated they don't get walked by staff on a regular basis. They stated they need to walk because it was use it or lose it and they do not want to lose the ability to walk. They stated that they try to walk to the bathroom by themselves, but they need help at times. Resident #51 stated it bothered them that they can't walk every day. Multiple observations during the survey period, Resident #51 was in bed and in their nightgown from 7:30 AM to 12:30 PM. During these observations, Resident #51 stated that they have not been ambulated by staff. During an interview on 1/17/2025 at 8:26 AM, Certified Nurse Aide #3 stated that if they have four aides working on the unit, they can walk the residents. They stated with two aides working on most days, it's not possible to walk the residents. They stated that Resident #51 wants to be independent, but the staff can't do their job to help Resident #51. Certified Nurse Aide #3 stated Resident #51 could lose the ability to ambulate if they were not walked daily. During an interview on 1/17/2025 at 8:34 AM, Registered Nurse Unit Manager #1 stated that they expect their staff to walk residents if residents were care planned to be walked daily. They stated that Resident #51 could lose the use of their legs or the strength in their legs. Registered Nurse Unit Manager #1 stated that it could be that having only two aides working, the nursing ambulation program was not getting completed. During an interview on 1/17/2025 at 8:45 AM, the Director of Rehabilitation stated that residents who were not walked daily could lose strength or range of motion. They stated that they expect the Certified Nurse Aides to walk residents if the residents were care planned for restorative ambulation. During an interview on 1/21/2025 at 8:40 AM, the Director of Nursing stated they expected their staff to follow the care plan and, if the care plan stated the resident should be walked every day, then the resident should be walked every day. They stated they would expect all the staff to help with caring for the residents including nurses and nurse managers. 10 NYCRR 415.12(e)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 1/21/25, the facility did not ensure that residents who had an indwelling (foley) catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for one (Resident #53) of two residents reviewed. Specifically, Resident #53 had a recent history of urinary tract infection, and the foley drainage bag was not kept below the resident's bladder nor was the drainage tubing kept free of kinks. Additionally, the foley drainage bag and tubing was observed to be placed on the floor by staff. The finding is: The policy and procedure titled Catheter Daily Care (Indwelling) modified on 11/23/22 documented position of the drainage bags should be below the level of the bladder. Collection bags and tubing should not touch the floor. Resident #53 had diagnoses including urinary tract infection, obstructive and reflux uropathy (obstructed urinary flow causing urine to flow backwards in the urinary tract), and benign prostatic hyperplasia (enlargement of the prostate). The Minimum Data Set (a resident assessment tool) dated 12/9/24 documented Resident #53 was understood, understands and was cognitively intact. Resident #53 had an indwelling catheter. Review of the Order Summary Report dated 1/16/25 documented an order starting on 1/12/25 for urinary catheter, change catheter as needed for plugging or leakage. Review of the [NAME] Report (tool for staff to provide care) dated 1/14/25 documented Resident #53 had an indwelling foley catheter. Review of the comprehensive care plan dated 12/3/24 documented Resident #53 required an indwelling urinary catheter related to urinary retention, overactive bladder, and benign prostatic hypertrophy. Interventions included enhanced barrier precautions, provide catheter care daily and as needed, empty urine and record every shift. Resident #53 had an alteration in bladder/bowel elimination related to decreased mobility, use of catheter and history of urinary tract infection. Interventions included to monitor/document for signs and symptoms of urinary tract infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, and foul-smelling urine. Review of the nursing progress note dated 1/7/25 at 4:06 PM, Registered Nurse #4 Unit Manager documented a physician assistant was in to assess Resident #53 related to tea colored urine, low urine output, and congestion. New order for bladder scan, flush foley, change foley, chest x-ray, and labs. Resident #53 was made aware of new orders and in agreement. Review of the physician assistant progress note dated 1/7/25 documented Resident #53 was noted by nursing to have decreased urine output from foley and some suprapubic (area in the lower abdomen above the pubic bone) discomfort. Instructed nursing to bladder scan, flush the foley catheter and if no improvement then change the foley catheter. During an observation and interview on 1/13/25 at 9:45 AM, Resident #53 was sitting up in their wheelchair, next to their bed. The foley catheter drainage bag was observed hanging on the right handle of the wheelchair, directly behind Resident #53's right shoulder above the level of their bladder. Resident #53 stated they had a urinary tract infection in December 2024, they were unable to reach behind them to move the drainage bag, and they would ask staff to move the drainage bag. During on observation on 1/13/25 at 1:00 PM, Certified Nurse Aide #6 and another staff member entered Resident #53's room stating they were going to boost them in their wheelchair, for better positioning. The wheelchair was alongside the bed and Resident #53's foley drainage bag was hanging on the bedframe. After providing a boost, both staff members asked Resident #53 if they would like their wheelchair pedals attached to the wheelchair, to prevent sliding in the wheelchair. Certified Nurse Aide #6 picked up the right wheelchair pedal, unhooked the foley drainage bag from the bed frame, and placed the foley drainage bag flat, directly on the floor underneath the wheelchair. Approximately eight inches of drainage tubing was on the floor underneath the drainage bag. The urine in the tubing was tea colored. Both staff members left the room, leaving the drainage bag and tubing directly on the floor. During an observation and interview on 1/15/25 at 12:12 PM, Resident #53 was sitting in their wheelchair in their room, with a visitor who stated they were a family member. Resident #53's foley drainage bag was attached and hanging from the left arm of the wheelchair above the level of their bladder. The tubing connected to the top of the drainage bag was bent downwards at a 180-degree angle, completely kinking the tubing. The family member stated Resident #53 was already transferred into the wheelchair with the drainage bag hanging on the armrest prior to their arrival. Resident #53 stated a staff member had hung the drainage bag on the wheelchair. During an observation and interview on 1/15/25 at 12:50 PM, Certified Nurse Aide #5 stated they were responsible for Resident #53's care, and they had transferred Resident #53 to their wheelchair, with help from Certified Nurse Aide #6. They stated they hooked the foley drainage bag on the left armrest on accident and it should have been hung lower, so the urine could flow into it. During an observation and interview on 1/15/25 at 12:53 PM, Certified Nurse Aide #5 moved Resident #53's foley drainage bag from the left armrest of the wheelchair to an area in front of the left wheel of the wheelchair. The bottom of the foley drainage bag was resting on the floor. Certified Nurse Aide #6 stated they had assisted Certified Nurse Aide #5 to transfer Resident #53 into the wheelchair and the foley drainage bag should not have been hung from the armrest of the wheelchair. Drainage bags were usually hung in a lower position, underneath the wheelchair for both dignity and for the urine to flow into it. They stated the current position of the drainage bag, in front of the wheel, was also incorrect because it was touching the floor, looked like it would drag if the wheelchair was moved forward, and would potentially get caught under the wheel. Certified Nurse Aide #6 stated they remembered helping someone from therapy to boost Resident #53 on 1/13/25 and they remembered unhooking the foley drainage bag from the bed frame so they could add the wheelchair pedal, but they could not recall where they placed the drainage bag. They stated they should not have placed it on the floor for infection control reasons. During an interview on 1/15/25 at 1:03 PM, Registered Nurse #3 stated the foley drainage bags should always be placed below the level of the waist for the urine to drain into it. Hooking the foley drainage bag on the handle of the wheelchair or on the armrest was not considered hanging it below the level of the waist. They stated the foley drainage bag and/or tubing should never be placed on or touch the floor because that would be an infection control problem. During an interview on 1/16/25 at 11:24 AM, the Medical Director stated the foley drainage bag should always be placed in a lower position than the bladder, so the urine was able to drain without any obstruction. They stated, when the urine does not drain properly, there was a higher chance for urinary tract infection and sepsis (a severe infection). Resident #53 should have had the foley drainage bag placed lower than where it was observed. The Medical Director stated they recently saw Resident #53 and they did not currently have any signs or symptoms of urinary tract infection. During an interview on 1/16/25 at 11:34 AM, Registered Nurse #4 Unit Manager stated the foley drainage bag should never be placed on the handle of the wheelchair, the arm of the wheelchair or on the floor because it was both a dignity and infection control concern. Certified nurse aides, nurses, or whoever transferred the residents were responsible for hanging the foley drainage bags in the proper place on the wheelchairs. Resident #53 had a recent history of urinary tract infection and was at risk for another urinary tract infection. During an interview on 1/17/25 at 12:01 PM, the Registered Nurse Infection Preventionist Nurse Educator stated they expected all foley drainage bags to be hung below the level of the bladder without any loops or kinks, and not touching the floor. When they were not below the level of the bladder or there was a kink of any kind in the tubing, then there was a potential for the urine that had already left the bladder to flow back into the bladder. Once urine leaves the body and was in the tubing then it was no longer considered sterile and if it were to flow back into the bladder then there would be a higher risk of infection. Foley drainage bags and tubing touching the floor was another infection risk. They stated residents who had a foley catheters had a five percent higher risk of infection, so the staff should be doing everything they could to prevent urinary tract infections. During an interview on 1/17/25 at 12:40 PM, the Director of Nursing stated they expected staff to hang foley drainage bags below the level of the bladder to prevent backflow and reduce the risk of infection. The drainage bag should never be placed on the floor for infection control purposes. They stated all staff including certified nurse aides, team lead nurses who were on the medication and treatment carts, the unit manager, and any staff who had placed their eyes on the resident was responsible for ensuring the drainage bag was hung in the correct location and was not touching the floor. 10NYCRR 415.12(d)(1)

Based on observation, interview and record during the Standard survey completed on 1/21/25, the facility did not ensure that food and drink was palatable, attractive and at a safe and appetizing temperature for five (Unit 1, Unit 2, Unit 3, Unit 4, and Unit 5) of five test trays. Specifically, food and beverages during meals were served at suboptimal temperatures, were not palatable and not attractive. Residents #53, #68, #94, #97, and #131 were involved. The findings are: The policy and procedure titled Food Temperature Requirements and Holding Time last modified on 6/28/2019 documented the Director of Dining Services was responsible for assuring that the proper temperatures and holding times for foods were maintained during the preparation and service of meals. It further documented the steam table thermostat was to be set to maintain hot food between 140-160 degrees Fahrenheit and cold food items were to be held in an appropriate container or bin to maintain the temperature below 41 degrees Fahrenheit. The policy and procedure titled Meal Serving - Resident, last modified 9/24/18 documented that dietary, nursing, and other appropriately trained staff were responsible for assisting with passing trays, serving food, and pouring of hot beverages; ensuring that all items identified on the tray label were in place, and in reach of resident; obtaining substitutes for food items, upon request. It further documented nursing staff were responsible for delivering trays to residents, pouring beverages, and any other eating and feeding assistance as needed. Resident Council Meeting Minutes for 1/9/25 documented that residents were having difficulty changing the alternative items of choice on their meal trays. The meeting minutes also mentioned continued concerns with hot beverages served cold. During a Resident Council Meeting with survey staff on 1/14/25 at 10:35 AM, residents stated that most foods were served cold, and they would like to bring in a celebrity chef who fixes failing restaurants to improve the quality and presentation of their meals. Another complaint residents had was that they did not receive condiments with their food items, even after asking for condiments, and that the food just generally did not taste good. During a lunch meal tray line observation on 1/15/25, the temperatures of food items taken on the steam table in the main kitchen at 11:23 AM were taken by the [NAME] and Surveyor prior to the start of tray line and were as follows: Salisbury Steak measure 186 degrees Fahrenheit Ground Salisbury Steak measured 160 degrees Fahrenheit Pureed Salisbury Steak measured 194 degrees Fahrenheit Diced Potatoes measured 158 degrees Fahrenheit Peas measured 160 degrees Fahrenheit Mashed Potatoes measured 180 degrees Fahrenheit Carrots measured 194 degrees Fahrenheit Chicken Noodle Soup measured 180 degrees Fahrenheit Tray line commenced at 11:45 AM and drinks such as juice, soda, and nutritional supplements were stored in plastic containers of drained ice. Ice cream cups were stored in plastic containers of drained ice. Single serve milk cartons were stored in plastic milk crates with no form of ice or other refrigeration. Pudding cups, salads, and cottage cheese cups were stored in trays with no ice or any other form of refrigeration. Unit 1 cart left the kitchen at 12:00 PM Unit 2 cart 1 left the kitchen at 12:11 PM Unit 2 cart 2 (containing the test tray for Unit 2) left the kitchen at 12:15 PM Main Dining Room cart left the kitchen at 12:20 PM Unit 5 cart (containing ground food test tray) left the kitchen at 12:35 PM Unit 3 cart (containing pureed food test tray) left the kitchen at 12:47 PM Unit 4 cart left the kitchen at 1:00 PM During an observation of a lunch meal tray on 1/15/25 on Unit 1, the meal cart arrived on the unit at 12:00 PM, all trays were passed at 12:20 PM, and food temperatures on the test tray were taken at 12:25 PM by the surveyor, using a digital thermometer and were as follows: Salisbury Steak with gravy measured at 115.6 degrees Fahrenheit; was dry and tasted bland; gravy lacked flavor. Rosemary Potatoes measured at 103.3 degrees Fahrenheit; and the potatoes were shriveled and dry. Coffee measured at 115.4 degrees Fahrenheit; lacked flavor and tasted like water, and there were no condiments on the tray for the coffee. During an observation of a lunch meal tray on 1/15/25 on Unit 2, the second cart with the test tray arrived on the unit at 12:23 PM, all trays were served at 12:35 PM, and the test tray temperatures were taken with a facility thermometer. Food was tested and tasted with Assistant Director of Dining Services #1 at 12:35 PM and were as follows: Potatoes measured at 121 degrees Fahrenheit and tasted cold. Peas measured at 128 degrees Fahrenheit; tasted bland and were lukewarm. Milk measured at 58.8 degrees Fahrenheit; tasted warm. During an interview at the time of the test tray, Assistant Director of Dining Services #1 stated the potatoes tasted good but were too cold and that the milk should be colder. They stated there had been some complaints from residents about food being cold and the plate warmer used on the tray line may be the issue. During an observation of a ground meal lunch tray on 1/15/2025 at 12:37 PM on Unit 5, temperatures were measured with a digital thermometer in the presence of Registered Dietician #1 were as follows: Ground Salisbury steak with gravy measured at 114.5 degrees Fahrenheit; tasted lukewarm and was bland. Diced carrots measured at 111.3 degrees Fahrenheit; tasted lukewarm and bland. Mashed potatoes with gravy measured at 123.3 degrees Fahrenheit; tasted warm but bland. Milk measured at 51 degrees Fahrenheit; tasted cool, but not cold. Coffee measured at 108.5 degrees Fahrenheit; tasted lukewarm. During an interview on 1/15/2025 at 12:37 PM, Registered Dietician #1 stated that the optimal food temperatures on a meal tray should be at least 140 degrees Fahrenheit. They stated that they were not sure how things were done on the tray line, but milk should be kept on ice prior to putting it on trays. They stated that the milk should be at 40 degrees Fahrenheit or below. During a lunch meal tray observation on 1/15/25 at 12:54 PM, the Unit 3 dietary cart arrived at 12:54 PM and meal trays were passed by 1:06 PM. A test tray was completed with Registered Dietitian #1 at 1:06 PM. The temperatures were taken by Registered Dietitian #1 using a digital thermometer. The results were as follows: Puree Salisbury Steak with gravy measured at 131 degrees Fahrenheit; lukewarm and lacked flavor. Mashed Potatoes with gravy measured at 129.7 degrees Fahrenheit; were lukewarm. 