Every finding on record at Alpine Rehabilitation and Nursing Center

Based on observations, record review, and interviews, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for two (2) of three (3) residents (Residents #24 and #64) reviewed. Specifically, Resident #64 was admitted to the facility with pressure ulcers and pressure relief measures were not implemented timely; Resident #24 was identified as high risk for the development of pressure ulcers and did not have adequate pressure relief measures in place and subsequently developed a pressure ulcer on their heel. Findings include: The facility policy Pressure Injury Prevention and Management/Wound Rounds, dated 12/2020, documented all residents were assessed for the risk of pressure injuries, would have an appropriate interdisciplinary preventive care plan implemented when indicated, and were evaluated for clinical condition and risk factors for pressure injury development. 1) Resident #64 had diagnosis including anemia, chronic kidney disease, and chronic pain. The 11/25/2025 admission Minimum Date Set assessment documented the resident's cognition was intact and was dependent for all activities of daily living including bed mobility. The resident was admitted with Stage 2 (partial thickness tissue loss) and Stage 3 (full thickness tissue loss) pressure ulcers, was at risk of developing pressure ulcers, had a pressure reducing device for bed and chair, was on a turning and repositioning schedule, and received application of ointments and medications. The 11/21/2025 Tissue Trauma Discovery Form completed by Registered Nurse Manager #21 documented the resident had a Stage 3 pressure ulcer on their sacrum (lower back) measuring 2.0 x 1.5 x 1.2 centimeters with undermining (separation of the wound edges from surrounding healthy tissue); and a Stage 2 pressure ulcer to the right lower buttock measuring 2.3 x 1.5 x 0.1 centimeters. Preventative treatment was initiated, the physician and family were notified, and the care plan was initiated and in place. Resident #64 was seen on weekly skin rounds on 12/03/2025, 12/10/2025, 12/17/2025 and 01/14/2026. There was no documented evidence the resident's comprehensive care plan included any pressure reducing devices or pressure relief interventions until the resident was readmitted to the facility from a hospital stay from 01/26/2026-01/28/2026. The 1/28/2026 Clinical admission readmission Evaluation Form completed by Registered Nurse #21 documented the resident had moisture associated skin damage on the left buttock measuring 3 x 2 centimeters and a Stage 3 pressure ulcer to the sacrum measuring 2.5 x 2 x 0.5 centimeters. The 1/28/2026 Comprehensive Care Plan documented the resident had a history of chronic pressure ulcers and was at risk of development of pressure ulcers. Interventions included chair cushion, air mattress, elevate heels on pillow, and turn and reposition every two hours. During a treatment observation on 04/01/2026 at 10:21 AM with Licensed Practical Nurse #15, the resident was assisted to their side by Certified Nurse Aide #23. The resident had a round pressure ulcer the size of a half dollar to the coccyx (end of spine) with no drainage. The area was cleansed and calcium alginate (absorbent dressing) dressing was applied. The sacral area had three (3) blister type areas, and the nurse cleansed the area and applied Balmex (protective cream). The gluteal fold (crease of buttock) had an open wound, and the wound bed contained yellowish and white tissue. The pressure ulcer was cleansed and the nurse applied a barrier cream and covered with a dry dressing. During an interview on 04/01/2026 at 11:19 AM, Certified Nurse Aide #23 stated the resident was transferred to the south unit from the rehabilitation unit a couple of months ago and the resident was admitted to the hospital with wounds on their bottom, and they were getting bigger. The certified nurse stated if they noticed any changes in the resident's skin, they would notify the licensed practical nurse or registered nurse. During an interview on 04/01/2026 at 1:16 PM, Licensed Practical Nurse #15 stated they thought one of the reasons the resident had problems with pressure ulcers was because of their bed. They thought the resident had a regular mattress when they first moved to the south unit and received their specialty air mattress soon after transfer. They stated the resident had an order for an alternating pressure mattress about three weeks ago, and they already had to replace it. They stated the resident refused to be repositioned back into their bed from their chair. During an interview on 04/03/2026 at 9:08 AM, Registered Nurse Unit Manager #6 stated they were the nurse that completed the admission on [DATE]. The resident was admitted with pressure wounds. They stated the resident was at risk for pressure ulcers and should have had a care plan with an air mattress, other pressure relieving devices, and pillows to assist. When residents were admitted they were assessed, and Resident #64 had wounds. The resident had a Stage 3 on their sacrum and another moisture associated wound on their left buttock. They completed a tissue trauma sheet and gave it to the Director of Nursing. The wound information was added to a progress note, and depending on severity of wounds, the resident would be added to weekly wound rounds. The wound rounds were completed by a team including a nurse practitioner, the Director of Nursing, and the registered nurse. They stated the Director of Nursing kept copies of the tissue trauma forms. The resident's wound on their sacrum was nasty. They had it for years and it was now a Stage 3 pressure ulcer. They also had a left buttocks moisture wound without staging. During an interview on 04/03/2026 at 11:30 AM, Nurse Practitioner #10 stated their expectation of the registered nurses during wound rounds was to document stage, measurement, treatment, if it was an initial wound finding, and communication. The entire wound assessment should be documented by the registered nurse including what the wound looked like in their assessment. Nurse Practitioner #10 said that the resident came in with wounds and they knew the resident from home care. The resident's wounds fluctuated. It was getting better at first. The wound status declined recently. The gluteal fold wounds were acquired. The resident spent a lot of time in their chair and often refused to go to bed. 2)Resident #24 had diagnoses including right hip fracture, intellectual disabilities, and seizures. The 01/21/2026 Minimum Data Set assessment documented the resident's cognition was intact; required supervision for most activities of daily living and was independent with bed mobility; was at risk of developing pressure ulcers; had an unhealed Stage 3 pressure ulcer; had pressure reducing device for chair; and received pressure ulcer care including application of ointments/medication. The 10/30/2025 comprehensive care plan documented the resident had potential for pressure ulcer development related to decreased mobility. Interventions included monitor and document any changes in skin. The 11/07/2025 at 10:21 AM, Licensed Practical Nurse #7 progress note documented Resident #24 had a large, deflated blister on the right heel. The area was cleaned and treatment to the area was applied. The information was reported to the Director of Nursing. A 11/07/2025 Director of Nursing progress note documented the resident had a ruptured blister on the right heel, and thinks it may be from the foot pedal on the wheelchair. The flap of skin over the blister was intact and the area measured 6 x 5 centimeters. Heel suspension boots were applied, to be on resident permits at all times when not in physical therapy or ambulating. A non-adhering dressing was applied. On 11/07/2025, the comprehensive care plan was updated to include heel suspension boots while in bed. Nurse Practitioner #10 documented the following wound observations during skin rounds: -11/11/2025 the deflated blister to the right heel was 7 x 7 centimeters and showed no signs or symptoms of infection. -11/24/2025 the wound as a deflated blister to the right heel, 7 x 7 centimeters with no signs or symptoms of infection. -12/07/2025 the outer aspect of right heel had a Stage 2 pressure ulcer which was two 2 x 4 x 0.1 centimeters with 100% granulation (a healthy red new tissue and scant drainage. -12/18/2025 right heel measured 1 x 1 centimeters and there were no signs or symptoms of infection. -01/07/2026 the right heel wound was 1 x 1 centimeters with no signs or symptoms of infection. -01/14/2026 the wound to outer aspect of the right heel was a Stage 3 pressure ulcer measuring 1 x 1 centimeter, superficial, with 100% granulation and minimal drainage. -01/30/2026 the right heel wound measured one 1 x 1 centimeters with no signs or symptoms of infection. -01/242026 the Stage 3 pressure ulcer to the right heel measured 2.5 x 2.5 centimeters with 100% slough (dead tissue) and noted foul smelling serosanguineous drainage (thin, pink, watery drainage). A new order was placed to cleanse the wound with normal saline, dry, apply medical-grade antibacterial honey (wound treatment) to the wound bed and cover with gauze dressing. -02/07/2026 the right heel wound was 1.5 x 1.5 centimeters with 100% granulation. -02/12/2026 the right heel Stage 3 pressure ulcer was 2 x 1 centimeters in diameter, with 100% granulation and no signs or symptoms of infection. -03/04/2026 the right heel wound measured 2 x 1 centimeters and was fully granulated with no signs or symptoms of infection. -03/18/2026 the right heel continued to improve and was 2 x 1 centimeters with 100% granulation. During an observation on 03/30/2026 at 1:48 PM, Resident #24 was sitting in their wheelchair with black surgical boots (used to protect and stabilize the foot and ankle while recovering from injuries or surgery, not designed to relieve heel pressure) with both feet on the floor. During an observation on 03/31/2026 at 3:44 PM Resident #24 was sitting in a wheelchair, had black surgical boots on each foot with both feet on the floor. Resident #24 was seated in their wheelchair on a yellow air cushion. There was no air mattress observed on the bed. During a skin and treatment observation on 04/01/2026 10:32AM, with Licensed Practical Nurse #11, Resident #24 was sitting in a wheelchair with ortho shoes on both feet, holding right leg over left leg. There was no heel suspension boots in the room. Licensed Practical Nurse #11 stated the treatment for resident's right heel was wash with soapy water and apply skin prep (a skin protectant). Licensed Practical Nurse #11 removed the ortho shoe and lifted resident's compression sock to expose the wound site. Licensed Practical Nurse #11 stated that Resident #24 used to have a sore on the right heel that was open with a little bit of drainage. Resident #24 had a 2.0 centimeter round area of thick calloused skin surrounded by pale/pink skin to the back of the right heel. There was no dressing on the wound, no drainage and no discoloration to the surrounding skin. Licensed Practical Nurse #11 cleansed the lesion with soapy water, wiped with sterile gauze, and applied skin prep. Resident #24 denied having pain when Licensed Practical Nurse #11 asked about pain. Resident #24 remained sitting in wheelchair with both feet in ortho shoes and both feet on the floor after wound care. During an interview on 04/02/2026 at 9:51 AM, Certified Nurse Aide #12 stated an air mattress, repositioning every two hours, and other interventions in the resident's care plan were what they do to prevent pressure ulcers. They generally find information about the care plan or the care instructions in electronic health record. Certified Nurse Aide #12 remembered Resident #24 when they were admitted , and when the resident got a sore on the right heel. They stated it looked like a little red mark on the back of the heel. They used compression stockings (sock to promote circulation in the legs), and the nurses also put sterile dressings on the sore, then covered it with compression stockings and then an open toe slipper. They stated Resident #24's family member brought in surgical boots for Resident #24 to wear. They stated they saw heel suspension boots used in the past on other residents, but Resident #24 did not have them. During an interview 04/02/2026 at 10:09 AM, Licensed Practical Nurse #11 