2 % milk measured at 58.6 degrees Fahrenheit; tasted warm. Coffee measured at 98 degrees Fahrenheit; tasted very bitter and was cold. During an interview on 1/15/25 at the time of test tray Registered Dietitian #1 stated that safe food temperatures should be that cold foods were served below 40 degrees Fahrenheit, and that hot food were to be served at 140-160 degrees Fahrenheit. The Registered Dietician #1 stated, after tasting the food for palatability, that the Salisbury steak could have been hotter. They stated the milk tasted very warm and that the coffee was too cold. During a lunch meal tray observation on 1/15/25 with Licensed Practical Nurse #5 using a facility thermometer on Unit 4, the cart arrived on the unit at 1:02 PM after the last tray passed, the test tray was completed at 1:26 PM and measured as follows: Salisbury Steak measured at 116 degrees Fahrenheit; tasted cold and was dry in the center. Potatoes measured at 101.1 degrees Fahrenheit; tasted cold and bland, and looked dry and shriveled. Peas measured at 96.7 degrees Fahrenheit; tasted cold and mushy. Milk measured at 58.5 degrees Fahrenheit; tasted warm. Coffee measured at 96.7 degrees Fahrenheit; tasted bitter and cold. During an interview at the time of the test tray, Licensed Practical Nurse #5 stated that if trays sat this long on the cart, they would be cold and they would not want to eat this food. Licensed Practical Nurse #5 tasted all items and stated they agreed with the above descriptions of the food taste and appearance. During an interview on 1/13/25 at 11:29 AM, Resident #68 stated the facility needed a better cook and that they had lived in the facility for over five years. The food used to be good, and residents used to be able to get ribs and shrimp alfredo, but the new menu no longer allowed for these options. During an interview on 1/13/25 at 10:35 AM, Resident #97 stated the food used to be good, but no longer tasted good. During an interview on 1/13/25 at 11:41 AM, Resident #131 stated that food was usually served too cold and what was on the menu did not always match what was on the meal tray, and there were often items missing. During a follow-up interview on 1/13/25 at 1:41 PM, Resident #131 stated that the lunch meal was horrible, the meat was cold, Resident #131 was observed to have eaten only a small part of their meat, had eaten their vegetable and mashed potatoes. During an interview on 1/15/25 at 1:32 PM, Resident #131 stated their lunch meal had been served cold again. They were observed to have eaten their potatoes and vegetable and only about half of their meat. During an interview on 1/15/25 at 12:35 PM, Resident #53 stated the lunch meal was terrible the meat was okay but not good, the potatoes were a 5 out of 10, the peas were a 7 out of 10, and the coffee was tasteless. Resident #53 was observed to have eaten a few bites of each item, about half of their dessert, and they stated they had not received any creamer for their coffee on their tray and that milk in a carton was not the same as coffee creamer. During an interview on 1/15/25 at 1:50 PM, Resident #94 stated they had sent their lunch back because the facility continued to serve them too many carbohydrates and the resident had a diagnosis of diabetes. Resident #94 then stated they were given vegetable medley, 2 fruit cups, and cottage cheese and fruit. They stated their coffee was too cold and when they had complained to staff about their coffee being cold, they were told that coffee could not be served too hot, so residents did not burn themselves. During an interview on 1/17/2025 at 1:13 PM the Registered Nurse/Infection Preventionist/Nurse Educator #1 stated that there was a concern for growth of bacteria in the food if a tray sat long enough. They stated that staff could re-heat the food and take the temperature of the reheated meal as there were thermometers on the units. 10 NYCRR 415.14(d) (1) (2)

Based on observation, interview, and record review during the Standard survey completed on 1/21/25, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, issues included a dust laden ceiling, including devices on the ceiling, and a damaged wall. This affected one of one Main Kitchen. The findings are: The policy and procedure titled Kitchen, Dining and Dietary Equipment Routine Cleaning Policy, modified 4/26/19, documented the Director of Dietary Services will plan a regular cleaning schedule for the thorough sanitation of the kitchen equipment, dish room, and staff dining areas. Dietary work areas will be kept clean and in order by designated department staff according to routine schedules established by the Director of Dietary Services. The cleaning procedures will be planned and conducted in conformance with pertinent sections of the State Health Code, Rules and Regulations. 1. Observation in the Main Kitchen on 1/13/25 at 11:32 AM revealed the entire ceiling area was dust laden. This included a visible layer of dark gray dust on the ceiling tiles, the ceiling tile grid, the vents, the sprinkler heads, and the heat detectors located on the ceiling in all areas. At the time of the observation, the Director of Dining Services stated Dietary staff did not clean the ceilings, which should be done by Maintenance staff. The Director of Dining Services stated they personally discussed cleaning the kitchen ceiling with the former Director of Maintenance, but that person left employment at the facility, and they had not spoken to other Maintenance staff about it, and they had not put in a maintenance work order for it. Review of the outside contractor's Fire Alarm and Life Safety System Inspection Certificate dated 1/22/24 revealed the Notes and Recommendations Report detailed additional inspection notes made by the Inspectors during the building inspection. This section included a list of seven heat detectors located in the First Floor Kitchen Area and First Floor Kitchen Dishwashing Area and the note for each was Dirty. Review of the outside contractor's Fire Alarm and Life Safety System Inspection Certificate dated 1/6/25 revealed the Notes and Recommendations Report included the same seven heat detectors and the note for six of them was Dirty and the note for the seventh heat detector was Dirty device is right next to HVAC (heating, ventilation, Air Conditioning) caked in dust needs to be moved. 2. Observation in the Main Kitchen on 1/13/25 at 11:42 AM revealed an area of the wall behind the extinguishment hood was chipped and cracked, with paint and drywall paper peeled. The affected area measured four feet wide by five feet high and a rack of dishes was stored against this wall. At the time of the observation, the Director of Dining Services stated the wall needed to be patched and painted or resurfaced. Additionally, they stated the dishes on the rack against the wall were clean and ready to use. During an interview on 1/13/25 at 11:45 AM, the Director of Facilities Maintenance/ Corporate stated kitchen cleaning should be done by Dietary staff, and deep cleaning of the kitchen was done by Maintenance staff. They stated the ceiling cleaning and wall repair needed to be scheduled for off-hours, when the kitchen was closed. During an interview on 1/17/25 at 2:15 PM, the Director of Dining Services stated they first noticed the dust on the ceiling and the area of wall damage about one year ago. They stated they discussed both issues with the former Director of Maintenance in the Fall of 2024, and the former Director of Maintenance left employment at the facility soon after. The Director of Dining Services stated they would normally submit a maintenance work order to communicate with Maintenance staff, as it was hard to get in touch with them because there were only two staff members and they were all over the building, but they did not submit a maintenance work order for these issues. They also stated the work on the ceiling and wall would need to be done after 8:00 PM, when the kitchen closed for the night. During an interview on 1/17/25 at 3:38 PM, the Administrator stated Maintenance staff would be responsible for cleaning kitchen ceilings. This should be done routinely with preventative maintenance, and as needed. It should be done by Maintenance staff because there would be ladders involved, and cleaning the sprinkler heads was not a task for the Dietary staff. The Administrator stated they were made aware of the status of the kitchen ceiling and the area of wall damage in the kitchen within the last two months, and they thought a plan was made to remedy both. They stated some of the other items that were discussed along with kitchen ceiling and wall damage did get done, so they assumed all items were in the works to be completed. The Administrator stated they saw the kitchen ceiling again this week and realized action was not taken, and it needed to be cleaned. 10 NYCRR 415.14(h) Subpart 14-1.171

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review conducted during complaint investigations (#NY00359668, #NY00335735, #NY00349153, #NY00347833, #NY00350434) conducted during a Standard survey completed on 1/21/2025, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not having sufficient nurse staffing on a 24-hour basis to adequately care for residents' needs. Reference: F 688 Increase/Prevent Decrease in range of motion/mobility F 689 Free of Accident Hazards/Supervision/Devices The finding is but not limited to the following: Review of the policy titled Master Staffing Plan dated 9/20/2021 documented the number of staff members, work status, required qualifications of staff members, and overall organization of the department will be determined by the Regional Director of Operations, Chief Operating Officer, Chief Nursing Officer, and Governing Body, in cooperation with the Administrator and Department Manager. The Dear Administrator letter 23-11 dated 6/30/2023 sent to nursing home administrators documented starting 4/1/2022 nursing homes were required to to maintain at minimum daily average staffing hours equal to 3.5 hours of care per resident per day (HPRD) by a certified nurse aid (CNA) and a licensed practical nurse (LPN) or registered nurse (RN). Out of such 3.5 hours, no less than 2.2 HPRD shall be provide by a CNA, and no less than 1.1 HPRD shall be provided by a Licensed Practical Nurses or Registered Nurses. Review of the Federal Register dated 5/10/2024 for the Centers for Medicare & Medicaid Services Medicare & Medicaid programs Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting documented that starting 6/21/2024 long term care facilities are to have 3.48 hours of care per resident day with 0.55 hours of a Registered Nurse and 2.45 hours of a Nurse Aide. The Executive Order 4.22 from the New York State Governor's office documented that the emergency staffing waivers expired on 6/22/2023. The Facility assessment dated [DATE] documented the minimum staffing levels for the day shift for the facility on the weekdays were seven nurses and nine aides; the evening shift six nurses and nine aides; and the night shift five nurses and five aides. It also documented the minimum staffing levels for the weekend on the day shift are seven nurses and nine aides; evening shift six nurses and nine aides; and the night shift five nurses and five aides. Review of the Payroll Based Journal Staffing Data Report Fiscal Year Quarter 4 (July 1 - September 30) 2024 documented that submitted weekend staffing was excessively low for that quarter. A review of ACTS Complaint/Incident Investigation Report #NY00335735 dated 3/12/2024 documented staff were not answering call lights. Review of the facility Report of Nursing Staff Directly Responsible for Resident Care from 3/1/2024 to 3/30/2024 documented that the average daily resident census was 138 per day and that the hours of care per resident per day was 1.14 hours. A review of ACTS Complaint/Incident Investigation Reports #NY00349153 dated 7/24/2024 and NY00347833 dated 7/11/2024 documented the facility was short staffed on all shifts. Review of the facility Report of Nursing Staff Directly Responsible for Resident Care from 7/1/2024 to 7/31/2024 documented the average daily resident census was 139 residents per day and that the hours of care per resident per day was 1.01 hours. A review of the ACTS Complaint/Incident Investigation Report #NY00350434 dated 8/6/2024 documented that there was only one nurse on the floor, food trays are not being passed, and residents aren't getting out of bed. Review of the facility Report of Nursing Staff Directly Responsible for Resident Care from 8/1/2024 to 8/31/2024 documented that the average daily resident census was 139 and the hours of care per resident per day was 0.97 hours. A review of the ACTS Complaint/Incident Investigation Report #NY00359668 dated 11/6/2024 documented that there was a lack of staffing on the unit and that a resident was not turned or re-positioned in bed for 16 hours. Review of the facility Report of Nursing Staff Directly Responsible for Resident Care from 11/1/2024 to 11/30/2024 documented that the average daily resident census was 145 and the hours of care per resident per day was 0.97 hours. A review of staffing levels from 12/12/2024 to 1/11/2025 documented the facility did not meet minimum staffing levels for the night shift of one nurse per unit on the following dates: 12/17/2024 - four nurses for five units and a resident census of 155 12/24/2024 - four nurses for five units and a resident census of 157 12/26/2024 - four nurses for five units and a resident census of 156 12/30/2024 - four nurses for five units and a resident census of 152 12/31/2024 - three nurses for five units and a resident census of 152 1/6/2025 - four nurses for five units and a resident census of 155 A review of acuity levels and average daily census of the facility documented the following from 12/17/2024 to 1/16/2025: Unit 1 - average daily census 19 residents; acuity rehabilitation unit from subacute unit, colostomies, urostomies, seven residents waiting for long term care beds. Vent Unit - average daily census 17 residents; acuity level 24-hour respiratory therapy services, tube feedings. Unit 2 - average daily census 25 residents; acuity level sub-acute and new admits with short term stays; most have physical or occupational therapy; basic medication passes. Unit 3 - average daily census 30 residents; memory care unit; indwelling catheters (tubing placed inside a resident's bladder to drain urine); some behaviors; very few treatments. Unit 4 - average daily census 40 residents; mostly alert and oriented residents; very few treatments; basic medication passes; there are supposed to be two nurses on this unit. Unit 5 - average daily census 30 residents; long term care unit; three cpaps & bipaps (a machine that treats obstructive sleep apnea by keep the airway open); few treatments. A review of the Resident Council minutes from October 2024 to January 2025, it documented the following: 10/9/2024 - corporate was looking into hiring agency again to assist with staffing needs and staff are taking breaks at the same time leaving no staff to care for the residents. 11/13/2024 - nurses helping aides caused medications to be delayed. 1/9/2025 - staff ignoring call lights; residents' laundry thrown on the floor and not in laundry basket after care from aides; and call lights being on for two hours. An observation on 1/13/2025 between 11:40 AM to 12:37 PM for call light outside of Resident room [ROOM NUMBER] observed: 1/13/25 11:40 AM - call light on. 1/13/25 11:59 AM -call light remained on above the doorways above door. No staff in the northeast hall. 1/13/25 12:04 PM -call light remained on 1/13/25 12:11 PM -Unit Clerk went into janitor closet by room [ROOM NUMBER], left area and did not ask resident in #309 if they needed anything. 