stated turning, positioning, skin checks, pushing fluids, and notifying the registered nurse in the care plan for interventions and the unit manager or the supervisor would initiate the interventions for the care plan. They stated Resident #24 had a sore on the right foot, it started out as a blister, then it just progressed. They stated Resident #24's family member wanted the resident to wear the surgical boots they brought from home as they used these when they had blisters before. Licensed Practical Nurse #11 stated after developing the sore to the heel, the staff used antibacterial honey, and some other treatments, and thought the staff were applying heel suspension boots, but could not remember. They were not sure if the resident had heel suspension boots in the room right now. They stated they were no longer using a covered dressing anymore on the wound, but the resident was still at risk for pressure ulcers. Licensed Practical Nurse #11 stated the registered nurses usually print out sheets of the changes in care plans and give them to the Licensed Practical Nurses. They stated interventions in the care plan included heel suspension boots, and they recalled seeing the heel suspension boots but had not seen them today or at all recently. During an interview on 04/02/2026 at 10:30 AM, Registered Nurse Unit Manager #6 stated preventing pressure ulcers depended on the resident's mobility. The less mobile they were the more interventions staff used. They stated Resident #24 came in with a hip fracture and was at high risk for developing pressure ulcers. Resident #24's sore started with a non-blanchable area of redness to the back of the right heel. They thought the sore may have been caused by the resident scooching up with their right foot. The wound developed into a blister, then it opened and became worse. They stated the resident had heel suspension boots, and this information should have been in the care plan, and the staff are expected to follow it. They stated they go over care plans every week and do a full review of care plans every three months. Interventions included a bigger bed to help with mobility, and all interventions were in the care plan. Registered Nurse Manager #6 stated heel suspension boots were initiated on 11/7/2026. They stated there were no real preventative treatments for pressure ulcers documented in the care plan before 11/07/2025. During an interview on 04/02/2026 at 10:45 AM Licensed Practical Nurse #7 stated they went into Resident #24's room and found no heel suspension boots but later found them in the laundry. During an interview on 04/02/2026 at 11:40 AM the Director of Nursing stated that residents who are immobile, have poor nutrition, diabetes, a history of wounds, or tube feedings are at risk for developing pressure ulcers, and a hip fracture could put a resident at risk for developing pressure ulcers as well. They stated turning and positioning, off-loading pressure, skin prep for heels and other portions of the skin and adding calorie supplements to diets were common interventions to prevent pressure ulcers for residents at risk. They stated resident specific interventions were in the care instructions, registered nurses were responsible for care plans, and they expected staff to follow the care plans. The Director of Nursing accessed the electronic health record and located the care plan for Resident #24 and stated they personally initiated the care plan upon Resident #24's admission on [DATE], and someone else later updated it on 11/07/2025. They stated there were not any specific individualized care plans initiated for Resident #24 to prevent pressure ulcers upon admission. They stated the heel suspension boot order came later, and they should have had the heel suspension boots in the care plan earlier. They stated the interventions on the care plan were not 100% appropriate or effective, Resident #24 developed a pressure ulcer, and the facility did have the responsibility to prevent pressure ulcers. 10 NYCRR 415.12 (c)(1)

Based on observation, record review, and interviews during a survey, the facility failed to ensure resident menus were followed for one (1) of one (1) meal preparations observed. Specifically, the facility ran out of preplanned barbeque chicken thighs and did not follow the recipe of the preplanned cheddar broccoli bake. Findings include:On 04/01/2026 the facility's resident census was 75 residents. The facility's week one (1) Fall Winter 2024-2025 menu at a glance documented the Wednesday lunch was barbeque chicken, garden rice, cheddar broccoli bake, and rosy pears. The alternatives were fish on a bun, mashed potatoes, and spinach. The facility's 04/01/2026 menu item tally for Wednesday week one (1) Fall Winter 2024-2025 documented the following was prepared for the poultry entree:-56 barbeque chicken with a buffer of two (2) barbeque chickens for a total of 58 barbeque chickens.-10 ground barbeque chickens.-Three (3) pureed barbeque chickens. The undated facility's Cheddar Baked Broccoli Recipe documented three (3) quarts of cheddar baked broccoli were poured into each of three (3) greased twelve inch by twenty inch by two (2) inch pans. During a kitchen observation on 04/01/2026 from 10:18 AM through 1:16 PM the lunch meal was prepared:-At 10:41 AM, [NAME] #14 pulled one twelve inch by twenty inch by six (6) inch hotel pan containing the cheddar baked broccoli out of the oven and the temperature measured at 120 degrees Fahrenheit, so they put it back in the oven.-At 11:11 AM [NAME] #14 pulled one hotel pan out of the oven containing chicken thighs, and the temperature was measured at 200 degrees Fahrenheit. They pulled the two (2) additional hotel pans with chicken out of the oven, and the chicken was moved to the steam table.-At 11:17 AM, the oven timer was going off. [NAME] #14 pulled the twelve inch by twenty inch by six (6) inch hotel pan containing the cheddar baked broccoli out of the oven, measured the temperature at an unknown degree, stated it was not up to temperature and was still hard, then put the pan back in the oven. -At 11:30 AM and 11:37 AM, the oven timer was going off. [NAME] #14 pulled the twelve inch by twenty inch by six (6) inch hotel pan containing the cheddar baked broccoli out of the oven, measured the temperature at 140 degrees Fahrenheit, stated it needed a few more minutes and put the pan back in the oven. -At 11:44 AM, the Food Service Director pulled the twelve inch by twenty inch by six (6) inch hotel pan containing the cheddar baked broccoli out of the oven. They stated [NAME] #14 did not make it right. They moved some of the cheddar baked broccoli into a smaller pan, placed it on the stove and put hot water in the pan on the stove with a hot water hose.-At 11:47 AM, the Food Service Director stated it might work because it was steaming.-At 11:50 AM, the Food Service Director asked [NAME] #14 to take more of the broccoli from the large pan and move to a smaller pan. [NAME] #14 told the surveyor they had never made this recipe before. -At 11:54 AM, the Food Service Director measured the temperature of the first pan of broccoli they moved to the stove top and measured it at 165 degrees Fahrenheit and stated it was good and tender. -At 11:56 AM, [NAME] #14 started to plate items from the steam table while the Food Service Director continued to warm smaller portions of broccoli on the stove top while adding hot water from the hose. -At 12:53 PM, [NAME] #14 told the Food Service Director they did not have enough chicken thighs. At 12:55 PM, they determined they were short nine (9) servings of chicken thighs. -At 12:57 PM, the Food Service Director pulled frozen cooked chicken dated 03/31/2026 out of the freezer, cut it up, placed it on a plate and microwaved it. At 1:04 PM, they stated it was from yesterday and was boiled chicken that was prepared for ground and pureed chicken. -At 1:16 PM, the last tray with the microwaved, previously frozen boiled chicken breast left the kitchen. During an interview on 04/01/2026 at 1:17 PM, [NAME] #14 stated they were supposed to reference the tally sheet to determine how many whole, ground, and pureed chicken thighs they needed to prepare for the lunch meal. They showed the surveyor the tally sheet and said they followed it, so they were not sure what happened. They were supposed to count the chicken thighs, but it was hard because they were frozen and sometimes stuck together. They just cooked the whole box and were not sure how many chicken thighs were in a box. They pulled the chicken from the freezer the prior Sunday (03/29/2026) and thought the box would have enough. They followed the recipe for the cheddar baked broccoli, but it did not turn out. They looked for the recipe they used but could not find it in the recipe book. During an interview on 04/01/2026 at 1:27 PM, the Food Service Director stated [NAME] #14 was supposed to follow the production sheet and count the chicken thighs. [NAME] #14 told them they counted the thighs, so they were not sure what happened because they ran out. Menus needed to be followed, or the residents could get upset. The cheddar baked broccoli should have been cooked in three (3) pans not one (1). It was important the recipes were followed, or the food would not turn out right. 10 NYCRR 415.14(c)(1-3)

Based on observations, record review, and interviews (iQIES intake 2809584), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for two (2) of two (2) residents (Residents #13 and #48) reviewed. Specifically, Resident #13 did not have a significant bowel movement from 07/25/2025-08/08/2025 and there was no documented evidence bowel interventions were consistently provided, the resident's gastrointestinal status was assessed, or the physician was notified; and Resident #48 had position changing alarms initiated, impacting the resident's freedom of movement, without trialing other interventions first. Findings include: The facility policy Certified Nurse Aide Documentation & Usual Performance, revised 01/01/2026, documented the certified nurse aides must document care at the time it was provided and the specific care offered per the care plan must be objectively and completely documented.The facility policy Managing Falls and Fall Risk, revised 05/2025, documented if falling recurred despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remained relevant. Position-change alarms would not be used as the primary or sole intervention to prevent falls and would be monitored for efficacy. The facility policy Personal Care: Toileting, revised 10/12/2029, documented residents would be toileted according to the individualized plan of care to promote continence and maintain the resident's highest level of function and maintain dignity. Additionally, the date and time the resident was assisted to the bathroom would be recorded.The facility policy Restraints, revised 09/2025, documented the facility would only consider utilizing a restraint when all other reasonable options had been exhausted and the resident's medical condition warranted their use; position changing alarms were not considered a restraint unless it caused agitation, interfered with the resident's sleep pattern, or caused the resident to be afraid to move; any device that prevented a resident from freely and easily arising out of a chair or bed was considered a restraint; and any device that met the definition of a physical restraint must have a physician order, a care plan and a process in place for systematic and gradual restraint reduction and physician identification and record of the specific medical symptom that supported the use of the restraint.The facility policy Bowel Management, revised 11/2025, documented each resident would have at least one (1) bowel movement every three (3) days unless the practitioner documented a clinically appropriate alternative goal; every resident would have daily monitoring of their bowel movement documentation and days since their last bowel movement; and four (4) or more days without a bowel movement was a red flag and required immediate nurse assessment and practitioner notification. 