1/13/25 12:17 PM- call light remained unanswered and still on 1/13/25 12:24 PM- Registered Nurse Unit Manager #1 walked down hall, call light remained on and unanswered 1/13/25 12:28 PM- Registered Nurse Unit Manager #1 retrieved supplies out of the clean utility room then went back down the hall past room [ROOM NUMBER] call light remained on and unanswered. 1/13/25 12:36 PM call light remained on and unanswered 1/13/25 12:37 PM Certified Nurse Aide #2 went into room [ROOM NUMBER] after family member went to the nurses' station and asked for help repositioning resident. During an interview on 1/13/2025 at 12:37 PM with Certified Nurse Aide #2 stated that there were only three aides working and they are doing the best they can when answering call lights. Unit 5- observation of a lunch tray pass on 1/13/2025 between 1:08 PM to 1:24 PM observed the following: -1/13/25 1:08 PM trays arrive to unit. There was one Certified Nurse Aide passing out trays. Registered Nurse Unit Manager was in their office, second Certified Nurse Aide was charting at nurses' station and Licensed Practical Nurse charting at nurses' station. -1/13/25 1:15 PM - 2nd Certified Nurse Aide #16 got up and goes down opposite hall of the lunch cart. Does not assist with passing trays at this time. 1/13/25 1:16 PM -2nd Certified Nurse Aide goes to pass out trays; grabs 2 trays and takes them to another hall. -1/13/25 1:18 PM- Licensed Practical Nurse walked past trays to give medication to resident; does not assist with tray pass. 1/13/25 1:19 PM- Licensed Practical Nurse walked past lunch tray cart again. -1/13/25 1:21 PM- Licensed Practical Nurse administers medication to another resident. -1/13/25 1:24 PM- Licensed Practical Nurse gives another resident medication. -1/13/25 1:25 PM- 2nd Certified Nurse Aide comes back; helps push lunch cart to another hall. -1/13/25 1:26 PM- Both Certified Nurse Aides pass trays on low hall. -1/13/25 1:29 PM- Registered Nurse Unit Manager talking to resident. -1/13/25 1:31 PM- Registered Nurse Unit Manager puts a breakfast tray in cart; however, does not pass any lunch trays. -1/13/25 1:32 PM - Lunch tray pass completed. There were approximately 20 trays in the meal carts to be passed to residents. Resident #53 on 1/13/2025 at 9:42 AM stated that it took three hours for staff to clean their dental partial plate. They stated the biggest problem was the staff start something then go away to do something else. Resident #51 on 1/13/2025 at 9:08 AM stated that they can wait up to hour to get help and the weekend staffing was terrible. Resident #67 on 1/13/2025 at 9:19 AM stated that it takes hours for a call light to be answered, and it doesn't matter what time of day or shift. During an interview on 1/14/2025 at 7:31 AM, License Practical Nurse #2 stated that they have been working with only two Certified Nurse Aides on their unit all week. They stated that they were told to help the aides, but they do that every day. They stated they help with passing trays, helping with resident care, and pass their medications. They stated there was not enough staff for them to do their job. During an interview on 1/14/2025 at 7:34 AM, Certified Nurse Aide #1 stated they try to do their best, but they can't always get their work done. They stated they work on a unit with wanderers, and they can't watch them if they have to care for other residents. They stated they can't get people out of bed until after breakfast. During an interview on 1/14/2025 at 11:00 AM, the Ombudsman stated there have been complaints about staffing levels at the facility from residents and family members. The Ombudsman stated the Administrator had sent them an email stating that they were aware of the staffing minimums but that they were not enforceable. During the resident council meeting on 1/14/35 at 10:35 AM, there were 19 residents present. They stated the facility needed more staff; one Certified Nurse Aide for 20 residents and one nurse for 40 residents was not enough. They stated their call lights rang for an hour at a time and the evening shift at bedtime was the worst for call light response time. Sometimes they were waiting three hours for staff to answer their call light. At those times a staff member would enter the room, turn off the call light, tell the resident they would be right back, but they never immediately went back to the room. They stated they believed staff did this because there was not enough of them to help all the residents when they needed it. During an interview on 1/15/2025 at 8:49 AM, Certified Nurse Aide #2 stated that they normally work with two aides for 30 residents and it's not easy to get work done. They stated they can't always get the residents showers done or get residents out of bed. During an interview on 1/15/25 at 9:47 AM, Certified Nurse Aide #9 stated they usually work the day shift on Unit Three. They stated usually work with one to two other certified nurse aides. Certified Nurse Aide #9 stated when there are only two aides on the floor, they do the best they can but they cannot toilet residents every two to four hours as the resident should be nor give the residents showers as they should. They stated they do tell the nurse or the unit manager when they cannot complete their duties. During an interview on 1/16/25 at 12:33 PM, Certified Nurse Aide #12 stated that they didn't have a nurse on the unit because the nurse was also the supervisor for the whole building and had to go to another floor. They stated they believed a resident eloped because they could not watch them and take care of other residents. During an interview on 1/16/2025 at 1:12 PM, Licensed Practical Nurse #1 stated that they cannot get their work done with one aide on their shift. They stated they can pass medications, but they cannot get treatments done. They stated that they have to stop doing their job to help an aide for any resident that was a two assist for toileting, incontinent care, or getting them out of bed. They stated a few months ago they were the only staff member working on a unit and could only assist the one assist or supervision residents with toileting. They stated that any two-assist resident had to wait until they got another staff member. During an interview on 1/16/25 at 1:42 PM, Licensed Practical Nurse #4 stated they usually work the day shift, and they mostly are the only nurse on the floor. They stated it was a lot of work to completed themselves and was doable, but they cannot help the certified nurse aides as much as they liked. They stated they work with two to three certified nurse aides and all the aide duties cannot get completed when there were only two aides. Licensed Practical Nurse #4 stated the two aides cannot shower the residents, toilet the residents as care planned and there were times when mechanical lift residents have to remain in bed for that shift. Licensed Practical Nurse #4 stated when there were only two aides on the unit, they do not feel the residents were safe due to their behaviors and attempts to stand. During an interview on 1/16/25 at 3:23 PM, Certified Nurse Aide #7 stated there were only three certified nurse aides on the unit. They stated with three certified nurse aides, they were barely able to complete their assignments, if nothing goes wrong on the unit, like a code blue or fall. They stated that if a resident who was not scheduled for a shower asked for an additional shower, they would not have the time to complete that. They stated because there were ventilator residents and subacute rehabilitation residents on the unit, it was very time consuming to attend to both types of residents. They stated the unit runs a lot smoother with four certified nurse aides. They stated when they needed help, they would ask the nurses, but they were unable to help because a lot of the time there was only one nurse for the entire unit. During an interview on 1/16/25 at 3:49 PM, Certified Nurse Aide #13 stated that they always worked short with just one aide on the unit and believed that is why a resident eloped the building during a shift. During an interview on 1/17/2025 at 8:35 AM, Registered Nurse #1 stated that it could be that they only have two aides on the day shift and resident care cannot be completed. They stated they do help the Licensed Practical Nurses with treatments for the residents, but they normally don't help on the medication cart. During an interview on 1/17/2025 at 12:05 PM, the Clinical Staffing Specialist stated that the minimum staffing levels for the facility on the day shift is nine floor nurses and 12 aides, the afternoon/evening shift is eight floor nurses and 12 aides, and the night shift is six nurses and 10 aides. They stated that having one nurse and one aide on a unit is critical staffing. They stated they didn't think staff should work by themselves because you don't know what could happen on a shift. During an interview on 1/17/25 at 3:19 PM, Certified Nurse Aide #4 stated there were many call-offs during the summer and they did the best they could to provide care for the residents. They stated they mainly worked the day and evening shifts and when there was only one Certified Nurse Aide to a lot of residents, they would give residents bed baths instead of scheduled showers. During an interview on 1/17/25 at 3:18 PM, Registered Nurse #2 stated that there had been times when they worked the evening shift with two Certified Nurse Aides and one Licensed Practical Nurse on Unit 4 and they passed medications on one wing, while the Licensed Practical Nurse would pass medications on the other wing of the unit. They stated there had also been times when they had to cover medications carts for both wings of the unit, pass meal trays, and assist with personal care after 7 PM, as they were the only nurse on the unit after 7 PM. They stated things were much better at this time. Registered Nurse #2 stated that the two units that needed to have two nurses always scheduled and working the evening shift and should always be fully staffed with Certified Nurse Aides on Unit 1 and Unit 2. Both units require the full attention of two nurses, as many residents need full sets of vitals taken, new admissions generally are admitted to these units first and require assessments, and the workload would not be able to be met by only one nurse throughout an entire shift. During an interview on 1/17/25 at 3:53 PM, Licensed Practical Nurse #3 stated there were times when families complained that there were not enough staff. The complaints relayed by families of residents were mostly about call lights not being answered in an acceptable time frame. During an interview on 1/21/2025 at 8:40 AM, the Director of Nursing stated they have been working on staffing levels since November 2024. They stated that would expect all their staff to help with resident care. During an interview on 1/21/2025 at 8:54 AM, the Administrator stated that having one nurse and one aide on a unit is not an ideal staffing level. They stated the staff would be busy getting their work done. They stated that it was not a reasonable expectation for a nurse to get their work done if they were the only nurse working with one aide. They stated they expect staff to help with resident care if possible. During an interview on 1/21/25 at 9:32 AM, Registered Nurse #5 stated they have worked for the facility for about three years. They stated the unit was usually staffed with one-two nurses but most of the time only one aide for the day shift; and one nurse and two certified nurse aides for the evening and night shift. Registered Nurse #5 stated they feel that was not adequate staffing for their dementia unit because it could get overwhelming at times to keep an eye on all the 30 residents on the unit due to their behaviors. Registered Nurse #5 stated they felt the residents were as safe as they can be with the staffing numbers on the unit. 10 NYCRR 415.13(a)(1)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY00294465) completed on 1/26/24, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for seven (Resident #3, #5, #6, #7, #8, #9, and #10) of seven residents reviewed for quality of care. Specifically, residents did not receive treatments as ordered by the physician. Issues involved pressure ulcer treatments (#3, 5, 6, 7, 8, 9, 10) and peripherally inserted central catheter (PICC) line care (#5, #9). The policy and procedure titled Medical Provider Notification Guidelines dated 2/13/20 documented the facility will utilize established guidelines as to when to notify the medical providers of urgent or non-urgent resident concerns. Guidelines for medical provider notifications include but not limited too; Routine (non-immediate notification) medications being held, refused or unavailable. Routine or non-immediate notification means that notification is the same day of the finding. The policy and procedure titled Skin Conditions, Wounds and Pressure Ulcers (Assessment and Monitoring Program) dated 2/27/23 documented the nurse will ensure that routine prevention measures and planned care and treatments for skin condition and/or wounds are carried out as planned. The findings are but not limited to: 1. Resident #5 had diagnoses that included paraplegia (the loss of the ability to move or feel in part or most part of body), chronic respiratory failure respirator (ventilator) dependent, and a stage 4 (extends below the subcutaneous fat into deep tissues, including muscle and tendons) pressure ulcer to the right buttocks. The Minimum Data Set (a resident assessment tool) dated 12/4/23 documented Resident #5 was cognitively intact, had no memory problems, no behaviors of rejection of care, and had pressure ulcers. The comprehensive care plan dated 12/8/23 documented to apply treatments to the sacral pressure ulcer per the provider orders. The care plan documented on 12/18/23 Resident #5 had a peripherally inserted central catheter (PICC) line to their right upper extremity. Interventions included to complete PICC line dressing changes per orders, and to measure and document on the treatment administration record (TAR) their arm circumference and migration of (PICC) catheter weekly. Review of facility's physician Order Summary Report dated 1/1/24 through 1/25/24 revealed the following orders: -1/6/24 H-Chlor 12 solution (a medicated topical solution used for wound care and skin infections) 0.125% (percent) apply to sacrum (area above the tail bone on right and left buttocks) topically ever day shift for wound healing. Cleanse ulcer with Dakins (topical antiseptic used to clean infected wounds) 0.125% solution, then apply skin prep (protective barrier) to peri wound (area surrounding a wound edge), then apply Vaseline gauze to the wound bed. Loosely pack ulcer with Dakins 0.125% moistened gauze and cover with Allevyn adhesive (cover dressing). -1/13/24 order was changed to Vashe Wound Therapy external solution (wound cleanser). Apply to sacrum topically every- day shift for wound healing. Cleanse ulcer with Vashe solution then apply Vaseline gauze dressing to cover exposed fascia (a sheath of stringy connective tissue that provides support to muscles, tendons, ligaments, tissues, organs, nerves, joints and bones), then loosely pack with Vashe moistened gauze and cover with Allevyn adhesive. -1/6/24 Xeroform Petroleum gauze (fine mesh absorbent gauze soaked in petroleum) 5-inch x 9 inch to right lateral lower leg topically every day for wound healing. Cleanse with normal saline, pat dry, apply Xeroform gauze to wound bed and cover with bordered gauze, discontinued on 1/17/24 and reordered on 1/19/24. -12/25/23 Peripherally inserted central catheter (PICC) line, Registered Nurse to measure and document arm circumference and external catheter length every Monday day shift. Additionally, Registered Nurse to change the central catheter line dressing (PICC)/Statlock (stabilization device to anchor the PICC line) every Monday day shift. Resident #5's Treatment Administration Record dated 1/1/24 through 1/23/24 revealed the following: -The physician ordered treatment with a start date of 1/6/24 to the sacrum revealed there was no documented evidence the treatments were completed on 1/7/24, 1/9/24, 1/10/24, 1/12/24 and 1/13/24. -The physician ordered treatment with a start date of 1/13/24 to the sacrum revealed there was no documented evidence the treatments were completed on 1/13/24, 1/14/24, 1/15/24, 1/16/24, 1/19/24, 1/21/24 and 1/22/24. -The physician ordered treatment with a start date of 1/6/24 to the right lateral lower leg revealed there was no documented evidence the treatments were completed on 1/7/24, 1/10/24, 1/12/24, 1/13/24, 1/14/24, 1/15/24, 1/19/24, 1/21/24, and 1/22/24. -The physician ordered treatment with a start dated of 12/25/23 for PICC line catheter care and dressing change revealed there was no documented evidence the treatments were completed on 1/1/24 and 1/15/24. Review of Progress Notes 1/1/24 through 1/26/24 revealed there was no documented evidence Resident #5 refused wound treatments. The form titled SNF SKIN ASSESSMENT - V1 dated 1/4/24 documented the right lower leg stage 2 pressure ulcer (shallow crater) measured 22 centimeters (cm) length (L) x 5 cm width (W) x 0.1 cm depth (D). The sacrum stage 4 pressure ulcer measured 11.5 centimeters length x 11 centimeters width x 0.9 centimeters depth. During an interview on 1/23/24 at 7:54 AM, Resident #5 stated their pressure ulcer started in the hospital and the nurses do not complete the treatments to their right lower leg and sacrum daily. The resident stated it bothered them that the treatments were not completed as ordered. During an interview on 1/23/24 at 1:06 PM, Registered Nurse #2 stated they were aware of the inability to complete treatments and related it to staffing concerns. They stated they had informed the evening shift nurses, when they were unable to complete the treatments but did not know if the evening nurses were able to complete them. Registered Nurse #2 stated if the Treatment Administration Record had a blank for the date and time of the treatment then it wasn't done. Registered Nurse #2 stated they believed that Unit Manager Registered Nurse #1 had informed the Director of Nursing that treatments were not completed as ordered. During an interview on 1/25/24 at 1:10 PM, Registered Nurse #2 reviewed the January 2024 Treatment Administration Record and stated, they were unable to complete the sacral treatment on 1/7/24, 1/10/24, 1/15/24, 1/17/24, 1/18/24 and 1/21/24. They stated they were unable to complete the right lower leg treatment on 1/7/24, 1/10/24, 1/15/24 and 1/21/24, and did not complete the peripherally inserted central catheter care and dressing change on 1/1/24 and 1/15/24. Registered Nurse #2 stated they informed had Medical Doctor #1 multiple times that they were unable to complete the treatments as ordered. During a telephone interview on 1/26/24 at 9:11 AM, Licensed Practical Nurse #4 stated they worked 1/14/24. They stated they were unable to complete the treatments to Resident #5's sacrum and right lower leg because they didn't have time and had informed the Nursing Supervisor Licensed Practical Nurse #5. During an interview on 1/26/24 at 10:35 AM, Unit Manager Registered Nurse #1 reviewed the January 2024 Treatment Administration Record and stated they were unable to complete the treatments to the sacrum and right lower leg on 1/12/24 and 1/22/24. Registered Nurse #1 stated they were not notified to complete the peripherally inserted central catheter dressing change and measurements on 1/1/24 and 1/15/24. Unit Manager Registered Nurse #1 stated they had informed the Assistant Director of Nursing and Director of Nursing in the past that treatments were not able to be completed as ordered, and their response was to do the best they could. During an interview on 1/26/24 at 12:55 PM, Licensed Practical Nurse #3 stated they did not have time to complete treatments as ordered on Unit 1 because the medication pass was very heavy. All the Nursing Supervisors and the Unit Manager were aware the treatments were not getting done. Licensed Practical Nurse #3 reviewed the January 2024 Treatment Record and stated they were unable to complete the treatment to the sacrum and right lower leg as ordered on 1/19/24. 2. Resident #8 had diagnoses that included quadriplegia (paralysis that affects all four limbs, plus the torso), chronic respiratory failure respirator (ventilator) dependent, and a stage 3 (full thickness tissue loss, subcutaneous fat may be visible) and 4 pressure ulcers. The Minimum Data Set, dated [DATE] revealed Resident #8 was unable to complete the brief interview for mental status, had no behaviors of rejection of care, and had pressure ulcers. An undated Brief Interview for Mental Status score identified as current provided by the Director of Nursing documented Resident #8 was cognitively intact. The comprehensive care plan dated 4/27/23 documented to completed treatments to stage 4 pressure ulcers per the provider orders. Review of facility's physician Order Summary Report dated 1/4/24 through 1/25/24 revealed the following orders: -Biostep Sheet 2 (collagen Matrix (porcine) (wound dressing) with a start date of 12/19/23 documented to apply to left hip topically every- day shift for wound healing. Cleanse with normal saline and pat dry, apply collagen dressing to wound bed and cover with Allevyn. -H-Chlor 12 solution 0.125% with a start date of 12/19/23 documented to apply to right mid back topically every- day shift for wound healing, cleanse area with Dakins 0.125% solution then loosely pack with Dakins 0.125% moistened gauze and cover with Allevyn adhesive dressing, discontinued 1/6/24. - 1/6/24 Santyl ointment (sterile ointment to remove dead skin tissue) apply to right mid back topically every- day shift for wound care, cleanse wound with normal saline, pat dry apply nickel thick layer of Santyl to wound bed then loosely pack with alginate (absorbent dressing) and cover with Allevyn adhesive. -Dakins solution 0.125% apply to sacrum and right hip topically every- day shift for wound care cleanse area with Dakins 0.125%, pat dry, loosely pack with Dakins moistened gauze and cover with an Allevyn adhesive. Resident #8's Treatment Administration Record (TAR) dated 1/1/24 through 1/23/24 revealed the following: -The physician ordered treatment with a start date of 12/19/2, Biostep Sheet 2 to the left hip revealed there was no documented evidence the treatments were completed on 1/1/24, 1/7/24, 1/9/24, 1/10/24, 1/14/24, 1/15/24, 1/17/24, 1/18/24, 1/19/24, 1/21/24, and 1/22/24. -The physician ordered treatment with a start date of 12/19/23 to the right mid back revealed there was no documented evidence the treatment was completed on 1/1/24. -The physician ordered treatment with a start date of 1/6/24 to the right mid back revealed there was no documented evidence the treatments were completed on 1/7/24, 1/10/14, 1/12/24, 1/14/24, 1/15/24, 1/17/24, 1/18/24, 1/19/24, 1/21/24 and 1/22/24. - The physician ordered treatment with a start date of 12/6/23 to the sacrum and right hip revealed there was no documented evidence the treatments were completed on 1/1/24, 1/7/24, 1/10/14, 1/14/24, 1/15/24, 1/17/24, 1/18/24, 1/19/24, 1/21/24 and 1/22/24. Review of Progress Notes 1/1/24 through 1/26/24 revealed there was no documented evidence Resident #8 refused treatments. Review Wound Assessment and Plan dated 1/4/24 Medical Doctor #1 documented left hip stage 4 pressure ulcer measured 0.7 centimeter length x 0.9 centimeter width x 0.1 centimeter depth; Right hip stage 4 pressure ulcer measured 1.1 centimeters length x 0.6 centimeters width x 0.9 centimeters depth; right mid back stage 3 pressure ulcer measured 1.2 centimeters length x 2.5 centimeters width x undetermined depth; sacrum stage 4 pressure ulcer measured 4 centimeters length x 1.4 centimeters width x 1.5 centimeters depth. During an observation on 1/25/24 at 10:44 AM, Resident #8 had a left hip stage 4 pressure ulcer, a right hip stage 4 pressure ulcer, and a right mid-back stage 3 pressure ulcer. During an interview on 1/23/24 at 8:42 AM, Resident #8 who was able to answer yes/no questions, expressed their pressure ulcer treatments were not completed daily as ordered. Resident #8 stated it bothered them and would like them completed as ordered to promote healing, During an interview on 1/25/24 at 1:10 PM, Registered Nurse #2 reviewed the January 2024 Treatment Administration Record and stated they were unable to complete the treatments for Resident #8 on 1/1/24, 1/7/24, 1/10/24, 1/15/24, 1/17/24, 1/18/24 and 1/21/24 as ordered. During a telephone interview on 1/26/24 at 9:11 AM, Licensed Practical Nurse #4 stated they were unable to complete the treatments for Resident #8 on 1/14/24. During an interview on 1/26/24 at 10:35 AM, Unit Manager Registered Nurse #1 reviewed the January 2024 Treatment Administration Record and stated they were unable to complete the treatments as ordered for Resident #8 on 1/12/24 and 1/22/24. During an interview on 1/26/24 at 12:55 PM, Licensed Practical Nurse #3 reviewed the January 2024 Treatment Record and stated they were unable to complete the treatments as ordered for Resident #8 on 1/19/24. 3. Resident #9 had diagnoses that included paraplegia, chronic respiratory failure dependent respirator (ventilator), and osteomyelitis (inflammation of bone caused by infection of vertebra (small bones forming the backbone), sacral and sacrococcygeal (pertaining to both the sacrum and coccyx (tailbone) region. The Minimum Data Set, dated [DATE] revealed Resident #9 was unable to complete brief interview for mental status, had no behaviors of rejection of care, and had pressure ulcers. Review of an undated Brief Interview for Mental Status scores identified as current provided by the Director of Nursing revealed Resident #9 was cognitively intact. The comprehensive care plan dated 12/14/23 documented interventions to complete treatments as ordered by the providers to the resident's stage 4 pressure ulcer on their left ischium (lower buttocks area). In addition, the care plan dated 12/7/23 documented Resident #9 had a peripherally central catheter (PICC) line in their right upper extremity with interventions to change dressing per orders and a Registered Nurse to measure and document on treatment record their arm circumference and migration of catheter weekly. Review of facility's physician Order Summary Report dated 1/4/24 through 1/25/24 revealed: -Vashe wound therapy- apply to left ischium topically every- day shift for wound care. Cleanse left ischium with Vashe, pack wound with gauze moistened with Vashe and cover with Allevyn adhesive dressing every day and as needed with a start date of 12/5/23. - Peripherally inserted central catheter (PICC) line, Registered Nurse to measure and document arm circumference and external catheter length every Monday day shift. Additionally, Registered Nurse to change the central catheter line dressing (PICC)/Statlock every Monday day shift. Resident #9's Treatment Administration Record dated 1/1/24 through 1/23/24 revealed the following: -The physician ordered treatment with a start date of 12/5/23 to the left ischium revealed there was no documented evidence the treatments were completed on 1/1/24, 1/7/24, 1/10/24, 1/14/24, 1/15/24, 1/17/24, 1/18/24, 1/19/24, 1/21/24 and 1/22/24. The physician ordered treatments with a start dated of 12/25/23 for PICC line catheter care and dressing change revealed there was no documented evidence the treatments were completed on 1/1/24 and 1/15/24. Review of Progress Notes dated 1/1/24 through 1/23/24 revealed there was no documented evidence Resident #9 refused treatments. Review of a Wound Assessment and Plan dated 1/4/24 revealed Medical Doctor #1 documented, left ischium pressure ulcer stage 4 measured 5.5 centimeters in length x 6.5 centimeters in width x 3.5 centimeters in depth with undermining at 12 o'clock 3 centimeters. During an observation and interview on 1/25/24 at 11:34 AM, revealed Resident #9 had a stage 4 pressure ulcer of left ischium with large amount of serosanguinous drainage. Medical Doctor #1 during the observation measured the ulcer and stated it was 6 centimeters x 5 centimeters x 3.5 centimeters with undermining at 12 0'clock that measured 3.1 centimeters. During an interview on 1/23/24 at 8:00 AM, Resident #9 who was able to answer yes/no questions expressed their pressure ulcer treatment was not completed as ordered and it was very upsetting. During an interview on 1/25/24 at 1:10 PM, Register Nurse #2 reviewed the January 2024 Treatment Administration Record and stated they were unable to complete the treatments as ordered for Resident #9 on 1/1/24, 1/7/24, 1/10/24, 1/15/24, 1/17/24, 1/18/24 and 1/21/24 as ordered. During a telephone interview on 1/26/24 at 9:11 AM, Licensed Practical Nurse #4 stated they were unable to complete the treatments for Resident #9 on 1/14/24. During an interview on 1/26/24 at 10:35 AM, Unit Manager Registered Nurse #1 reviewed the January 2024 Treatment Administration Record and stated they were unable to complete the treatments for Resident #9 on 1/12/24 and 1/22/24. During an interview on 1/26/24 at 12:55 PM, Licensed Practical Nurse #3 reviewed the January 2024 Treatment Record and stated they were unable to complete the treatments for Resident #9 on 1/19/24. During an interview on 1/23/24 at 2:15 PM, Unit Manager Registered Nurse #1 stated Registered Nurse #2 had reported to them on multiple occasions they were unable to complete resident treatments because the workload was too great. Registered Nurse #1 stated they last reported the concern to the Director of Nursing on Friday 1/19/24, and was directed to inform the evening nurses to complete the treatments. During an interview on 1/26/24 at 10:50 AM, Unit Manager Registered Nurse #1 stated the Nurse Practitioner and Medical Doctor #1 were aware treatments were delayed but had not informed them the treatments were not completed on multiple days. During an interview on 1/23/24 at 3:00 PM, Registered Nurse #5 stated staffing had been challenging at times and was not aware the nurses were unable to complete the treatments on Unit 1. Registered Nurse #5 stated they would expect the Unit Manager to directly inform the Assistant Director of Nursing and/or the Director of Nursing if treatments were not able to be completed. During an interview on 1/23/24 at 3:32 PM, Registered Nurse #6 stated they were not aware treatments on Unit 1 were not being completed as ordered. Registered Nurse #6 stated it extremely important the resident's receive treatments as ordered to promote wound healing. During an interview on 1/25/24 at 11:14 AM, Nursing Supervisor Licensed Practical Nurse #5 stated everyone including the Director of Nursing and the Administrator were aware the treatments were not being completed on Unit 1 and related the reasoning to staffing. Nursing Supervisor Licensed Practical Nurse #5 stated if there was a blank on the Treatment Administration Record then it was most likely the treatment was not done. During an interview on 1/25/24 at 11:39 AM, Medical Doctor #1 stated they were not aware Residents #3, #5, #6, #7, #8, #9, and #10 treatments were not completed as ordered. Medical Doctor #1 stated nurses would say they were unable to complete the treatment yet, and believed they meant for that day, not for 24 hours or greater. Medical Doctor #1 stated the nurses should be following the physician orders and if they were unable to complete treatments they should be notifying the Director of Nursing or the Administrator so additional staffing could be assigned. They stated they would have expected the nurses to inform them if treatments were not able to be completed as ordered. During an interview on 1/25/24 at 4:15 PM, Licensed Practical Nurse #1 (evening shift) stated were aware the day shift nurses on Unit 1 were unable to get the treatments completed and the evening shift does not have time to complete them. LPN #1 stated they believed the Director of Nursing and Administrator were aware. Additionally, they stated treatments were important to promote healing and physician orders should be followed. During an interview on 1/25/24 at 4:36 PM, Registered Nurse #3 stated they worked evenings and often were unable to complete all the treatments on the evening shift because of the acuity of the residents on Unit 1. Registered Nurse #3 stated they believed the Director of Nursing and the Administrator were aware. During an interview on 1/25/24 at 5:15 PM, Registered Nurse #4 stated they were aware the day shift nurses were unable to complete all treatments as ordered and related the reasoning to staffing concerns and the acuity of the residents. Registered Nurse #4 stated they would have expected the evening nurses to inform them during the shift if day shift asked them to help with treatments, and to inform them if they were unable to complete the evening shift treatments. During an interview on 1/26/24 at 11:41 AM, Nurse Practitioner #1 stated the staff on Unit 1 have told them that they were short staffed and treatments were being completed later during the day, was not aware treatments were not being completed for days. NP#1 stated Unit Manager Register Nurse #1 should have made sure the Director of Nursing, the Administrator and a provider were aware of the issue. NP #1 stated the physician orders should be followed to promote wound healing. NP #1 stated they did not inform the Administrator and the Director of Nursing because they believed they already were aware of the concern. During an interview on 1/26/24 at 1:47 PM, the Director of Nursing stated they were not aware treatments were not completed for days and would have expected the staff nurses, Nursing Supervisors and the Unit Managers to inform them. The Director of Nursing stated treatments were not an option and expected the physician's orders to be followed. During an interview on 1/26/24 at 2:28 PM, the Administrator stated they were not aware treatments were not completed as ordered by the physician and would have expected the Unit Manager to have informed them. During an interview on 1/26/26 at 4:00 PM, Medical Doctor #2 (acting Medical Director) stated they were not aware the nurses were unable to complete treatments as ordered and would have expected communication from the nurses to the providers and administration that orders were not being followed. Medical Doctor #2 stated they expect physician orders to be followed and all residents receive the treatments as ordered. Additionally, they stated there should be a note in the resident's medical record that it was not completed as ordered. 