1) Resident #13 had diagnoses including schizophrenia (a serious mental health condition), morbid obesity, and intestinal bypass. The 09/30/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition, was incontinent of bowel, and required moderate assistance for most activities of daily living. There was no documented evidence the resident's Comprehensive Care Plan included reference to the resident's bowel function. The Bowel and Bladder Elimination Report documented from 07/25/2025 through 07/28/2025 the resident did not have a bowel movement (four days).The 07/27/2025 Nurse Practitioner #10 progress note documented the resident had multiple loose stools and was now constipated after Clostridium difficile (a bacteria causing diarrhea) culture was ordered. The resident had not had any bowel movements. There was no documented evidence the resident's gastrointestinal system was assessed by Nurse Practitioner #10.The 07/2025 Medication Administration Record documented the resident received Milk of Magnesia (laxative) on 07/28/2026 for no bowel movement for three (3) days. The Bowel and Bladder Elimination Report documented on 07/29/2026 the resident had a small bowel movement.The 07/2025 Medication Administration Record documented the resident received a Dulcolax suppository (laxative) one time only for no bowel movement for four (4) days on 07/29/2025.08/01/2025 Nurse Practitioner #10 progress note documented the resident's abdomen was soft, nontender, and without masses. Bowel sounds were active. The Bowel and Bladder Elimination Report documented from 07/30/2025 through 08/08/2025 the resident did not have a bowel movement (10 days).The 08/05/2025 Physician #20 progress note documented the resident was seen for a 60 day follow up. Review of systems found the resident doing well without complaints of gastrointestinal symptomatology. Recent nursing notes were reviewed. The resident was examined with the nurse present. Their abdomen was soft, nontender, and without masses. Bowel sounds were active. There was no documented evidence the physician was made aware of the resident's lack of bowel movements since 07/30/2025. The 8/2025 Medication Administration Record documented:-on 08/05/2025 Enemeez Mini Rectal enema, insert one (1) suppository rectally one time only for no bowel movement x five (5) days. There was no documented evidence the suppository was administered as ordered. -on 08/06/2025 Enemeez Mini Rectal enema, insert one (1) suppository retally one time only for no bowel movement x six (6) days. The suppository was documented as administered at 10:34 PM. -on 08/07/2025 magnesium citrate give 148 milliliters by mouth one (1) time only for no bowel movement x seven (7) days. The magnesium citrate was administered at 11:30 AM. -on 08/08/2025 magnesium citrate give 148 milliliters by mouth one (1) time only for no bowel movement x eight (8) days. The magnesium citrate was administered at 11:48 AM with a 9 indicating other/see nurses note (the resident was sent to the hospital).The 08/08/2025 Nurse Practitioner #10 progress note documented the resident's presenting problem was constipation. Resident was noted to be multiple days without having a bowel movement and was complaining of abdominal pain. A KUB (an x-ray to assess abdominal area) was recommended. Due to the resident's size and weight, they were unable to have the KUB performed in-house. The resident was then noted to have some vomiting and extreme abdominal pain. The resident would be sent to the hospital to have imaging and rule out obstruction. The 07/27/2025- 08/07/2025 daily 24-Hour Report Sheets did not document the resident's bowel status had been monitored or assessed.Nursing progress notes did not document ongoing physician notification of the resident's bowel status or ongoing nursing abdominal assessments.During an interview on 04/02/2026 at 1:12 PM, Licensed Practical Nurse #15 stated a bowel movement report was ran daily that tracked how many days a resident went without a bowel movement. If two (2) or more days without a bowel movement the provider should be called for orders, and an abdominal assessment should be performed for anything beyond three (3) days. That assessment along with the physician notification should be documented. Resident #13 was not usually constipated. They stated during August of last year the resident had gone quite a few days without a bowel movement. There should be documentation of what intervention was provided for each day they were without a bowel movement. During an interview on 04/02/2026 at 3:57 PM, the Director of Nursing stated the nurse managers monitored the bowel list daily. If a resident had two (2) or more days without a bowel movement the provider was called for orders and should be called again if there were no results. That should go on the 24-hour report sheet and there should be a daily abdominal assessment that included bowel sounds, distension, gas, and appetite. Resident #13 should have had daily abdominal assessments and daily physician notification during the time they were not having any bowel movements but did not. The 08/05/2026 docusate sodium mini rectal enema order should be signed as administered but was not which indicated that medication was not administered. 2) Resident #48 had diagnoses including dementia, paralysis and weakness following a brain bleed, and seizures. The 02/18/2026 Minimum Data Set assessment documented the resident had moderately impaired cognition; required substantial assistance for most activities of daily living; was frequently incontinent of bowel and bladder; had one (1) fall with minor injury and two (2) falls without injury since admission; and used a bed and chair alarm daily. The Comprehensive Care Plan documented: -11/18/2025 at risk for falls. Interventions included a bed alarm, a chair alarm, low bed, and floor mats. The resident had actual falls on 11/22/2025, 01/31/206, 02/08/2026, 02/21/2026, 03/01/2026, 03/21/2026; and 03/25/2026. -11/20/2025 and revised 03/09/2026 activity of daily living and mobility deficit. Interventions included assistance of two (2) for toileting hygiene and toilet transfer; moderate assistance of two (2) to move from lying on back to sitting on the edge of the bed without back support; moderate assistance of two (2) for toileting hygiene; and check and change and toilet every two (2) to three (3) hours and as needed. -11/26/2025 functional bladder incontinence related to impaired mobility. Interventions included ensure resident had an unobstructed path to the bathroom.The Comprehensive Care Plan did not document any fall prevention interventions used prior to the initiation of the position changing alarms or a process for the systematic and gradual reduction of their use.The Resident's Accident/Incident Reports documented the following: -On 11/22/2025 at 11:10 AM found sitting on the floor in their room.-On 01/03/2026 at 7:45 PM found on the floor next to their bed.-On 01/31/2026 at 6:30 PM fell when trying to get out of their wheelchair.-On 02/08/2026 at 9:20 PM found lying prone on the floor in the common area. They sustained a raised purple area to their left face.-On 02/21/2026 at 11:00 AM fell in the bathroom-On 03/01/2026 at 6:40 AM found on the floor in their room. Their bed alarm was turned off, and they said they needed to use the bathroom.-On 03/25/2026 at 2:00 AM they got out of bed, urinated on the floor, slipped in the urine, fell, and sustained a nasal fracture. The resident was toileted at 1:45 AM.Nursing progress notes documented the following:-On 02/272026 at 10:14 PM the resident frequently attempted to self-transfer and alarms alerted the staff.-On 03/08/2026 at 10:46 PM the resident was non-compliant with alarms and transfers. -On 03/09/2026 at 10:01 PM the resident was non-compliant with staying in the chair or bed, was setting off alarms multiple times during the shift, and stripped off their clothing and brief and was incontinent. -On 03/12/2026 at 8:18 PM the resident was consistently undressing and walking around getting off their chair alarm.-On 03/15/2026 at 10:07 PM the resident was up and out of bed multiple times that shift and was non-compliant with the alarms.-On 03/16/2026 at 9:47 PM the resident was non-compliant with staying seated and often tried to walk to the bathroom.-On 03/19/2026 at 10:13 PM the resident was very anxious, was up and down out of bed and in and out of the bathroom multiple times.-On 03/25/2026 at 10:12 PM the resident persistently tried to ambulate themselves.-On 03/26/2026 at 3:08 PM the resident was constantly reminded to ask for assistance when needing to use the restroom so they would not fall again.-On 03/29/2026 at10:41 PM the resident was found self-transferring multiple times and was non-compliant with alarms.-On 03/30/2026 at 10:59 PM the resident was awake all night. They got up to walk to the bathroom, but they were incontinent along the way making the floor wet and increasing risk of falling. They moved quicker than the alarm alerted staff.-On 03/30/2026 at 5:09 PM the resident was non-compliant and was getting out of their chair, walked around, activated alarms and pushed staff so they could take a walk.-On 03/30/2026 the resident was non-compliant with staying seated. There was no documented evidence an attempt was made to determine the root cause of why the resident was attempting to rise or was not compliant with the alarms and alternative interventions attempted. The following observations were made of Resident #48:-On 03/31/2026 at 1:51 PM the resident attempted to stand from their wheelchair and a high-pitched alarm sounded. The resident said oh and immediately sat back down.-On 03/31/2026 at 2:18 PM, the resident stood from their chair and began pulling at a straight back chair as though they were going to sit in it. Their chair alarm immediately sounded, and several staff ran down the hall saying no, no, no and directed the resident to sit back down.-On 04/01/2026 at 12:02 PM the resident was lying in bed, the bed was in lowest position, and the bed alarm began playing the song It's a Small World.-On 04/02/2026 at 10:24 AM the resident's bed alarm went off, and they were sitting at the edge of the bed. An unidentified staff member went into the room, talked briefly to the resident who then laid back down.-On 04/02/2026 at 10:34 AM the resident was in bed, the bed was in lowest position, and they started to move towards the edge of the bed and the alarm started playing It's a Small World.During interviews on 03/30/2026 at 12:01 PM, 03/31/2026 at 1:51 PM and 04/03/2026 at 12:41 PM, the resident stated they did not like the alarms, and no one asked them how they felt about them. The chair alarm went off if they stood up or if they leaned too far forward. When it went off everyone and their brother came running to tell them to sit down. The alarm made them jump and feel like they were doing something wrong. They knew when they had to go to the bathroom, but would not get up because of the alarm, which resulted in bladder accidents. They had accidents two (2) to three (3) times a day and the smell of urine killed them. Not being able to get up to use the bathroom and having accidents made them feel like they were losing their liberty. If staff were not going to let them get up to use the bathroom, then staff needed to take them to the bathroom in time. They did not like the bed alarm. It alarmed when they were just changing position and startled them when they were trying to sleep. Sometimes they turned it off. They hated the bed alarm tune and asked the surveyor how they would like to be awoken at 4:00 AM by a children's song. During an interview on 04/02/2026 at 12:13 PM, Certified Nurse Aide #16 stated a resident's toileting plan could be found on their care instructions. If a resident was incontinent, they were checked and changed every two (2) hours. If a resident was incontinent but sometimes continent, they asked the resident if they needed to be changed. Position change alarms were loud and alarmed a lot. Some residents became upset when staff responded to them. Usually, residents just wanted to get up and move. Resident #48 was checked and changed every two (2) hours and was not on a set toileting schedule. The resident asked to go to the bathroom all the time, tried to take themself and they witnessed the resident urinate while on the toilet. The resident had a bed and chair alarm that sounded a lot and were activated even if the resident was only repositioning themselves. Their bed alarm played a song, so the staff were better able to determine whose alarm was sounding. The resident got frustrated with the alarms and had turned them off in the past. During an interview on 04/03/2026 at 9:28 AM, Licensed Practical Nurse #15 stated toileting frequency was on the care instructions and should be followed. The facility used position changing alarms for residents who had a lot of falls. Alarms allowed staff to know when a resident was getting up and sounded even if the resident was readjusting their position. Resident #48 tried to get up a lot saying they had to urinate. They believed their care plan stated they should be toileted every two (2) to three (3) hours. They had a chair alarm, a bed alarm and a low bed. During an interview on 04/03/2026 at 10:32 AM, Registered Nurse Unit Manager #6 stated the least restrictive fall prevention interventions should be tried first. On admission if a resident was at high risk for falls, alarms might be initiated immediately. Alarms were not considered a restraint, did not require an order, did not need a documented medical condition, and were used primarily to alert staff that the resident was moving. Alarms did not decrease the risk of falls but sometimes they startled the resident enough to make them sit back down. Residents should be asked, when appropriate, how they feel about the alarms. Fall intervention effectiveness was evaluated quarterly and as needed and was based on how many times that resident fell. Residents who were both continent and incontinent of urine were checked and changed every two (2) to three (3) hours. When Resident #48 was admitted they were incontinent, not able to move their left side and unable to speak. Alarms were initiated without trying other fall interventions first. Now they were up and down all the time trying to get to the bathroom. The resident might be a good candidate for bladder training. If the alarms agitated them, they should be asked about how they felt about the alarms. It could be upsetting to them if the alarm attracted everyone. During an interview on 04/03/2026 at 11:30 AM, Registered Nurse Unit Manager #4 stated alarms were not considered a restraint. Resident #48 had fallen numerous times and had alarms that alerted staff the resident was already up. Their bed alarm played It's a Small World so staff could differentiate their alarm from others. They thought the resident did not like the alarm because they tried to turn it off. During an interview on 04/03/2026 at 12:05PM, the Director of Nursing stated the effectiveness of fall prevention interventions was based on the number of falls. Position changing alarms and low beds were not considered a restraint, did not require an order or a related physician documented medical condition. Their use should be discussed with the family and resident and documented as such. The resident's feeling about the alarms should trump everything else. For residents at high risk for falls, alarms were used without trying other interventions first. If a resident was turning off their alarms and still falling, then those alarms were not effective and would likely be discontinued. They expected residents to be toileted in accordance with the comprehensive care plan and staff documented each time the resident was toileted. 10 New York Code Rules and Regulation 415.12 (k)(1)

Based on observation, record review, and interviews the facility failed to ensure the correct medication was administered in the correct dose in accordance with manufacturer's specifications and with standards of practice for of one (1) of six (6) residents (Resident #2) reviewed. Specifically, Resident #2's insulin pen was not primed (removal of air bubbles to ensure the precise dosage of insulin) prior to administration. Findings include: The facility policy Blood Glucose Management documented when using an insulin pen the needle would be screwed onto the end of the pen, the cap removed, and the flow of the delivery device checked by priming with two (2) units of insulin and pressing the button on the non-needle end of the pen all the way down. Next, the dose prescribed by the physician for administration would be selected by dialing the number of units on the pen.Resident #2 had diagnoses including diabetes. The 12/16/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition and received daily insulin injections.The 01/07/2025 Comprehensive Care Plan, revised 04/27/2025, documented the resident had diabetes. Interventions included diabetes medications as ordered by the physician.The 01/19/2026 physician order documented aspart (a fast-acting insulin) five (5) units daily with meals via a pen injector. During an observation and interview on 04/01/2026 at 12:50 PM, Licensed Practical Nurse #5 attached the needle to the aspart insulin pen, dialed it to five (5) units, then administered it to the resident. They did not prime the pen first. They stated priming was not needed because when the button on the end of the pen was pushed during administration it was priming. During an interview on 04/01/2026 at 1:05 PM, Registered Nurse Unit Manager #4 stated when preparing an insulin pen, after attaching the needle the needle should be primed by performing a waste dose of one (1) or two (2) units. If that was not done there might be air in the needle and then the correct dose of insulin would not be given. 10 NYCRR 415.12(m)(2)

48895 Based on record review, observation, and interview during the recertification and abbreviated (NY00309906 and NY00338730) surveys conducted 4/29/2024-5/3/2024, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 2 of 2 resident units (north and south units) reviewed. Specifically, the South Unit hallways and common areas smelled of urine and had sticky floors; there was a stained ceiling tile on the South Unit; resident room [ROOM NUMBER] had sticky floors and strips of missing paint; resident room [ROOM NUMBER] had strips of missing paint; the South unit shower room had tiles missing around the drain; the floor in resident room [ROOM NUMBER] was unclean and sticky; resident rooms [ROOM NUMBERS] were cluttered with refuse; and resident rooms [ROOM NUMBERS] smelled of urine. Findings include: The facility policy Quality of Life - Homelike Environment, dated 5/2018, documented the facility staff and management should maximize, the characteristics of the facility that reflected a personalized, homelike setting. These characteristics include a clean, sanitary, and orderly environment and pleasant, neutral scents. The facility policy Dust Mopping, dated 7/2016, documented all areas were maintained in a clean and pleasant manner. Removal of litter, dust, and light soil from floors was a daily maintenance procedure, or in preparation for wet mopping. For resident rooms, dust mopping started at the entrance of the room, and a broom and dustpan were used to pick up trash and dirt. The facility policy Facility Cleaning - General Policy and Procedure, dated 7/2016, documented floors were mopped daily. Floors should be dust mopped then wet mopped using an approved diluted cleaning agent in mop water. The following observations were made on the South Unit: - on 4/29/2024 at 10:47 AM, the lobby area between rooms [ROOM NUMBERS] had a strong urine odor. - on 4/29/2024 at 11:31 AM, the area between rooms [ROOM NUMBERS] had a strong, sharp, sour smell. - on 4/29/2024 at 11:19 AM, the floor outside room [ROOM NUMBER] was sticky. Inside of room [ROOM NUMBER] there were long strips of paint missing along the wall where the television was. - on 4/29/2024 at 11:22 AM, room [ROOM NUMBER] had strips of paint missing along the wall under the window. - on 4/29/2024 at 11:57 AM, the South Unit shower room had missing tiles around the drain. - on 4/29/2024 at 11:58 AM, the South Unit hallway floors were sticky. - on 4/30/2024 at 9:12 AM, the ceiling above the puzzle table between rooms [ROOM NUMBERS] had dark colored stains. - on 4/30/2024 at 8:38 AM, the seating area near room [ROOM NUMBER] smelled of urine. - on 4/30/2024 at 12:42 PM, the seating area at the far end of the unit, between rooms 114, 116, 119, and 121 had sticky floors. The following observations were made on the North Unit: - on 4/29/2024 at 10:16 AM, room [ROOM NUMBER] had unclean, sticky floors. - on 4/29/2024 at 10:21 AM, room [ROOM NUMBER] had a tray table cluttered with books, food, soda, and water bottles; paper, cups, and tubing on the floor; a half-eaten donut and chip bag were on the chair; bags of empty bottles were in the corner; and there were personal items on the bed. - on 4/29/2024 at 11:45 AM, room [ROOM NUMBER] smelled of urine. - on 4/29/2024 at 1:05 PM, room [ROOM NUMBER] smelled of urine. - on 5/1/2024 at 7:54 AM, room [ROOM NUMBER] had crumbs on the floor between the bed and window, and dirty linen on the floor by the door. - on 4/29/2024 at 1:09 PM, room [ROOM NUMBER] had a chip bag, cups and tubing, a chip tube container, and piles of clothing on the floor; there was pizza crust on the over bed table; a large chip bag on the chair; and a bag of bottles in the corner of the room. - on 4/30/24 at 9:26 AM and 1:14 PM, Resident #59's room had a cup and crumbs on the floor. Resident #59 stated the debris had been on the floor for 3 days and they wished the facility would clean their room. During an interview on 5/1/2024 at 9:11 AM, certified nurse aide #10 stated there were bags of food on the ground in room [ROOM NUMBER], and it was not homelike to have crumbs on the floor of a resident room. They stated there were a lot of resident rooms that were not maintained in a homelike environment. Certified nurse aide #10 stated and this could lead to odors, bugs, and it was an infection control issue. During an interview on 5/2/2024 at 11:35 AM, the Director of Maintenance stated if a room was cluttered, they would advise staff to clean the room. They stated that resident rooms should not have trash on the floor. They expected each resident room to be swept each day, and other area of the rooms should also be cleaned. The housekeeping staff should wipe down resident rooms with bleach wipes and dust the surfaces every day. If food was left in resident rooms, it could lead to pests and infection control issues. During an interview on 05/02/24 at 4:20 PM, the Director of Environmental Services stated the floor tiles were missing on the floor in the South Unit shower room. Resident room walls could be damaged by chairs and wheelchairs. The damaged sections of walls, like resident room [ROOM NUMBER] and resident room [ROOM NUMBER], should be repaired as soon as they were observed. Resident rooms should also be checked for damaged walls and other environmental concerns when the rooms were deep cleaned. The damaged wall in the North Unit housekeeping room was repaired. The resident room call bell cord plates came out of the wall very easily and could have been pulled out by accident. If urine and other odors were detected in resident rooms or hallways it would be immediately cleaned. The resident hallways were cleaned daily. They stated it was important for the facility to be maintained for residents and for staff. 10 NYCRR 415.29(j)(1)