10NYCRR 415.12 (c)(2)(k)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey started on 12/14/22 and completed on 12/20/22, 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 one (Resident #17) of two residents reviewed for ADLs. Specifically, the CNA performed incomplete morning (AM) care, staff did not wash residents' hands which included long fingernails with brown debris under their nails and did not provide oral care or deodorant. In addition, there was lack of adequate hand hygiene and glove changes during care. The findings are: Review of the facility Policy and Procedure (P&P) titled A.M. Care revised 4/2018 documented to wash hands thoroughly. Assist with or perform oral hygiene. Wash face, and hands. Perform perineal care if applicable. Discard gloves and wash hands thoroughly. Assist with application of deodorant/powder. Assist with dressing or dress resident in clean clothes. Provide nail care if indicated. Clean and return equipment to proper location. Discard gloves (if worn) and wash hands thoroughly. Review of the (P&P) titled Perineal, Incontinence Care revised 5/2018 documented perineal care will be provided with a.m. care and when residents are incontinent or cannot provide such care for themselves. The steps of the procedure included to: Wash hands thoroughly: Apply gloves: Place barrier pad under the resident: Provide perineal care: Turn the resident and wash, rinse, and dry buttocks and both hips. Discard gloves and wash hands thoroughly was required for infection control. 1.Resident #17 was admitted to the facility with diagnoses which included dementia, peripheral vascular disease, and hypertension-HTN. The Minimum Data Set (MDS, a resident assessment tool) dated 12/9/22 documented the resident had moderate cognitive impairment, was usually understood and usually understands. The MDS further documented the resident required extensive assistance of one staff member for personal hygiene. The Visual/Bedside [NAME] Report (a guide used by staff to provide care) with an as of date 12/18/22 documented Resident #17 was always incontinent of bladder and was to be encouraged and assisted with oral care every morning. The Comprehensive Care Plan (CCP) dated 9/27/22 documented Resident #17 required one-person physical assist for personal hygiene/bathing, incontinent care every 2-4 hours and as needed, and oral care every morning. During observation and interview on 12/14/22 at 1:46PM and 12/15/22 at 9:26AM, Resident #17 had ½ inch long fingernails, dirty with brown debris. Resident #17 stated their nails needed to be cleaned. During observation of morning care on 12/16/22 at 9:56AM, certified nurse aide (CNA) #6 put gloves on without washing their hands prior to providing care. CNA #6 washed and dried Resident #17's face, chest and did not clean Resident #17's arms, back, legs, feet, hands, or fingers. CNA #6 put a shirt on Resident #17 without offering deodorant. CNA #6 provided urinary incontinent care and dried Resident #17. Without changing their gloves or performing hand hygiene, CNA #6 applied a clean brief and pants to Resident #17. With the same gloves on, CNA #6 opened the bathroom door touching the doorknob, returned a bottle of soap into the bathroom and emptied the basin of water. CNA #6 then closed the bathroom door by touching the doorknob. With both gloved hands, CNA #6 positioned the over the bed table at the bedside. CNA #6 then discarded the soiled linen and stated morning care had been completed. CNA #6 did not offer or assist Resident #17 with oral care or cleaning their fingernails. During an interview on 12/16/22 at 10:35AM, CNA #6 stated a.m. care included washing the face, armpits, chest, and peri care. Arms, legs, and the back were washed on shower days. Hands were washed prior to meals and as needed. CNA #6 stated Resident #17 regularly refused deodorant and nail care therefore they didn't provide nail care or deodorant but should have. CNA #6 stated the soiled gloves should have been removed and hand hygiene performed after providing incontinent care to avoid contamination. CNA #6 stated they didn't think to provide oral care and should have. During an interview on 12/16/22 at 11:15AM, Licensed Practical Nurse (LPN) #5 stated Resident #17's fingernails were long, dirty, and needed to be cleaned and cut. CNAs were responsible for providing nailcare unless the resident was diabetic. LPN #5 stated CNA #6 should have soaked, cleaned and trimmed them during am care. During an interview on 12/16/22 at 11:36AM, Registered Nurse (RN) #5 Nursing Supervisor stated a.m. care included oral care, washing the face, hands, armpits, peri area, and feet daily. Nails were expected to be inspected during a.m. care daily and cleaned, if necessary, Not just on bath days, for hygiene and infection control practices, hands touched everything. CNA #6 should have performed hand hygiene and put on gloves prior to giving care and should have removed their soiled gloves and wash hands after performing peri care. Clean gloves should have been put on before touching various objects and avoided contaminating and spreading the bacteria. During an interview on 12/20/22 at 12:30PM, RN # 1 Unit Manager, stated a.m. care included a full bed bath from head to toe, which included the face, underarms, arms, hands, peri care, legs, feet and back. Oral care and nail care was expected to be provided daily. Hand hygiene should be performed by CNAs before care, during care, and after peri care to reduce the spread of infection. During an interview on 12/20/22 at 12:51PM, RN #2, Nurse Educator stated bed baths were expected to be given daily. Bed baths included oral care, washing face, chest, arms, hands, legs, feet, back and buttocks. Nails were expected to be visualized daily and cleaned if needed. CNA #6 should have provided Resident #17 oral care or should have offered to rinse or swabbed their mouth. During an interview on 12/20/22 at 1:27PM, the Director of Nursing (DON) stated oral care, nail care and putting on deodorant were included in am care. Hand hygiene was expected before care, after care, and anytime gloves were visibly soiled and prevented the spread of infection. 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 started 12/14/22 and completed 12/20/22, the facility did not ensure that a resident who enters the facility with an indwelling catheter (Foley-tube inserted into the bladder to drain urine) received the appropriate care and services to prevent urinary tract infections (UTIs) to the extent possible for one (Resident #70) of one resident reviewed for urinary catheters. Specifically, the Foley catheter was not secured to prevent kinking or tension, and a leg bag was not applied per the plan of care and the physician's orders for a resident with a history of urinary tract infections (UTIs). In addition, the Foley catheter and drainage bag were not secured properly, and the drainage bag fell to the floor during a mechanical lift transfer. The finding is: The facility policy and procedure (P&P) titled Catheter, Emptying/Changing of Urinary Drainage bag dated 9/18/2020 documented to place catheter bag in a privacy/cover and ensure proper positioning of bag to allow for drainage via gravity. Ensure the catheter drainage bag, tubing and privacy cover are not touching the floor. The P&P did not reflect how to secure the Foley catheter or prevent kinking. The facility (P&P) titled Catheter, Daily Care (Indwelling) dated 11/23/2022 documented to avoid pulling on the catheter. This could cause injury to the urinary meatus or bladder wall. Position of the drainage bag should be below the level of the bladder. Collection bags and tubing should not touch the floor. The policy and procedure did not reflect securing the catheter or tubing during transfers. 1.Resident #70 was admitted with diagnoses which included sepsis related to urinary tract infection (UTI), multiple sclerosis (MS- a disease where the immune system eats away at the protective covering of the nerves), and obstructive uropathy (obstruction in urinary tract). The Minimum Data Set (MDS- a resident assessment tool) dated 11/21/22 documented Resident #70 had intact cognition and an indwelling catheter. The hospital Discharge summary dated [DATE] documented Resident #70 had a septic shock complicated UTI and bacteremia (the presence of bacteria in the blood) in the setting of a chronic Foley due to neurogenic bladder. The Comprehensive Care Plan (CCP) dated 11/17/22 documented Resident #70 had an indwelling Foley catheter. Interventions included to provide catheter care daily, urinary catheter security strap at all times and a urinary leg bag when out of bed. The current Visual/Bedside [NAME] Report (a guide used by staff to provide care) with an as of date of 12/19/22, documented an indwelling Foley catheter, urinary leg bag out of bed, and urinary catheter security strap. The Order Summary Report dated 12/19/22 documented active physician's orders with a start date of 11/16/22 for a urinary catheter, a urinary catheter leg bag while out of bed, and a urinary catheter drainage bag while in bed. On 12/15/22 at 9:05AM, Resident #70 was observed seated in their wheelchair. A Foley catheter drainage bag was positioned underneath the wheelchair. Resident #70 stated the catheter pulled and was uncomfortable, the catheter strap was lost and wasn't replaced. During intermittent observations from 12/15/22 through 12/16/22 between the hours of 9:00AM and 3:00PM Resident #70 had no urinary catheter leg bag when out of bed. The catheter was not secured with a leg strap. On 12/19/22 at 9:34AM, Resident #70 was observed in bed with their left leg on top of the urinary catheter and tubing and obstructed the urine flow. The catheter tubing had milky yellow urine with brown sediment from the catheter along the full length of the catheter tubing to the drainage bag. No security strap anchored the Foley catheter in place. The drainage bag was not labeled or dated. Observation on 12/19/22 at 10:12AM, revealed during a mechanical lift transfer certified nurse aide (CNA) #7 hooked the Foley catheter drainage bag on the bar of the mechanical lift above the level of Resident #70's bladder. During the transfer from the bed to the wheelchair, the drainage bag fell off the bar to the floor. CNA #7 picked up the drainage bag off the floor and hung the drainage bag under the wheelchair. During an interview on 12/19/22 at 10:32AM, CNA #7 stated the leg strap held the catheter in place and prevented tugging and pulling. Leg bags were used for comfort when out of bed. Nurses were responsible to ensure the leg strap and leg bag were used. CNA #7 stated they overlooked the leg strap and leg bag on the [NAME] and should have notified the nurse to secure the catheter and change the bag. The Foley drainage bag should have been positioned on the resident's lap or held below the level of the bladder during the transfer. CNA #7 stated the catheter could have been pulled out and caused trauma. During an interview on 12/20/22 at 12:16PM, Registered Nurse (RN) #1 Unit Manager (UM) stated nurses were responsible to ensure leg straps and urinary leg bags were on. CNAs were expected to read the [NAME] prior to care and notify the nurse when the leg strap was missing. Nurses changed the urinary drainage bag to the leg bag and this should have been done prior to the transfer and decreased the potential risk of trauma. The urinary drainage bag should have been replaced because at no point should it touch the floor for infection control purposes. During an interview on 12/20/22 at 12:51PM, RN #2, Nurse Educator stated nurses signed for leg straps and leg bags on the Treatment Administration Record (TAR) per the physician's order. CNAs were expected to read the [NAME] prior to care. CNA #7 should have notified the nurse or unit manager. The nurse or unit manager should have secured the catheter. The urinary drainage bag should have been changed prior to the mechanical lift transfer and it would have prevented the drainage bag from falling on the floor. RN #2 Nurse Educator stated when the drainage bag touched the floor, it's contaminated, and should be changed. During an interview on 12/20/22 at 1:41PM, the Director of Nursing (DON) stated CNAs could switch the drainage bag to the leg bag with proper infection control measures. Catheter straps held the catheter tubing in place and prevented tugging. Resident #70 should have had a leg strap and leg bag on. CNA #7 should have transferred Resident #70 with the urinary drainage bag between the residents' legs, not on the bar. The urinary drainage bag should have been replaced after falling on the floor due to contamination. The DON stated when positioned higher than the bladder you can have backflow of urine, causing infection. Changing to a urinary leg bag before the transfer would have prevented possible trauma, and contamination. 415.12(d)(1)

Based on observation, interview, and record review conducted during the Standard survey started on 12/14/22, completed on 12/20/22, the facility did not ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with the physician's orders, and the comprehensive person-centered care plan for one (Resident #21) of one resident reviewed. Specifically, there was lack of physician orders and Registered Nurse (RN) assessment, for monitoring arm circumference, external length, and dressing changes of a PICC line catheter (peripherally inserted central catheter - a catheter that is inserted through a vein and advanced until the tip enters the central venous system). Additionally, normal saline (NS-a mixture of salt and water, compatible with body fluid, used to maintain IV (intravenous) catheter patency) flushes were not administered since course of IV antibiotics completed on 12/11/22. The finding is: The facility policy and procedure (P&P) titled PICC Line-Dressing Change, Site Care, and Monitoring last modified 8/26/19, documented PICC line dressings are routinely changed every seven days; when the dressing becomes loose, wet, or soiled; or per the orders of the attending physician. The dressing/monitoring procedure will be performed by an appropriately trained and competent licensed nurse, pursuant to state law, as ordered by a practitioner. The P&P documented to measure the length of exposed line (migration), every week, and document the measurement on the Treatment Administration Record (TAR). After dressing changes, apply label to dressing including date and time of change and nurse initials. Document the following in the nursing progress notes and monitoring/TAR: Performance of procedure; Observation of insertion site; Catheter length (migration); Arm circumference-measure 4-6 inches above insertion site; Resident tolerance to treatment; follow up monitoring and care. The policy provided did not contain maintenance/saline flushing guidance. Facility P&P titled Electronic Physician Orders (Create, Confirm, Processing Orders) last modified 7/23/18, documented physician 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 (EMR) system by the nurse following confirmation from the practitioner or directly entered by the medical provider. 