Based on observation and interview during the recertification survey conducted 4/29/2024-5/3/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and included expiration dates when applicable for 1 of 2 medication refrigerators (North Unit), 1of 4 medication carts (North Unit), and 1 of 2 treatment carts (North Unit) reviewed. Specifically, the North Unit medication and treatment carts were unlocked and unattended; and there was an open vial of Purified Protein Derivative (used to diagnose tuberculosis) solution in the North Unit refrigerator that was not labeled with an opened date. Findings include: The facility policy Storage and Maintenance of Medications revised 10/2020 documented medications and biologicals were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Medications with shortened expiration dates (i.e., insulin, and ophthalmic drops, etc.) must be dated when opened. Medication must be checked regularly for expiration dates and deterioration. During an observation on 4/29/2024 from 12:55-1:06 PM the North Unit medication cart was unlocked and unattended. At 1:06 PM licensed practical nurse #7 locked the medication cart. During an observation of the North Unit medication refrigerator on 4/30/2024 at 8:45 AM with registered nurse #35, there was an open vial of Purified Protein Derivative in the refrigerator. There was no opened date documented on the box or on the vial. During an observation on 4/30/2024 at 8:53 AM the North Unit treatment cart was unlocked. The top drawer of the cart contained bacitracin (antibiotic ointment), moisturizing cream, medical honey, scissors, Santyl (an enzymatic ointment used to remove dead tissue), antifungal cream, and triple antibiotic cream. During an observation on 4/30/2024 at 9:59 AM, the North Unit treatment cart was unlocked. During an interview 5/2/2024 at 8:22 AM licensed practical nurse #7 stated the treatment cart should never be unlocked and unattended because residents could get into medications and eat the creams. If they ate the creams, they could get sick. They did not lock the medication cart on 4/29/2024 because the meal was delivered, and they went to pass trays. They noticed the medication cart was unlocked, but they were not sure how long it had been unlocked. Multidose medications (vials) were good for 30 days once opened and should be labeled the day they were opened. If the medications were not labeled, they should not be administered. If a medication was open and did not have a date on it, they would take it to the Director of Nursing for replacement. During an observation on 5/2/2024 at 11:49 AM, the North Unit medication cart was unlocked and unattended. At 11:51 AM, licensed practical nurse came out of a resident room and locked the medication cart. During an interview on 5/2/2024 at 1:37 PM, registered nurse Unit Manager #35 stated they expected treatment carts and medication carts to always be locked so residents and unauthorized staff could not get into them. During an interview on 5/2/24 at 4:11 PM the Director of Nursing stated medication and treatment carts should be locked and parked at the nursing desk when not in use. Bandages, creams, scissors, bacitracin, antifungal, cortisone cream, triple antibiotic were some items stored in the treatment carts. The carts should be locked for safety. Purified Protein Derivative should be dated when opened and discarded after 30 days. 10NYCRR 483.45 (g)(h)

48895 Based on observation and interview during the recertification survey conducted 4/29/2024-5/3/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, the main kitchen had outdated and undated food, an unclean stove/oven/flattop cooking area, an unclean walk-in freezer, a leaking dish machine, missing tiles at the bottom of the handwash sink, an unsecured wall covering, and a plate warmer cord that was in disrepair. Findings include: The undated facility policy, Cleaning of Counters and Food Contact Surfaces, documented the cleaning procedure was to thoroughly saturate a cleaning rag with cleaning solution, ring out the excess, and wipe down the counter of food contact surface; this removed visible dirt and debris. For sanitizing, the procedure was to thoroughly saturate a second rag with sanitizing solution and apply it to the counter of food contact surface liberally and allow to air dry. The undated facility policy, Cleaning and Mopping of Floors ([NAME] Tile and Walk in Cooler) documented all floor areas of the department would be swept and mopped three times daily. The Cleaning Schedule for Saturday 4/27/2024 documented that Cook #31 was to de-ice the freezer door and freezer floor, wipe down the dessert rack, and wash garbage cans. Cook #31 only initialed next to the tasks for wiping down the dessert rack and the garbage cans. The Dietary Department Daily Cleaning & Closing Checklist for week ending 5/4/2024 documented Cook Supervisor #30 signed off for the following: - the range ovens were cleaned and turned off; - the microwave was cleaned; - the toaster was cleaned; - the mixer was cleaned; - the slicing machine was cleaned and assembled; - the can opener was run through the dish machine; - the pot sinks were clean, and the counter was cleaned; - the food in the refrigerator was covered, labeled, and dated; - the perishables were discarded from the refrigerator after the third day; - all garbage was removed from the kitchen; - and the kitchen door was locked. The following observations of the main kitchen were made on 4/29/2024 between 10:00 AM and 11:00 AM: - in the reach-in refrigerator, there was jelly in a plastic container with an opened label date of 4/16. This jelly was from another shelf stable jelly container and was poured into this container. - the front section and the back of the stove/oven/flattop combo unit was unclean. - the shelf over the stove/oven/flattop combo unit was sticky and had miscellaneous food debris on it. - there was a 1/4 full container of ham-based paste on the shelf over the stove/oven/flattop combo unit that did not have an open date. - a metal wall cover near the handwash sink was not secured to the wall and was missing three screws. - the bottom of the wall near the handwash sink had chipped and missing wall tiles. - the floor under the walk-in freezer was not clean and had miscellaneous debris on it. - the ceiling in dish machine area was stained and unclean. - the electric wire that entered the plate warmer was wrapped with electrical tape. - the dish machine had a section that was leaking water out of the side, with a plastic bucket underneath to collect the water. During an interview on 5/2/2024 at 12:30 PM, the Director of Environmental Services stated that ceilings would be cleaned as needed, or when the kitchen staff or maintenance staff identified an issue. They stated that they would also clean the floors in the kitchen if asked. During an interview on 5/2/2024 at 12:40 PM, the Assistant Food Service Director stated they were not aware of the kitchen environmental issues identified during the first tour of the main kitchen. They stated that it was part of their job to check and maintain a clean kitchen environment. The Assistant Food Service Director stated there were different daily cleaning schedules for the cooks and the rest of the dietary staff, and that these forms were required to be initialed after completion each day. They stated the cook was responsible for cleaning the stove/oven/flattop combo unit area, and the other food service workers were responsible for cleaning the floor of the walk-in freezer and other areas within the kitchen. During an interview on 5/2/2024 at 1:05 PM, cook supervisor #30 stated that the oven/stove and the shelf above it should have been cleaned daily. After looking at pictures taken from the first day of survey, this area did not look like it had been cleaned for a couple of days. They stated they had worked the closing cook shift on 4/28/2024 and had not cleaned the back wall of the stove/oven/flattop combo unit or the front knobs of this device. Cook supervisor #30 viewed the Closing Cook Cleaning Checklist dated 4/28/2024 and verified the presence of their initials. During an interview on 5/2/2024 at 1:15 PM, cook #31 stated the last time they were the closing kitchen staff they had not cleaned the walk-in freezer floor, and had never cleaned the walk-in freezer floor since they were hired in July 2023. They stated they had not initialed the Cleaning schedule for: Saturday, task to de-ice the walk-in freezer, as they had not completed that task. Cook #31 stated they were asked every day by the Food Service Director or the Assistant Food Service Director if the kitchen was clean, had been asked to make sure that the walk-in cooler and walk-in freezer was swept, and was never asked to clean under the racks within the walk-in freezer. They stated that sometimes they would use a degreaser to clean the back of the stove/oven/flattop combo unit, and that the back of the stove/oven/flattop combo unit was sometimes clean. Cook #30 stated the front knob section was part of the stove/oven/flattop combo unit, and that they had last cleaned this part of the oven a couple of weeks ago. During an interview on 5/2/2024 at 1:35 PM, the Assistant Food Service Director stated the shelf over the stove/oven/flattop combo unit area looked like it had not been cleaned for a couple of days. They stated that the Cleaning schedule for: Saturday, included a task to de-ice the walk-in freezer, and they assumed that staff would keep the floor clean as the word cleaning was in the title. The Assistant Food Service Director was aware that Cook #31 was initialing the walk-in freezer daily checklist and was not aware that the section not initialed by Cook #31 meant that it had not been completed. 10NYCRR 415.14(h)

48052 Based on observation, record review, and interview during the recertification survey conducted 4/29/2024-5/3/2024, the facility did not maintain an effective pest control program so that the facility was free of pests for 2 of 2 nursing units (North and South Units) and the main kitchen. Specifically, there was evidence of ants and house flies on the South Unit, and fruit flies on the North Unit and in the main kitchen. Findings include: The facility policy, Pest Control, effective 10/2017, documented the facility provided a safe and sanitary environment by preventing the entry of insects and rodents into the facility. This reduced the threat of infection and disease caused by pests. A licensed pest control company was contracted by the facility and provided most of the insect and rodent control. The Environmental Services Director was responsible to schedule monthly inspections and to arrange for an on-call pest control agent for an emergency. Any staff who noticed an insect or rodent infestation should notify maintenance and it should be logged in the logbook. Pest control vendor records dated 3/7/2024, 4/4/2024, and 4/11/2024 documented ants as a targeted treatment pest. There was no documented target treatment for flies or fruit flies. The facility pest sighting memo had no documented sightings of flies or fruit flies from 11/15/2023 to 4/28/2024. Ant sightings were documented: - on 1/5/2024 in the break room. - on 1/12/2024 in room [ROOM NUMBER] by housekeeping. - on 2/10/2024 in room [ROOM NUMBER]. - on 2/16/2024 at 9:50 AM in room [ROOM NUMBER] by housekeeping - on 2/18/2024 in the hallway between rooms [ROOM NUMBERS]. - on 3/6/2024 in room [ROOM NUMBER] - on 4/27/2024 at 12:21 PM in room [ROOM NUMBER]C and in the hallway between rooms [ROOM NUMBERS] by housekeeping. - on 4/28/2024 at 9:30 AM in room [ROOM NUMBER] by housekeeping. Fruit Flies During observations on 4/29/2024, between 10:00 AM and 11:00 AM, there were 25 fruit flies in the main kitchen dish machine area. There was 1 fruit fly on a hallway wall near resident room [ROOM NUMBER], 1 fruit fly on a hallway wall over the access door to the staff lounge, and 1 fruit fly on the ceiling in the main dining room. During observations on 4/30/2024, between 12:50 PM and 1:05 PM, there was one fruit fly on a hallway wall near resident room [ROOM NUMBER], one fruit fly on a hallway wall near the staff lounge, and one fruit fly on the ceiling in the main dining room. Ants During observations on 4/30/2024 at 9:12 AM, and on 5/1/2024 at 8:23 AM, a puzzle table between resident rooms [ROOM NUMBERS] had ants walking on it. House Flies During an observation on 4/29/2024 at 11:49 AM and at 12:20 PM, the windowsill of resident room [ROOM NUMBER] had dead house flies. During an observation on 4/29/2024 at 12:35 PM, the day room where a resident was eating had a house fly flying around. During an interview on 5/2/2024 at 4:10 PM, the Director of Maintenance stated when staff verbally told them about a pest sighting, a pest control vendor was called to come onsite. They stated all staff had been trained to contact the maintenance department if a pest was seen. The Director of Environmental Services stated it was not acceptable for a fly to land on a resident's tray of food while they were eating. They stated they could not determine if the fruit flies found in the main kitchen had been there prior to the first day of survey. The Director of Environmental Services stated that a pest control vendor came onsite monthly, and that the vendor investigated all parts of the facility. 10NYCRR 415.29(j)(5) 48895