1. Resident #21 was admitted to the facility with diagnosis including sepsis (severe blood infection), surgical aftercare following surgery on the skin, and diabetes. The Minimum Data Set (MDS-a resident assessment tool) dated 11/23/22 documented Resident #21 was cognitively intact, understands and was understood. A hospital OR-Attending Operative Report dated 12/2/22 documented Resident #21 had a PICC line placed in the RUE (right upper extremity), was in proper position, and was ok to use the line. The comprehensive care plan (CCP) initiated 12/5/22 documented Resident #21 had a PICC in the RUE. Documented interventions included to change the dressing per policy/MD orders, flush per MD orders, IV administration per MD orders, PICC: Measure/document on resident TAR (treatment administration record) the arm circumference and migration of catheter on admission/insertion of PICC line, and the RN was to measure and document on TAR the circumference and migration of PICC catheter weekly. Review of EMR physician's orders documented the following: -Start date 12/2/22 -Vancomycin (antibiotic) 1.5 gram (1500 milligrams-mg) IV every (q) 12 hours(h) for infection. Administer at 9:00 AM and 9:00 PM. Stop date 12/5/22. -Start date 12/6/22- Vancomycin 1000 mg IV q12h for infection until 12/12/22 6:00 AM. Administer at 6:00 AM and 6:00 PM. -Hold date 12/6/22- 12:45 PM to 12/7/22 5:59 AM and 12/7/22 1:23 PM to 12/8/22 3:00 AM. -Start date 12/2/22-Sodium Chloride Solution 0.9% (NS) use 10 milliliter (ml) IV q12h for flush. Stop date 12/5/22. -Start date 12/2/22-PICC Line: Monitor for signs/symptoms (s/s) of infection q shift The physician orders did not include PICC line dressing changes, catheter length (migration), or arm circumference-measurement guidance/orders. Review of the Medication Administration Record (MAR)/TAR dated 12/1/22 through 12/31/22 lacked documented evidence of PICC line dressing changes, catheter length (migration), or arm circumference-measurements. There was no documented evidence of NS flush after 12/5/22. Review of the nursing and physician/provider progress notes from 12/2/22 through 12/18/22 lacked documented evidence of PICC line dressing changes, catheter length (migration), arm circumference-measurements, or NS flushes. During interview on 12/15/22 at 7:57 AM, Resident #21 stated they had to go to the hospital the week before last to have the PICC line placed. The resident stated the last time the PICC was used for the IV antibiotic was this past Sunday or Monday. The resident stated they were taking oral antibiotic at this time. I imagine they will leave this (PICC) until they know I won't need it again. Intermittent observations of Resident #21 from 12/14/22 through 12/19/22 identified the following: -12/14/22 at 11:20 AM PICC line observed RUA (right upper arm). Transparent dressing over PICC site was lifting away from skin medially and laterally. PICC sutured in placed. PICC insertion site visible beneath transparent dressing was observed with yellowish/tan discoloration. There were no initials, date, or time visible on dressing. -12/15/22 at 8:12 AM PICC line observed RUA. Transparent dressing over PICC site was lifting away from skin medially and laterally. PICC sutured in placed. PICC insertion site visible beneath transparent dressing was observed with yellowish/tan discoloration. There were no initials, date, or time visible on dressing. -12/16/22 at 1:58 PM AM PICC line observed RUA. Transparent dressing over PICC site was lifting away from skin medially and laterally. PICC sutured in placed. PICC insertion site visible beneath transparent dressing was observed with yellowish/tan discoloration. There were no initials, date, or time visible on dressing. -12/19/22 at 9:35 AM PICC line observed RUA. Transparent dressing over PICC site was lifting away from skin medially and laterally. PICC sutured in placed. PICC insertion site visible beneath transparent dressing was observed with yellowish/tan discoloration. There were no initials, date, or time visible on dressing. During interview on 12/19/22 at 9:38 AM, Licensed Practical Nurse (LPN) #9 stated LPNs were responsible for monitoring PICC line sites for signs of infection. RN's take care of the rest as far as medications, flushes, dressing changes. I just let them know when antibiotics, flushes, medications or dressing changes are due. Upon review of Resident #21's eMAR LPN #9 stated the resident was not receiving antibiotic or flushes at this time. I guess I didn't realize there were no dressing changes, on the MAR/TAR, because RN's do that. During interview on 12/19/22 at 9:45 AM, RN Unit Manager (UM) #4 stated the NP (Nurse Practitioner) ordered Resident #21 to go out and have PICC placed on 12/2/22 for concern of infection/cellulitis. Upon reviewing the residents EMR, orders, MAR/TAR RN UM #4 stated NS flushes were standard practice pre and post IV antibiotic infusion and they were getting done when the resident was receiving the IV antibiotic. When a resident completes a course of IV antibiotics NS flushes should be continued q12hrs for patency of the PICC line, to prevent occlusion. Additionally, RN UM #4 stated there were no orders for dressing changes, catheter length, or arm circumference and that should be done weekly, for infection control and monitoring for any issues with the PICC line. The orders should have been put in when the resident had the PICC placed, baseline arm circumference and catheter length should have been done, but they were not. I was not here when the resident returned from procedure. The Supervisor would have been responsible to update the orders upon the residents return. It was an oversight. RN UM #4 stated the resident did not return with any paperwork, from the hospital, post procedure, documenting information regarding PICC line brand, catheter length, or additional orders that they were aware of. I haven't seen any residents come with PICC line information, after placement or from the hospital, in a long time. During an interview on 12/19/22 at 3:40 PM, the Director of Nursing (DON) stated they would expect baseline documentation regarding PICC line when the resident returned to the facility after having the PICC line placed. All PICC line care needs to be added to the record when the resident has one placed. During an interview on 12/20/22 at 2:07 PM, the Nurse Practitioner stated they would expect PICC line care to be done based on facility policy and procedure. Dressing changes, assessments, measurements, flushes were standard practice when a resident has a PICC line. I was not aware that was not being done. It is standard practice and should have been. Facility policy should be followed. It should be flushed q12h, at least, to maintain patency of the PICC line and dressing changes for assessment and infection control purposes. During an interview on 12/20/22 at 2:15 PM, the DON stated they would expect staff to follow facility policy and procedure for PICC line care. There were batch, standing, PICC line orders in the EMR. They should be added on admission/readmission when a resident has a PICC line. When a resident with a PICC line completes their IV antibiotics the PICC should continue to be flushed q12h to maintain patency, in the event, that it is needed again. Assessments and dressing changes should be done weekly, and as needed for infection control purposes and safety monitoring of the central line. 415.12

Based on observation, record review, and interview conducted during the Standard survey started 12/14/22 and completed 12/20/22, the facility did not ensure that residents who use psychotropic drugs receive gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #85) of four residents reviewed for antipsychotic medications. Specifically, an order to decrease the antipsychotic medication Quetiapine Fumarate (Seroquel) was not implemented, which caused the resident to receive additional doses on 12/16/22 through 12/19/22. The finding is: Review of facility policy and procedure (P&P) titled Psychotropic Drugs last modified 7/6/18, documented residents prescribed psychotropic drugs will receive only those medications, in doses and for duration clinically indicated to treat the resident's assessed condition(s). Review of facility P&P titled Electronic Physician Orders last modified 7/23/18, documented the License Nurse transcribing the medical order into the EMR (electronic medical record) will ensure the correct date, time, ordering prescriber, medication name, order category, communication method, route of administration, frequency, schedule, indications for use or diagnosis and source details are listed. 1. Resident #85 was admitted with diagnoses including unspecified dementia with agitation, history of falls and unspecified injury of left lower leg. The Minimum Data Set (MDS - a resident assessment tool) dated 10/22/22 documented the resident had severe cognitive impairment. The MDS documented the resident received antipsychotic medication on a routine basis, a GDR had not been attempted, and a GDR had not been documented by a physician as clinically contraindicated. Intermittent observations of Resident #85 from 12/15/22 through 12/19/22 between 8:00 AM and 1:30 PM, revealed the resident was confused, unable to identify self, sat in a wheelchair positioned near the nurse's station or in the dining room with their head positioned down on chest, sleeping. Resident #88 was observed to sleep through meals. The comprehensive care plan (CCP) initiated on 10/3/22 documented the resident had the potential for alteration in mood/behavior related to progressive disease process, dementia with verbal behavioral symptoms directed towards others and was non-compliant with plan of care. On 10/4/22 the CCP documented the resident had been ordered psychotropic medication related to dementia. Interventions included to administer medications per order. The goal was to be maintained on the lowest therapeutic dose of the psychotropic medication. The Progress Notes dated 12/16/22 at 9:57 AM, written by the Physician's Assistant (PA), documented a trial reduction of Seroquel to 12.5mg at HS (bedtime). If tolerated well, will d/c (discontinue) in the future. No history of psychosis warranting antipsychotic medication. Review of an Order Recap Report dated 12/18/22 documented the following physician orders: -Seroquel 25 milligrams (mg) give 1 tablet by mouth (po) at bedtime (HS) for dementia with a start date of 9/30/22 and no end date. -Seroquel 25mg, give 0.5 tablet=12.5mg, po at hs for dementia with a start date of 12/16/22 and no end date. Review of electronic Medication Administration Records (MAR) dated 12/16/22 through 12/19/22 documented the resident received a Seroquel 25mg dose and a Seroquel 12.5mg dose at HS from 12/16/22 to 12/19/22. Review of nursing Progress Notes dated 12/16/22 to 12/19/22, revealed no documentation that Resident #85 refused their medications. During an interview on 12/20/22 at 9:50 AM, LPN #2 UM, stated on 12/16/22 Resident #85 had a reduction in their Seroquel from 25mg to 12.5mg daily for dementia. LPN #2 UM stated they received, confirmed, and accepted an order for the Seroquel dose change from the PA. LPN #2 UM stated Seroquel 25mg should have been discontinued, so Resident #85 was not over medicated and to prevent a medication error from occurring. LPN #2 UM reviewed Resident #85's orders with surveyor in the electronic medical record (EMR) and discontinued the Seroquel 25mg order at this time. LPN #2 UM stated they didn't know why they hadn't discontinued Seroquel 25mg on 12/16/22, but that they should have. LPN #2 UM stated Resident #85 should have only received Seroquel 12.5mg daily at HS since 12/16/22. During a telephone interview on 12/20/22 at 11:53 AM, LPN #4 stated they administered medications to Resident #85 during the evening shifts at hs on 12/16/22, 12/18/22 and 12/19/22. LPN #4 stated they did not remove any medications from the prefilled pharmacy packages prior to administration. LPN #4 stated Resident #85 should not have had an order for both doses of Seroquel and if Resident #85 did, they would not have known not to give it. Additionally, LPN #4 stated their initials on the MAR indicated that the medications were given. A chart code would be used, and they would write a note to indicate something different, like a refusal. During a telephone interview on 12/20/22 at 11:29 AM, the PA stated Resident #85 recently started a trial dose reduction of Seroquel 25 mg to 12.5mg as they did not have any kind of psychosis. Resident #85 should have only been receiving Seroquel 12.5mg daily since 12/16/22. During an interview on 12/20/22 at 12:09 PM, the Director of Nursing (DON) stated their expectation would be that when a new order for a new dose of medication was given, that the prior order be discontinued. Additionally, the DON stated it was a GDR order and Seroquel should have been reduced. During a follow up interview at 12:36 PM, the DON stated Resident #85 received an extra half tablet of Seroquel because the previous order was not discontinued. 415.12 (l)(2)(i)(a)

Based on observation, record review, and interview conducted during a Standard survey started 12/14/22 and completed 12/20/22, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, three (Unit 1, Unit 3, and Unit 5) of four resident units reviewed for food temperatures during meals had issues involving food items that were not palatable and at safe and appetizing temperatures. Residents' #15, #85, #87 and #122 were involved. The findings are: The facility's policy and procedure titled Food Temperature Requirements and Holding Time dated 6/28/19 documented the Director of Dining Services or designee will be responsible for assuring the proper temperatures and holding times of foods are maintained during the preparation and service of meals. Steamtable thermostats will be turned on 30 minutes prior to the meal service and set to maintain hot foods between 140-160 degrees Fahrenheit (°F). Cold food items should be held in an appropriate container or bin to maintain the temperature below 41°F. During an interview on 12/14/22 at 11:56 AM Resident #15 stated Meals were served cold most of the time. During an interview on 12/14/22 at 1:03 PM Resident #87 stated the food is always cold and has to wait a long time to get their tray when the cart comes to the unit. Further interview on 12/16/22 at 10:14 AM Resident #87 stated breakfast was Ok not that good same as usual food was cold. During an interview on 12/14/22 at 1:21 PM Resident #122 stated The food was always served cold. During an observation on 12/19/22 the dietary cart arrived on Unit 3 at 12:26 PM. All the lunch trays from the Unit 3 dietary cart were passed to the resident's by 12:51 PM. The test tray temperatures were then taken by the surveyor using the surveyor's thermometer at 12:52 PM. The temperatures obtained and taste were as follows: -Baked ham, sliced 91.4°F, tasted cool, tough to chew -Au gratin potatoes 100.4°F, tasted lukewarm -Mixed vegetables 88.1°F, tasted cool -Coffee measured 104.6°F, tasted lukewarm During an observation on 12/19/22 all lunch trays for Unit 5 last meal cart were passed to the residents by 12:39 PM. The test tray temperatures were then taken by the surveyor using the surveyor's thermometer at 12:40 PM. The temperatures obtained and taste were as follows: -Baked ham 106.5°F, cold, tasted bland -Au gratin potatoes 117.9°F, tasted lukewarm -Mixed vegetables 114.8°F, tasted cold and bland -Milk 50.6°F, tasted lukewarm -Apple juice 53.6°F, tasted lukewarm During an observation on 12/19/22 the last dietary cart arrived on Unit 1 at 12:43 PM. All lunch trays for Unit 1 were passed to the residents by 1:08 PM. The test tray temperatures were then taken by the surveyor using the surveyor's thermometer at 1:09 PM. The temperatures obtained and taste were as follows: -Baked ham 107°F, tasted cold and bland -Au gratin potatoes 127.2°F, tasted lukewarm -Mixed vegetables 118°F, tasted mushy, bland, and cold -Milk 55.1°F, tasted lukewarm -Coffee 99°F, tasted cool During an interview on 12/19/22 at 12:53 PM Resident #15 stated the lunch meal served today was cold. The ham, potatoes and the mixed vegetables were blah and had no taste. During an interview on 12/19/22 at 12:55PM Resident #122 stated Lunch was cold again. During an interview on 12/19/22 at 1:09 PM, Resident #85 stated the ham was salty and cold. Additionally, Resident # 85 stated the potatoes were cold. During an interview on 12/20/22 at 9:34 AM the Assistant Director of Dietary Services stated hot foods should be severed above 165°F and cold foods below 41°F. The coffee is pre-poured before the meal at 160°F. Dietary and nursing have to come together and make sure trays are passed in a timely manner. The plate warming unit has been out of service since January, we had to return the new unit last week because the plates did not fit. With the new unit, foods would stay hotter. During an interview on 12/20/22 at 1:49 PM the Registered Dietitian (RD) stated hot foods should not be served below 140°F and cold foods not below 40°F, milk and pre-poured cold beverages should be stored over ice during tray line service. 415.14(d)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the Standard survey started 12/14/22 and completed 12/20/22, the facility did not provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks. Three (Resident #7, #14 and #85) of three residents reviewed for assistive devices were not provided inner lip plates for their meals. The findings are: The facility policy and procedure titled Adaptive Equipment dated 1/19/2018 documented staff will ensure that each resident, as appropriate, is provided any necessary equipment and trained in its use, designed to facilitate, and enhance the resident's ability to function independently. This applies to equipment designed to aid self-feeding. Equipment will be listed on the Resident Care Plan, as appropriate. The facility document titled Feeding Guidelines dated 3/12 documented to provide verbal cueing/assistance and adaptive equipment as indicated on meal ticket/Profile of Care. Encourage resident to feed self as much as possible. Review of the facility document for Unit 3 titled Adaptive Equipment by Unit for Friday, December 16, 2022 listed Adaptive Equipment, inner lip plate, for Resident's #7, #14 and #85. 