Based on record review and interview during the recertification and abbreviated survey conducted 4/29/2024-5/3/2024, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for 2 of 3 residents (Residents #71 and #233) reviewed. Specifically, Resident #71 remained in the facility after discontinuation of Medicare Part A services and the facility did not provide the resident with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (Centers for Medicare and Medicaid Services-10055) for Medicare Part A as required; and Resident #233 was discharged home and the facility did not provide the resident with a Notice of Medicare Non-Coverage (Centers for Medicare and Medicaid Services-10123) for Medicare Part A as required. Findings include: The undated facility policy, Medicare Cut Letters documented Medicare cut letters would be issued by Minimum Data Set staff, working with the financial coordinator, in a timely fashion and the Financial Coordinator would upload the notice into the system. A Notice of Medicare Non-coverage was given when a resident was going to be terminated from skilled services and going home once cut. The notice must be issued a minimum of 2 days before cutting. When a resident on Part A services still had days remaining, but was being cut, and was staying in the facility under custodial care, they must be provided a Notice of Medicare Non-coverage and a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage. The Center for Medicare and Medicaid Services form instructions for the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage Center for Medicare and Medicaid Services-10055, expiration date 1/31/26, documented a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (form 10055) must be issued by providers to beneficiaries in situations where Medicare payment is expected to be denied. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage must be delivered far enough in advance that the beneficiary or representative had time to consider the options and make an informed choice prior to services ending. The Center for Medicare and Medicaid Services form-10123 instructions documented a Medicare health provider must give an advance, completed copy of the Notice of Medicare Non-Coverage to enrollees receiving skilled nursing no later than two days before the termination of services. 1) Resident #71 was admitted to the facility with diagnoses including peripheral vascular disease, diabetes mellitus, and anxiety. The 11/3/2023 Minimum Data Set assessment documented it was a Skilled Nursing Facility Prospective Payment System Part A discharge (end of stay) assessment. An 11/1/2023 social service note documented a care conference was held on 11/1/2023 and it was determined the resident would remain at the facility for long term care. The Notice of Medicare Non-coverage documented the last covered day of Resident #71's Medicare Part A skilled services was 11/3/2023. The notice was delivered via phone to the resident's representative on 11/1/2023 at 2:08 PM. The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. The facility did not provide the resident a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage Centers for Medicare and Medicaid Services-10055 for Medicare Part A as required. 2) Resident #233 was admitted to the facility with diagnoses including a fracture and diabetes. The 1/18/2024 Minimum Data Set assessment documented it was a Skilled Nursing Facility Prospective Payment System Part A discharge (end of stay) assessment. The 1/18/2024 social service progress note documented the resident was discharged home with family and services were in place. The SNF Beneficiary Protection Notification Review documented the resident's Medicare Part A skilled services start date was 12/15/2023 and the last covered day of Part A service was 1/18/2024. A Notice of Medicare Non-Coverage Centers for Medicare and Medicaid Services-10123 was not provided with an explanation, no letter was generated prior to discharge. During an interview on 5/2/2024 at 4:15 PM, Financial Coordinator #32 stated the process for issuing Notice of Medicare Non-coverage documents was initiated by the therapy department. The process for issuing a Notice of Medicare Non-coverage was determined in the utilization review meeting. Following the Utilization Review process, the Financial Coordinator #32 was notified by therapy of service discontinuation for residents. The resident or resident representative was provided 48 hours advance notice of service discontinuation. Financial Coordinator #32 stated they were unaware Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverages needed to be issued until recently. They stated Resident #71 remained in the facility after their benefit end date of 11/3/2023 and was not issued an Advanced Beneficiary Notice of Medicare Non-coverage because they were not aware of this requirement. Financial Coordinator #32 stated Resident #233 was not issued a Notice of Medicare Non-coverage prior to their discharge because they were not aware that a notice had to be provided to residents who were discharged from the facility while still covered by their Medicare benefit. They stated if a resident was not provided a Notice of Medicare Non-Coverage or a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage, they would not know their appeal rights and may have a potential loss of benefits. During interview on 5/2/2024 at 4:43 PM, the Administrator stated issuing the Notice of Medicare Non-Coverage, and the Advanced Beneficiary Notice of Non-Coverage was previously the responsibility of the Minimum Data Set person. When that person left, it became the responsibility of the finance department. They were unaware that the Financial Coordinator did not realize that Notices of Medicare Non-Coverage had to be issued to discharging residents or they had to issue Skilled Nursing facility Advanced Beneficiary Notice of Non-coverages. They stated the notices needed to be issued so the residents knew their services were ending. 10 NYCRR 483.10 (g) (18)

Based on record review and interview during the recertification and abbreviated (NY00333325) surveys conducted 4/29/2024-5/3/2024, the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for 1 of 1 resident (Resident #37) reviewed. Specifically, Resident #37 eloped (exited the facility without being detected) out of an egress door, and the incident was not thoroughly investigated. Findings included: The facility policy Completing an Accident/Incident Investigation Guidelines effective 8/21/2020 documented it was the responsibility of the facility to immediately initiate and conduct a thorough investigation that included appropriately managing the investigation to ensure a factual and objective accounting of the events to determine if potential abuse, neglect, or mistreatment occurred. The investigation included protecting the resident, gathering evidence, interviewing witnesses to the event, analyzing the documents obtained, addressing any gaps of the incident, documenting the gaps, concluding based on the facts, and taking corrective action. Staff who conducted interviews with residents, staff, and visitors who were witnesses of an incident were to take clear notes or organize transcription of the interview. The summary of the investigation was to include a synopsis, the factual details, and a conclusion that included if a reasonable cause threshold has been established. Resident #37 had diagnoses including Pick's disease (a type of dementia) and pseudobulbar affect (uncontrollable laughing or crying). The 2/2/2024 Minimum Data Set documented the resident had severely impaired cognition, had physical behavioral symptoms directed towards others on 1-3 of 7 days, was independent with ambulation, did not wander, and had a wander/elopement alarm used daily. The comprehensive care plan did not include risk for elopement prior to 2/11/2024. A 2/11/2024 at 11:42 AM Resident Accident/Incident Report completed by licensed practical nurse #3 documented Resident #37 was found outside the window of Resident #23's room. The resident walked out the back egress door. The resident was observed walking out the door by a visiting family member (unidentified). They were alerted immediately by the family member of Resident #23 and Resident #37 was brought back inside. Vital signs were stable and there was no injury. The Director of Nursing was notified at 11:45 AM. Investigation Statements included: - on 2/11/2024 certified nurse aide #4 documented they were walking down the hallway after providing care to another resident when they were alerted by another resident's family member that Resident #37 was standing outside their parent's window. They and licensed practical nurse #3 went outside to get the resident. - on 2/11/2024 licensed practical nurse #3 documented they were alerted by a certified nurse aide that Resident #37 was outside another resident's window. They went to the end of the hall and there was a resident's family member (unidentified) sitting there. The family member stated the resident had just walked out the door. The resident was standing at the window, wearing pants, a long-sleeved shirt, and grip socks. The temperature outside was 40 degrees with no snow on the ground. The resident's vital signs were taken, no injuries were noted, and the resident denied being cold. - on 2/11/2024 the Director of Maintenance documented all egress doors were checked, functioning, and they could not find any issues with the doors. The monthly maintenance log for the magnetic door locks on the egress doors documented the doors were last checked on 2/2/2024. A 2/12/2024 investigation summary completed by the Director of Nursing documented facility staff was alerted by a visitor that Resident #37 was outside at their parent's window. The resident had last been seen by facility staff standing outside another resident's door inside the facility shortly before that. Licensed practical nurse #3 went outside to get the resident and brought the resident back in where an assessment was conducted. Licensed practical nurse #3 reported there was a family member (unidentified) of another resident sitting at the end of the hall who watched Resident #37 exit the facility through the egress door at the end of the South Hall. The facility conducted a head count to ensure residents were accounted for. The door locked appropriately when staff brought the resident back inside, but the door did not sound when the resident exited. The resident's wander alert device was immediately checked and found to be functioning. The egress door was not a wander alert device activated door. Inspection of the door revealed no device was used to prop the door or that the door was utilized by staff. The Maintenance Director was called to the facility and checked all doors for proper function. Elopement education and the importance of checking the security of the doors was conducted. The investigation revealed there was cause to believe alleged resident abuse, mistreatment, or neglect occurred. The investigation did not include if the facility determined how the resident was able to exit the facility. There were no documented witness statements from the family member of Resident #23 who reported the resident was outside the window, or the unidentified visitor who witnessed the resident going outside. During an interview on 5/1/2024 at 11:58 AM, the Director of Maintenance stated the egress doors open by a passcode put into the keypad next to the door. They stated the door would not open if a resident pushed on the door and did not enter the code. The doors stayed unlocked for five seconds and when the door was opened, an alarm sounded after five seconds. They stated the alarm continued to sound until the magnetic strips met and the code was entered into the keypad again. They stated the alarm was loud and if it sounded staff would hear it. If the door was not opened, the door relocked after five seconds. They stated they audited the egress doors every month to ensure functionality. They stated prior to Resident #37's elopement, the licensed practical nurses and the charge nurses could have the code to the doors. Staff were not supposed to use the egress doors. They did not have a system that logged when the doors were opened. After the elopement the door was set to five seconds to alarm if opened and relock if not opened. The door could not be propped without the alarm sounding. The door could not be tampered with unless the maintenance department or a vendor was working on it. During the interview, the Maintenance Director stated they had to verify information and returned at 12:17 PM. They stated at the time of the elopement, there was a malfunction on the timer of the door. They could not state what happened or what the timer was set at. They did not have a vendor look at the door as they were able to fix the issue themself, so a vendor was not called. During a follow up interview on 5/2/2024 at 11:29 AM, the Maintenance Director stated they determined a door malfunction by looking at the door. They checked the wires and there was nothing frayed so they determined it was a malfunction. They could not explain how the door malfunctioned or what the malfunction was. They did not know if the staff who retrieved the resident had noted if the keypad was green which indicated the door was unlocked and unalarmed. There was not a way to leave the door unlocked and unalarmed. They stated they had reviewed the camera, but they were not able to see details of the door when they zoomed in because the picture became pixelated (blurred with a grid of squares). During an interview on 5/1/2024 at 1:11 PM, certified nurse aide #4 stated no staff should go out the egress doors. They had previously been informed of the door code but did not remember what it was. Resident #37 had been following them around that day, but they had been busy. They asked Resident #37 to wait outside another resident's room when they went in to provide care so Resident #37 would not follow them in. They were alerted by another resident's family that Resident #37 was outside their family member's window. They did not know how or why the door was unlocked as no one had used it on their shift. The door did not alarm when the resident exited. They and licensed practical nurse #3 went out the back egress door and retrieved the resident. The door was unlocked when they went out of it and did not alarm. They stated a resident's family member (unidentified) who was sitting next to the egress door told them they thought Resident #37 was a family member exiting the facility. They did not know when the door was unlocked or how long it had been unlocked. During a telephone interview on 5/1/2024 at 1:35 PM, licensed practical nurse #3 stated they were alerted by a staff member and a resident's family member that Resident #37 was outside. They went and retrieved the resident from outside. They stated they went through the egress door on the South unit, the same door the resident went out of. They stated the door was unlocked and the keypad light was green. No alarm sounded when they went through the door. They stated they relocked the door by entering the code when they returned inside. The keypad light turned red when it was locked, and they double checked by pushing on the door which did not open. They were unsure if all staff had the code to the door, but the code was in the supervisor book in the front of the building. They were unaware how long the keypad stayed green and was unlocked and unalarmed. The family member who sat at the end of the hall and watched the resident walk out the door stated to them they had watched Resident #37 walk out the door and thought they were someone's family member. During an interview on 5/1/2024 at 2:03 PM, the Director of Nursing stated on 2/11/2024 licensed practical nurse #3 was the nurse Supervisor on shift and called to inform them Resident #37 had eloped outside. They were informed that licensed practical nurse #3 was leaving the dining room when they were told by another staff member that Resident #37 was outside. A resident's family member had seen the resident exit through the door at the end of the South wing, but the visitor had not thought anything of the resident exiting out of that door. The staff checked the resident's temperature, noted what the resident had on, did a complete head count of the facility, and checked the other doors. They stated they did not see anything propping open the door, so they called the Maintenance Director. The Maintenance Director went in and checked the doors. The Maintenance Director did not report to them what the outcome of the inspection was but reported to the Administrator. They were informed that the door did not sound when the resident or staff went out the door. No one knew what happened. They stated they had asked if the door was pushed open or if someone had unlocked it and was informed no one had unlocked it but the resident went out if it. They were not aware the door keypad was green when the staff went through the egress door. They were unsure if anyone observed the camera footage following the elopement. They would normally look at the camera as part of an investigation and it would be in the investigation summary if they had. They stated they wrote the investigation summary but was only involved in the direct nursing portion. They did not know if staff had the codes to the egress doors prior to the incident but they should not have. They did not know what happened to allow the resident to get outside through the door. They assumed it was a door malfunction because the alarm did not sound. It was not a door that people went in and out of. During a follow up interview on 5/2/2024 at 3:55 PM, they stated they did not take a formal statement of the family visitors who witnessed the resident outside or leave out the egress door. During an interview on 5/2/2024 at 10:41 AM, the Administrator stated they were informed of the elopement when it happened. The resident went out the back door on the South unit (the egress door). Staff was unaware how the resident got outside, and the door had not alarmed when the resident exited. Staff had gone out the same door when they retrieved the resident but had not informed them that the door was unlocked and did not alarm when the staff went through the door. They were not informed the keypad for the door had a green light or that the nursing Supervisor put in the code to relock the door which turned the keypad light red. The Maintenance Director had told them everything was functioning normally when they checked the door. They determined it was a malfunction with the door system as there was no other cause and it would be in the investigation. They were unsure if a vendor came to look at the system. They did not check the cameras and was unsure if the door was visible on the cameras. They could not determine how long the door was unlocked or unalarmed. 10NYCRR 415.4(b)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00309906) surveys conducted [DATE]-[DATE], the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 1 resident (Resident #70) reviewed. Specifically, Resident #70 was not provided anti-nausea medications when needed. Additionally, there was emesis (vomit), feces, and a full urine bag visible at the resident's bedside. Findings include: The facility policy, Quality of Care, dated ,d+[DATE] documented that based on the comprehensive assessment of a resident, the facility would ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's personal preferences. Residents would have an individualized plan of care that was consistent with their needs/goals for care and professional standards of practice. Resident #70 had diagnoses including end stage renal disease (kidney disease), bladder injury, and heart failure. The [DATE] Minimum Data Set assessment dated documented the resident was cognitively intact, required maximum assistance for toileting hygiene, had an indwelling catheter and an ostomy for urinary devices, and was incontinent of bowel. The comprehensive care plan initiated [DATE] documented the resident had an activities of daily living self-care performance deficit and decreased physical mobility due to activity intolerance, limited mobility, and pain. Interventions included extensive assistance of 1 for personal hygiene and toileting, place on toilet every morning and as needed. The [DATE] physician #13 progress note documented the resident was status post cystectomy (bladder removal) and ileal conduit (creation of urostomy, or tubing for urine to exit the body) with abdominal wall reconstruction. A [DATE] physician order documented ondanestron (anti-nausea medication) 4 milligrams every 12 hours as needed for end stage renal disease for 14 days. The [DATE] licensed practical nurse #23 progress note document the resident had liquid emesis 3 times during the shift before dinner. Ginger ale was offered, and the resident refused dinner. There was no documented evidence the medical provider was notified of the emesis to re-evaluate the need for a new order for ondansetron (previous order expired on [DATE]). A [DATE] physician order documented ondansetron 4 milligrams give 1 tablet every 8 hours as needed for nausea and vomiting. The [DATE] physician #13 progress note documented the resident was nauseous which was possibly secondary to their end-stage kidney disease. The anti-nausea medication was increased to 8 mg every 8 hours as needed. The resident's prognosis was extremely poor, with less than 6 months due to underlying end-stage kidney disease, for which they did not want dialysis. A [DATE] physician order documented ondansetron 8 milligrams every 8 hours as needed for nausea and vomiting. The [DATE] at 2:15 PM registered nurse #12 progress note documented the resident had complaints of nausea but had no emesis at the time of the assessment. The ,d+[DATE] Medication Administration Record did not include documentation ondansetron was administered to the resident on [DATE] after they had complained of nausea. During an observation on [DATE] at 11:37 AM and 12:26 PM, Resident #70 was in their room, nude, with a full urine collection bag on the fall mat with the urine window of the bag facing upward. There was a feces soiled brief on the fall mat, and a gray basin approximately one quarter full of vomit. The resident's bare backside was visible from the doorway and to the resident's roommates. At 12:35 PM, the resident had a blanket covering their lower body, no shirt, a completely full urine collection bag on the fall mat with the urine window of the bag facing upward, a feces soiled brief was on the fall mat, and a gray basin approximately one quarter full of vomit. The ,d+[DATE] Certified Nurse Aide documentation for Output in cc's documented that Resident #70's urine bag was emptied on [DATE] at 6:47 AM and 2:40 PM. During an observation on [DATE] at 12:52 PM, Resident #70's lunch tray was in their room, with one bite taken from the entree and an empty coffee cup. The resident stated their stomach hurt too much to eat. They stated they had medication for their stomach, and they had asked for it. The ,d+[DATE] medication administration record did not document ondansetron was administered on [DATE]. There were no corresponding nursing progress notes referencing the resident's complaints of their stomach hurting. During an observation on [DATE] at 8:37 AM, Resident #70 was sitting up on the side of their bed. The urine collection bag was on the floor uncovered. The collection bag contained approximately 1200 milliliters of yellow urine. The spout to the urine bag was folded under the resident's right foot. During an interview on [DATE] at 9:02 AM, certified nurse aide #16 stated urine bags should be emptied every shift. They stated they cared for Resident #70 on [DATE] and noticed the basin of emesis when they went into the resident's room after lunch. They did not tell anyone that the resident had vomited, as they were told that vomiting was normal for this resident, but they still should have reported it. The resident's urine bag was half full when they went into the room in the morning, about 9:00 AM, and they should have emptied it, but did not. They stated there was no feces soiled brief in the morning, but it was there after lunch at the side of the bed. It was not dignified to eat lunch with urine, feces, and emesis at the bedside. Having a full urine bag, a basin of emesis, and a feces soiled brief at the bedside was not the quality of life the certified nurse aide would want for the resident. During an interview on [DATE] at 11:39 AM, registered nurse Unit Manager #15 stated urine bags should be emptied at least twice a shift. The urine bag should be inside another bag to hide the contents, should never be on the floor, and the fall mat would be considered part of the floor. The urine bag should never be fully expanded with, it could burst, or backup the tubing and give the resident a urinary tract infection. If emesis was noted at the bedside, it should be reported to the nurse. It was not dignified to consume a meal with urine, feces, and emesis at the bedside. They reviewed the resident's electronic medical record, and stated the resident's urine bag was only emptied once on [DATE]. If