1) Resident #7 had diagnoses including unspecified dementia, Type 2 Diabetes Mellitus (DM) and dysphagia (difficulty swallowing). The MDS dated [DATE] documented the resident was severely cognitively impaired, sometimes understood and sometimes understands. Required supervision, one-person physical assist with eating. Had mechanical altered diet. The comprehensive care plan (CCP) initiated 9/22/22 documented the resident had a deficit in ADL function/mobility related to unspecified dementia and anxiety. Interventions/Tasks initiated 11/18/22 included eating-supervision/setup help only**colored inner lip plate. Review of Resident #7 Visual/Bedside [NAME] Report as of 12/18/2022 documented eating-supervision/setup help only** inner lip plate. During an observation on 12/14/22 at 8:59 AM and on 12/15/22 at 12:23 PM, Resident #7 was sitting in unit dining room with meal on tray. The resident's meal ticket documented blue inner lip plate, food observed on regular plate, no inner lip dish present on tray. Resident observed to have difficulty transitioning food onto utensils. During an observation on 12/16/22 at 12:28 PM, Resident #7 was sitting in unit dining room with lunch meal, with no blue inner lip plate provided. Resident's meal ticket documented the resident was to have a blue inner lip plate. Resident # 7 was observed having to utilize fingers to assist with placement of food onto fork. Resident #7 was unable to tell surveyor if they minded using fingers to assist with placement of food onto fork. Review of occupational therapy evaluation and plan of treatment baseline 9/23/22 states, Resident #7 requires minimal assist to complete self-feeding at that time to avoid spillage and ensure adequate nutritional intake. Review of the Occupational Therapy Treatment Encounter Note(s) dated 11/9/22 revealed Resident #7 would benefit from inner lip plate. Care plan and meal ticket updated. Additionally, on 11/18/22 documented continued recommendation of colored lip plate, however not on breakfast tray this morning. Care plan and meal ticket up to date and accurate. Review of the printed email dated 11/9/22 at 8:25 AM, OT email to Meal Ticket Updates, documented Resident #7 now requires limited assistance for all meals with inner lip plate. Additionally, email sent 11/18/22 at 8:15 AM documented Resident #7 now requires supervision after set-up with continued use of colored inner lip plate. Review of the nutritional assessment dated [DATE] documented, adaptive equipment, inner lip plate, resident has poor eyesight. During an interview on 12/16/22 at 12:58 PM, Certified Nursing Assistant (CNA) #3, stated adaptive equipment is usually on residents' meal ticket on their trays or under eating on a resident's care plan. CNA #3 did not know if Resident #7 required any adaptive equipment. Upon looking at meal ticket present on Resident #7's tray CNA #3 stated that Resident #7 was supposed to have an inner lip plate and didn't. CNA #3 stated that whoever passes the tray to the resident is responsible for making sure they are being provided with everything indicated on meal ticket, including level of assistance and adaptive equipment. If it is noticed that something is missing during tray pass, then dietary should be called. Additionally, CNA #3 stated adaptive equipment assists residents to eat and would help promote intake. 2) Resident #14 had diagnoses including Alzheimer's disease, type 2 DM, and dementia with mood disturbance. The MDS dated [DATE] documented the resident was moderately cognitively impaired, usually understood and sometimes understands. Resident #14 required supervision with setup help only for eating. The CCP revised on 12/14/22 documented the resident had deficit in ADL function/mobility related to Alzheimer's disease. Interventions/Tasks with revision of 11/11/22 included eating-supervision/setup help only**inner lip plate. Review of Resident #14 Visual/Bedside [NAME] Report as of 12/18/22 documented eating-supervision/setup help only**inner lip plate. During an observation on 12/14/22 at 8:59 AM, Resident #14 was sitting in unit dining room with breakfast meal on paper plate. Meal ticket on tray documented inner lip plate. Spillage of food noted on tray. Additionally, on 12/15/22 at 12:24 PM and 12/16/22 at 12:26 PM, inner lip plate was not present for meals as indicated on meal ticket. No assistance was observed to be given. Review of the progress note dated 11/11/22 at 10:14 AM written by therapy revealed late entry-on this date Resident #14 changed to inner lip plate at meals, dietary staff verbally informed. The nutritional assessment date 11/20/22 documented, adaptive equipment, inner lip plate, supervision for eating pet OT. 3) Resident #85 had diagnoses including unspecified dementia with agitation, history of falls and unspecified injury of left lower leg. The Minimum Data Set (MDS-a resident assessment tool) dated 10/22/22 documented the resident was severely cognitively impaired, usually understood and usually understands. Required supervision/ one person assistance for eating. The CCP revised on 10/11/22 documented the resident had a deficit in ADL (Activities of Daily Living) function/mobility related to unspecified dementia, unspecified severity, with agitation. Interventions/Tasks, revised 12/16/22, included eating-supervision/setup help only**inner lip plate. Review of Resident #85s Visual/Bedside [NAME] Report as of 12/18/2022 revealed eating-supervision/setup help only**inner lip plate. During an observation on 12/14/22 at 12:28 PM, Resident #85 was in the dining room with their lunch meal. The resident's meal ticket documented inner lip plate, supervision/set up. Resident #85 was observed without an inner lip plate and eating food off the plate with their fingers. Sausage on the plate was not cut up. No assistance was observed to be given. During an observation at lunch on 12/15/22 at 12:22 PM, Resident #85 was not provided with an inner lip plate per meal ticket and food was going over the side of the plate onto the tray as the resident attempted to feed self. No assistance was observed to be given. Review of the document titled SNF Rehab Screen-V 6 dated 11/7/22 at 2:11 PM revealed Resident #85 was referred for skilled OT to address resident needing more assistance feeding. Review of the printed copy of email dated 11/7/22 at 3:04 PM from OT to Meal Ticket Updates revealed Resident #85 requires an inner lip plate with all meals. The nutritional assessment dated [DATE] documented, adaptive equipment, supervision w/setup inner lip plate per OT (occupational therapy). During an interview on 12/16/22 at 1:07 PM, Licensed Practical Nurse (LPN) #3 stated the residents should have adaptive equipment indicated on meal ticket because they cannot eat properly without it. LPN #3 stated that speech or OT usually determine a residents need for adaptive equipment for eating. Additionally, LPN #3 stated they truly did not pay attention when passing trays to identify any trays with missing adaptive equipment. During an interview on 12/16/22 at 1:13 PM, CNA #1, stated if there was missing adaptive equipment they would have called dietary or would have gone to kitchen to get equipment so the residents could feed themselves properly. During an interview on 12/16/22 at 1:18 PM, CNA #4, stated meal tickets are to be checked to make sure everything is accurate, including adaptive equipment. CNA #4 stated an inner lip plate has a built-up edge to help residents catch food and assist them in eating. Adaptive equipment provides more independence for the residents. CNA #4 stated they did not know off hand what residents required inner lip plates on the unit. During an interview on 12/16/22 at 1:27 PM, LPN #2, unit manager, stated the process is to look at each meal ticket, identify resident, make sure they have everything they are supposed to on their trays. Whoever passes the tray should observe for missing equipment and call dietary to get missing items. LPN #2 stated all adaptive equipment should be on the resident's tray when they come from the dietary department, so meals flow freely. During an interview on 12/16/22 at 1:36 PM, Dietary Supervisor, stated whoever is calling the tray line is responsible to call off required plate equipment, including inner lip plates, to the employee dishing the food. It would be their expectation that everything listed on the meal ticket would be on the trays. The Dietary Supervisor stated there is a lot to read on the meal tickets, which makes them very difficult to read. Additionally, the Dietary Supervisor stated they did not have any supply issues and had adequate inner lip plates available. During a combined interview on 12/16/22 at 1:47 PM, Dietician #2, stated an inner lip plate would assist residents in getting food on their utensils, assisting residents in feeding themselves, giving them more independence. Food service department would provide listed adaptive equipment on meal ticket on the resident's trays as needed. Dietician #1, stated the adaptive equipment is printed small on meal ticket, making it hard for some people to see. During an interview on 12/16/22 at 2:01 PM the Therapy Director stated if a recommendation for an assistive device was made, it would be their expectation that the residents would be provided with it and CP followed. This would allow the residents to be at their highest functional level, and to reduce their level of assistance on unit. 415.14(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey started 12/14/22 and completed 12/20/22, the facility did not store and distribute food in accordance with professional standards for food service safety. Specifically, there was unlabeled, undated, and outdated food in the refrigerators, the interior of the refrigerators and microwaves were soiled, and the refrigerators were missing thermometers on four (Unit 1, Unit 3, Unit 4, and Unit 5) of five resident unit nourishment rooms and one of one Activities refrigerator and Atrium freezer. Additionally, dietary staff with facial hair approximately one quarter of an inch long were observed in the Main Kitchen without beard nets. The findings are: 1. The facility policy and procedure (P/P) titled Food Brought into Facility from Outside Sources, Reheating Food approved 11/16/21, documented the Nursing staff member or designee will be responsible for assuring that the proper precautions are taken to prevent the contamination of potentially hazardous food items, as required by State Health Code, when handling food brought into the facility for resident use by an outside source. Food items brought into the facility for a particular resident from an outside source will not be held, prepared, handled, or served from the facility kitchen nor by facility food service staff. All food items brought in from an outside source will be properly labeled by Nursing staff with the resident's identifying information. Perishable food items will be discarded three days after the label date. Non-perishable items will be discarded after the manufacturer's expiration date. The facility P/P titled Kitchen, Dining and Dietary Equipment Routine Cleaning Policy modified 4/26/19, documented the Director of Dietary Services will plan a regular cleaning schedule for the thorough sanitation of the equipment, kitchen, dish room, and staff dining room areas. This policy and procedure also listed nourishment area as a daily cleaning task to be performed by dietary aides and cooks. Cleaning the inside and outside of reach-in coolers was listed as a monthly task. The facility P/P titled Dietary Food Supply Orders - Storage, modified 10/26/18, documented each refrigerator or freezer area has a numerically scaled thermometer accurate to plus or minus two degrees Fahrenheit (°F). 1a. Observation of the Unit 5 Nourishment Room on 12/14/22 at 9:04 AM revealed the following items were in the refrigerator: -Clear plastic container of cooked noodles with a paper towel with green and brown specs, about one cup, no name or date -Opened commercially packed deli meat, nine-ounce container about two-thirds full, date printed on package by manufacturer 05Dec2022, no name or date opened -Various food spills and splatters in the interior of the refrigerator During an interview at the time of the observation, Occupational Therapist (OT) #1 stated all food in the nourishment refrigerators should be labeled with a resident's name and date. OT #1 also stated the contents of the clear plastic container needed to be thrown away. During an interview on 12/14/22 at 9:10 AM, the Registered Nurse (RN) #1 Unit Manager (UM) stated all foods in nourishment refrigerators needed resident name and date. The food was good for three days in the refrigerator. RN #1 UM also stated they did not know what the green and brown specs on the paper towel inside the noodle container were, but the noodle container and the opened deli meat needed to be thrown away. During an observation on 12/14/22 at 11:32 AM, the interior of the Unit 5 microwave in the Nourishment Room had a dark grey discoloration on the ceiling and sides, concentrated in the upper center and upper left areas. During a second observation of the Unit 5 Nourishment Room microwave on 12/16/22 at 3:23 PM with the Director of Maintenance, the interior of the microwave had a dark grey discoloration on the ceiling and sides, concentrated in the upper center and upper left areas. At this time, the Director of Maintenance wiped the area with a paper towel and the gray discoloration did not appear on the paper towel. During an interview at the time of the observation on 12/16/22 at 3:23 PM, the Director of Maintenance stated this microwave should be taken out of service, given a deep cleaning, and then determine if it will be kept or replaced. The Director of Maintenance further stated they were unaware of the condition of the interior of this microwave and were not sure what the grey discoloration was. During an interview on 12/16/22 at 3:34 PM, the Director of Environmental Services stated the interior of the Unit 5 Nourishment Room microwave appeared to be burnt through and needed to be replaced. 1b. Observation of the Unit 4 nourishment room on 12/14/22 at 9:20 AM revealed the following items were in the refrigerator: -Container of diced tomatoes, about two cups, no name or date -Container of red/ brown liquid, about two cups, labeled Dan, no date -Opened 16-ounce bottle of eggnog, appeared curdled, date printed on bottle by manufacturer sell by 11/26/22, no name or date opened -Opened 16-ounce jar of mango salsa, date printed on jar by manufacturer use by 1/26/23, no name or date opened -[NAME] jar of yellow cloudy liquid, about one cup, no name or date -Opened 23.7-ounce commercial water bottle that contained a purple liquid, no name or date -Unopened two-ounce bag of commercially prepared apple slices, date printed on bag by manufacturer best by 11/26/22 -Pizzeria leftovers carboard box of chicken fingers and French fries, no name or date -Plastic restaurant leftovers container of Chinese food, about two cups, no name or date -Plastic cup of thick green liquid, about one cup, no name or date -Zip top bag of grapes, about one cup, no name or date -Large, opened bag of lettuce, about 10 cups, no name or date -Various food spills and splatters in the interior of the refrigerator -There was no thermometer in the refrigerator Continued observation of the Unit 4 nourishment room revealed the following items were in the freezer: -One corndog in a plastic restaurant leftovers container, no name or date -One commercially wrapped frozen pizza, no name or date -Opened 23.7-ounce commercial water bottle, no name or date -Zip top bag with one breakfast sandwich, no name or date -Opened small container of rainbow sherbet, no name or date opened -Various food spills and splatters in the interior of the freezer During an interview at the time of the observation, the RN #4 UM stated the dietary department took care of the nourishment refrigerators, but not sure how often. The RN #4 UM stated both the refrigerator and the freezer need a cleaning and there should be a thermometer. The RN #4 UM also stated the restaurant leftovers were likely from one resident and they would have to re-educate that resident about the need to label their leftovers. All foods in the nourishment refrigerator need to be labeled and dated and families should be instructed to label and date the food they bring into the facility. The RN #4 UM stated they did not like the look of the bag of salad or the eggnog and voluntarily discarded them at this time. They further stated the nourishment refrigerator was for resident food only and foods could be stored in this refrigerator for 48 to 72 hours before discarding. 1c. Observation of the Atrium freezer on 12/14/22 at 10:00 AM revealed the interior had ice buildup on all sides and the entire bottom of the unit was covered in a pink food spill layer. During an interview at the time of the observation, the Director of Maintenance stated the Maintenance department defrosted this freezer three times per year, but dietary staff were responsible for cleaning it. The Director of Maintenance stated they were not sure how often the freezer was cleaned, but it needed a cleaning now. 1d. During an observation of the Unit 3 Nourishment Room on 12/14/22 at 9:04 AM, the bottom of the interior of the refrigerator was soiled with a sticky-appearing cream-colored substance with strands of long, dark hair present. There were also several opened undated 46-ounce juice cartons noted: one nectar thickened apple juice, one honey thickened apple juice, one honey thickened cranberry cocktail juice, two nectar thickened cranberry cocktail juice and one honey consistency hydrolyte thick and easy in a clear plastic container. Additionally, no thermometer was observed in the refrigerator. Observation of the Unit 3 Nourishment Room on 12/14/22 at 10:12 AM revealed the refrigerator had two signs posted. One sign said, Unit refrigerators are for residents' meals/ nourishments only. All food items and drinks need to have a resident's name and date on them. Items will be thrown out three days later. Anything without a name and date will be thrown out. Staff food/ drink must be placed in EDR (Employee Dining Room) fridge! The other sign said, Attention Families and Staff - All food put in the refrigerator must have the following: date - we can only keep things in the refrigerator for three days, name, room number, must be covered. Per NYS (New York State) regulation - anything over three days will be discarded. During an interview at the time of the observation on 12/14/22 at 10:12 AM the Director of Maintenance stated the interior of the refrigerator was not clean. During an interview on 12/14/22 at 10:15 AM, the Licensed Practical Nurse (LPN) #2 UM stated nursing staff cleaned out the nourishment refrigerators weekly during the night shift. They added that dietary staff came to remove food that was over three days old from the nourishment refrigerator but was not sure how often. The LPN #2 UM stated every item in the nourishment refrigerator needed a resident name and room number, date, and time opened, and this refrigerator needed to be cleaned. During an additional observation of Unit 3 nourishment room on 12/15/22 at 8:42 AM, the refrigerator did not have a thermometer. 1e. Observation of the Unit 1 nourishment room on 12/14/22 at 11:20 AM revealed the following items were in the refrigerator: -One-half pound of supermarket-packed deli meat in a zip top bag, supermarket label stated, packed on 12/5/22, sell by 12/5/22, a name was written on the bag, no date opened -One-half pound of supermarket-packed deli meat in a zip top bag, supermarket label stated, packed on 12/10/22, sell by 12/10/22, a name was written on the bag, no date opened -Opened 16-ounce container of commercially packed deli meat, date printed on container by manufacturer 2/18/23, no name or date opened -Pizzeria leftovers cardboard box of chicken wings, a name and room number were written on the box, but no date -A grocery bag that contained a bowl of rice and beef covered in tin foil and a piece of cornbread, no name or date -Plastic restaurant leftovers container of sausage, about one half pound, a name, room number, and 12/6 were hand-written on the container -Various food spills and splatters on the interior of the refrigerator During an interview at the time of the observation, RN #5 UM stated all food in the nourishment refrigerator must be labeled. RN #5 UM stated about every three days, dietary staff checked the nourishment refrigerator for expired food. The chicken wings needed to be thrown out because the box was undated. The sausage needed to be thrown out because it was more than three days old. The bowl of rice and beef had no label, and it would have to go in the garbage. RN #5 UM stated there was one family member who brought in food regularly for a resident on this unit and that family member usually labeled the foods they brought. Additionally, RN #5 UM stated dietary staff cleaned out the nourishment refrigerator at least weekly, and it looked like juice spilled in this refrigerator and it needed to be cleaned. During multiple intermittent observations on Unit 1 on 12/14/22, 12/15/22, 12/16/22 and 12/20/22, the interior walls and rotating plate of the nourishment room microwave were covered with dried food debris. During an interview on 12/20/22 at 8:48 AM, LPN #6 stated dietary staff was responsible for maintaining nourishment rooms and restocking the refrigerator. All foods brought in from the outside should be labeled with resident's name and date and discarded after three days, if not, it should be thrown away. LPN #6 also stated housekeeping staff was responsible for cleaning the nourishment room, including the microwave. During an interview on 12/20/22 at 8:54 AM, Housekeeping Aide #2 stated they cleaned the floor and counter of the nourishment rooms, they did not clean the microwaves, but could if need be. During an interview on 12/20/22 at 9:04 AM, RN #5 UM stated housekeeping staff were responsible for cleaning the nourishment room including the microwave. Nursing staff should also clean the microwave if something spills, the microwave should not look like that, it needs to be cleaned. During an interview on 12/20/22 at 1:57 PM, the Director of Environmental Services stated dietary staff were responsible for cleaning the microwaves on the units. During an interview on 12/20/22 at 9:34 AM, the Assistant Director of Dining Services stated nursing staff were responsible for cleaning the microwaves on the units. 1f. Observation in the Activities Room on 12/14/22 at 1:12 PM revealed the following items were in the refrigerator: -Store-bought boxed pumpkin pie slice, store label stated, best if used by 11/29/22, hand-written date on a piece of tape stated 11/23 -Opened jar of commercially prepared salsa, date printed on jar by manufacturer May 03, 2022 During an interview at the time of the observation, the Director of Activities stated the activities department maintained this refrigerator. The Director of Activities further stated the boxed pie was an oversight and should have been thrown out. Additionally, they stated foods were normally dated when opened and condiments, such as salsa, were good in a refrigerator for a few months after being opened. They did not know if the date the manufacturer printed on the salsa jar was a manufacture date or a best by date, and it should be thrown out. During an interview on 12/14/22 at 1:25 PM, the Director of Dining Services stated dietary staff was in charge of nourishment refrigerators and there was one dietary employee that was assigned the task of checking each nourishment refrigerator for cleanliness and unlabeled or outdated foods three times per week. That dietary employee left their job at this facility about six weeks ago and the task had not been re-assigned. The Director of Dining Services further stated since that dietary employee left, the nourishment refrigerators task had been delegated on the fly, assigned to any dietary staff member who had an extra minute. Dietary staff stock nourishment refrigerators daily and should be checking them for cleanliness and unlabeled or outdated foods at least two times per week. There was a written log for this task, but it was too outdated to use. Additionally, the Director of Dining Services stated foods brought in from home for residents need to be dated. Commercially prepared drinks should be dated when opened, and they can be kept in a refrigerator for up to five days after opened. Condiments should also be labeled with the date opened, and they can be kept until the manufacturer's expiration date printed on the container, or for about 90 days. The Director of Dining Services also stated food and drink items were always thrown out by the manufacturer's best by date. 2. The facility P/P titled Dietary Rules (Hygiene, Behavior, Attire and Health), modified 9/7/18, documented effective hair restraints are used by all staff members engaged in food preparation. This includes restraints of facial hair for male staff members. During an observation on 12/14/22 at 9:45 AM during the initial kitchen tour, the Assistant Director of Dining Services and the Dietary Supervisor were noted to have facial hair approximately a quarter inch long and were wearing surgical masks that covered their mouth and nose and were not wearing a beard net in the food preparation areas. During an observation on 12/19/22 at 10:28 AM while the Assistant Director of Dining Services was preparing puree ham and mixed vegetables, they were noted to have facial hair approximately a quarter inch long and was wearing a surgical mask that covered their mouth and nose and was not wearing a beard net. During an observation on 12/19/22 at 11:49 AM throughout the entire tray line lunch service, the Dietary Aide, the Dietary Supervisor, and the Assistant Director of Dining Services were noted to have facial hair approximately a quarter inch long and were wearing surgical masks that covered their mouth and nose and were not wearing a beard net while serving food. During an interview on 12/20/22 at 9:34 AM the Assistant Director of Dining Services stated dietary employees with facial hair should wear a beard net, staff wore beard nets prior to COVID-19. Staff do not wear beard nets now that we have to wear a surgical mask. 415.14(h) 14-1.43(e) 14-1.44 14-1.72(c) 14-1.110(d)

Based on interview and record review conducted during a Standard survey completed on 9/23/20, the facility did not ensure that the resident's right to manage his or her financial affairs was maintained for one (Resident #74) of one resident reviewed for personal funds. Specifically, the resident requested a check of greater than $100.00 from his/ her facility personal funds account and did not receive the check within 3 business days. The finding is: The State Operations Manual effective November 28, 2017 documented residents requests for access to their funds should be honored by facility staff as soon as possible but no later than: the same day for amounts less than $100.00 ($50.00 for Medicaid residents); three banking days for amounts of $100.00 ($50.00 for Medicaid residents) or more. Facility policy and procedure Resident Fund Transactions and Accounts last modified 9/14/18 documented upon request the resident will have the opportunity during the scheduled hours to examine their personal allowance account record including balance, deposits and withdrawals. The Business Office staff will respond to such requests within one (1) business day or as soon as possible. Deductions are entered for other checks written at resident's request. The resident is asked to sign a check request form or have a bill submitted to the business office monthly for payments such as: telephone bills, insurance premiums, newspaper bills, etc. Withdrawals are posted using the check number for the disbursement. 1. Resident #74 was admitted to the facility with diagnoses including chronic respiratory failure, diabetes mellitus, and hypertension. The Minimum Data Set (MDS - a resident assessment tool) dated 7/30/20 documented the resident understands, was understood, and cognitively intact. During an interview on 9/17/20 at 9:43 AM, Resident #74 stated they had requested checks from their facility personal funds account and had not received the requested checks in a timely manner. Review of a Resident Account Withdrawal dated 1/30/20 documented Resident #74 requested $350.80 from their personal funds account. Review of facility Check Requisition dated 2/6/20 revealed Resident #74 received the funds six (6) business days after the initial request. During an interview on 9/23/20 at 8:50 AM, Business Office worker #1 stated she did not recall the reason for the delay of the 1/30/20 request. Review of a Resident Account Withdrawal dated 9/11/20 documented Resident #74 requested $100.00 from his/ her personal funds account. Review of a Resident Account Withdrawal dated 9/11/20 documented Resident #74 received the requested funds 9/21/20, seven (7) business days after the initial request. During an interview on 9/22/20 at 8:57 AM, Business Office worker #1 stated Resident #74 requested a check on 9/11/20, and the request was processed. The Administrator is the only authorized signatory for checks in the building, and the Administrator was on vacation. During an interview on 9/22/20 at 9:12 AM, the Administrator stated once a resident requests funds, the business office confirms availability of funds, and then the Administrator signs the check. The Administrator stated he is the only authorized signatory in the facility. 415.26(h)(5)

Based on interview and record review conducted during a Standard survey completed on 9/23/20, the facility did not ensure that all alleged violations involving abuse are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the appropriate officials (including the State Survey Agency) in accordance with State Law through established procedures. Specifically, for one (Resident #82) of one resident reviewed the facility did not report an incident of failure to follow the care plan resulting in Resident #82 falling out of bed (OOB) and sustaining a skin tear to the New York State Department of Health (NYSDOH) within the required timeframe. The finding is: Review of the facility's policy and procedure (P&P) entitled Abuse Prevention, Identification, Protecting and Reporting dated 4/17/19 documented all staff are obligated to report to the administrator and the State Department of health all incidents or suspicion of physical abuse, mistreatment or neglect of residents. The P&P further documented the facility should report to the NYSDOH immediately upon having reasonable cause to believe that abuse has occurred. The results of the completed investigation must be reported to the Administrator and to the NYSDOH state licensing agency and any other agency as required by law within time frames required by regulations. Resident #82 has diagnoses including Cerebral Palsy (a disorder that affects movement, muscle tone, balance and posture), depression and muscle weakness. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/30/20 revealed the resident is sometimes understood, usually understands and is moderately cognitively impaired. The MDS further revealed the resident is non ambulatory and requires extensive assist of two people for transfers. Review of the comprehensive Care Plan (CCP) with a revision date of 8/5/20 revealed the resident was at risk for falls related to decreased mobility, history of falls, non-compliant with plan of care (POC), attempts to self-transfer especially OOB and will place self on the mat next to bed on the floor. Interventions include low bed, mat on left side of bed on the floor and winged mattress. Review of the untitled investigation report dated 6/27/20 revealed an incident of resident falling from bed was investigated by the Unit Manager and the Assistant Director of Nursing (ADON) on this date. Resident #82 was left in bed; the bed was not in low position and there was no mat on floor next to the bed. The resident was being uncooperative and the Certified Nursing Assistant (CNA) did not think it was safe to transfer them during the behavior. The CNA left the room to allow the resident to calm down and the resident rolled from the bed onto the floor. The CNA admitted to leaving the resident alone with the bed elevated and no mat on the floor. The CNA was re-educated, and discipline was issued related to the incident. Review of the Accident and Incident Report (A&I) dated 6/27/20 revealed the resident had an unwitnessed fall from the bed and sustained a skin tear to the right elbow. The resident was calling out, call bell was not activated, and the bed was noted to be raised and the floor matt was folded in the corner. During an interview on 9/21/20 at 1:45 PM, the Assistant Director of Nurses (ADON) stated she recalled the incident of the resident falling, would attempt to locate the investigation and would check with the Director of Nursing (DON). During an interview on 9/21/20 at 2:19 PM, the DON stated the incident should have been reported to the NYSDOH, they realized today (9/21/20) when it was brought to the facilities attention by the surveyor. Review of the Complaint/ Incident Tracking System Report (software that logs and tracks nursing home complaints) revealed the incident was reported to the NYSDOH on 9/21/20 at 2:31 PM. During an interview on 9/23/20 at 10:14 AM, Registered Nurse (RN #1) Unit Manager (UM) stated she was unaware the incident was not reported until this week and the ADON was responsible for reporting to NYSDOH. During an interview on 09/23/20 at 10:46 AM, the ADON stated she would have expected the CNA to put the bed in a low position and the mat on the floor before leaving the room as per the resident's plan of care. The ADON stated she should have reported the incident to the NYSDOH. 415.4 (b)(4)