a resident was checked and changed every 2 hours, staff should notice a full urine bag, a soiled brief, and a basin of emesis at the bedside. The resident should have received their anti-nausea medication if they had nausea and vomiting. During an interview on [DATE] at 12:59 PM, the Director of Nursing stated urinary catheter care was to be done every shift and included emptying the bag and placing it inside a privacy bag. Staff should be checking the urine bag every time they entered the room. If staff found a basin of emesis, they should notify a nurse immediately. It was not dignified to consume a meal with urine, feces, and emesis at the bedside. The resident's urine bag should never be on the floor and the fall mat was part of the floor. It should never be full expanded with urine. Full urine bags that were directly on the floor could potentially put weight on the catheter and be uncomfortable. The bag could burst and then it would be an infection control issue. A feces soiled brief at the bedside violated the dignity of the resident and was an infection control issue. During a telephone interview on [DATE] at 8:36 AM, licensed practical nurse #14 stated they were the resident's nurse on [DATE]. They stated the resident told them they were not feeling well after lunch. They noted the basin of emesis when they went to give them medication. They told the certified nurse aide about the emesis and was told that this resident vomited every day. They must have overlooked the order for the anti-nausea medication, as they were attempting to control the resident's pain. The resident should have been given anti-nausea medication on [DATE]. During a telephone interview on [DATE] at 9:17 AM, physician #13 stated if a resident was consistently nauseous or vomiting, they expected nursing to complete an assessment and give the resident as needed medications as ordered. They relied on the nursing assessment to decide if additional interventions were needed. Resident #70 was on comfort care and if the resident stated they were nauseous, they expected the resident to receive the as needed anti-nausea medication. 10NYCRR 415.12

Based on observation, record review, and interview during the recertification surveys conducted 4/29/2024-5/3/2024, the facility did not ensure that residents were free of any significant medication errors for 1 of 1 resident (Resident #5) reviewed. Specifically, Resident #5 was administered Humalog insulin (fast-acting insulin, starts working approximately 15 minutes after injection to lower blood glucose levels) and was not served their meal timely. Findings include: The facility policy Blood Glucose Management effective 7/2018 documented the facility provided residents with an appropriate plan to assist in the prevention of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). Additionally, the timing of dosing of insulin was critical to achieve desired blood sugar management and to prevent hypoglycemia due to insulin administration time versus food intake. The undated facility mealtimes for the dining room documented: - Breakfast was served 8:15 AM to 8:45 AM; - Lunch was served 12:15 PM to 12:45 PM; and - Dinner was served 5:15 PM to 5:45 PM Resident #5 had diagnoses including diabetes. The 2/2/2024 Minimum Data Set assessment documented the resident was cognitively intact, had diabetes, and received insulin. The comprehensive care plan initiated 4/2/2023 and revised 2/21/2024 documented the resident had diabetes and was started on insulin. Interventions included insulin with meals, insulin may be given in the dining room/near vicinity or other meal location with resident's permission during the meal. The 4/16/2026 physician order documented finger stick blood sugar before meals and at bedtime, call physician if below 60 milligrams/deciliter or above 450 milligrams/deciliter. Humalog insulin (fast acting insulin, 30 units with meals for diabetes. The 4/2024 medication administration record documented Humalog insulin inject 30 units subcutaneously with meals for diabetes at 6:00 AM, 12:00 PM, and 5:00 PM. During an interview on 4/30/2024 at 10:44 AM, Resident #5 stated they received their fast-acting insulin before breakfast, which was early so they did not have symptoms of hypoglycemia. They stated breakfast was scheduled to come between 8:15 AM and 8:45 AM, however, at times it was after 9:00 AM. Resident #5 stated that when they brought their concerns about mealtimes and insulin administration, the Assistant Administration told them to carry a snack. The 4/2024 medication administration record documented 30 units of Humalog Insulin was administered by licensed practical nurse #36 on 4/30/2024 at 7:39 AM and at 11:07 PM. The resident's blood glucose was 167 milligrams/deciliter at 7:30 AM and 158 miligrams/deciliter at 11:30 AM. During an interview on 4/30/2024 at 12:04 PM Resident #5 stated they were administered their fast-acting insulin at 11:15 AM when their blood sugar check was completed. They stated lunch was normally served between 12:00 and 12:30 PM. During an observation on 4/30/2024 at 12:44 PM, Resident #5 was served lunch, approximately 1 1/2 hour after their insulin was administered. During an observation and interview on 5/1/2024 at 7:48 AM Resident #5 was in the hallway wheeling themselves towards the dining room and stated they already received their insulin and had not had breakfast. During an observation on 5/1/2024 at 8:40 AM, Resident #5 was served their breakfast approximately an hour after the resident reported receiving their insulin. At 8:55 AM, Resident #5 stated they ate the eggs and did not eat the pancake because they were full. They stated they had eaten 2 bags of chips they carried with them before breakfast, because they felt their blood sugar was too low. During an interview on 4/30/2024 at 2:11 PM, registered dietitian #32 stated fast-acting insulin should be given with meals to prevent hypoglycemia, chills, and shaking. Residents should be expected to carry a snack with them as many residents were confused. During an interview on 5/2/2024 at 8:22 AM, licensed practical nurse #7 stated they always waited for residents to have their breakfast tray in front of them before administering fast-acting insulin because they were afraid the resident's blood sugar could drop too low. Residents should eat within 10 minutes of fast-acting insulin administration. They administered fast-acting insulin to Resident #5 at 7:42 AM and was not sure if the resident had eaten. They stated the resident was at risk for hypoglycemia as they administered insulin prior to the resident being served breakfast. During an interview on 5/2/2024 at 1:37 PM, registered nurse Unit Manager #35 stated meal trays were often delivered late. Insulin should not be given until the meal was received and eaten. Residents sometimes refused meals and the nurse should wait to make sure the resident ate. They stated quick acting insulin worked within 15 minutes. If someone did not eat within 15 minutes of receiving quick acting insulin the insulin does not have food to work on and could cause hypoglycemia. During an interview on 5/2/2024 at 4:11 PM, the Director of Nursing stated they expected insulin to be administered with meals, but no earlier than 15 minutes before the meal was eaten as the resident could become hypoglycemic. Any time after 15 minutes was too early for insulin to be administered. During a follow up interview on 5/3/2024 at 11:09 AM, the Director of Nursing stated administering fast-acting insulin without food would be considered a significant medication error. During an interview on 5/3/24 at 9:11 AM the Medical Director stated regular insulin should be given 10-15 minutes before a meal. If the nurse was concerned about the resident not eating, they should wait until the resident had consumed about 1/3 of their meal to administer the insulin. If the insulin was administered outside the 10-15 minute window before eating this placed the resident at risk for hypoglycemia. 10NYCRR 415.12(m)(2)

48446 49831 Based on observation and interview during the recertification and abbreviated (NY00309906 and NY00338730) surveys conducted 4/29/2024-5/3/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and appetizing for 1 of 2 test trays (4/29/2024 lunch meal) reviewed. Specifically, the lasagna served at the 4/29/2024 lunch meal was burnt; and 7 of 7 anonymous residents at the Resident Council meeting complained of food not being flavorful and not being served at palatable and appetizing temperatures. Findings include: The undated facility policy, Taste Testing, documented that all food should be taste tested prior to meal service. The cook was responsible for tasting all food prior to it being served to residents. Any food that did not pass the taste test due to seasoning, toughness, color, or other negative factors would not be served until the problem was corrected. During an interview on 4/29/2024 at 10:52 AM, Resident #21 stated the food lacked flavor and was not served hot. They received a bowl of cereal and toast with butter for breakfast and the toast was cold. During a resident group interview on 4/29/2024 at 2:00 PM seven anonymous residents in attendance stated the food was often overcooked and lacked flavor, and hot items were often cold. During an interview on 4/29/2024 at 2:13 PM, Resident #5 stated the food was not cooked well, was sometimes burnt, and lacked flavor. During an observation on 4/30/2024 at 12:30 PM, a food tray arrived at Resident #77's room. The tray was tested , and a replacement tray was requested for Resident #77. The meat lasagna was 152 degrees Fahrenheit (acceptable) and the bottom of the lasagna appeared burnt and blackened and did not have an appetizing appearance. During an interview on 4/30/2024 at 12:58 PM, Resident #1 stated the food was not good, lacked flavor, and was not warm. During an observation and interview on 4/30/2024 at 1:01 PM, Resident #5 stated the food was hot today, but the bottom of the lasagna was burnt. Resident #5 showed the corner of the lasagna that was burnt. During an interview on 4/30/2024 at 1:15 PM, certified nurse aide #18 stated they observed burnt food served to the residents. They stated Resident #11's lasagna was burnt and they did not eat it. During an interview on 4/30/2024 at 1:23 PM, licensed practical nurse #19 stated residents complained to them about burnt food. During an interview on 5/1/2024 at 9:11 AM certified nurse aide #10 stated the residents always complained about the food being burnt, or too cold. Sometimes it was difficult to cut the food because it was too hard. During an interview on 5/1/2024 at 1:10 PM, Assistant Food Service Director #27 stated they tried to make every monthly resident council meeting, and residents had complained about the food. They stated residents told them the food was overcooked but not burnt. They had not heard comments about burnt food during the 4/30/2024 lunch meal. They told the cooks in the past not to overcook the resident's food. It was important that appetizing and palatable food was served to residents. During an interview on 5/2/2024 at 8:22 AM licensed practical nurse #7 stated the residents frequently complained about the food being burnt and cold. 10NYCRR 415.14(d)(2)

Based on observation, record review, and interviews during the recertification survey conducted 4/29/2024-5/3/2024, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 licensed practical nurses (licensed practical nurse #7) observed during medication administration. Specifically, licensed practical nurse # 7 did not perform hand hygiene after removing their gloves during medication administration. Findings include: Licensed practical nurse #7's education records documented: - on 4/28/2022 they completed a personal protective equipment and hand hygiene competency. - on 10/17/2022 they completed a handwashing quiz. Licensed practical nurse #7 documented handwashing was the single most important means of preventing the spread of infection. Appropriate hand hygiene must be done when visibly soiled, when removing gloves, after using the bathroom, and before meals. - on 6/5/2023 they demonstrated competency with hand hygiene. During an observation on 5/2/2024 at 8:00 AM licensed practical nurse #7 did not perform hand hygiene between administering medications to Resident #68 and administering medications to Resident #18. Licensed practical nurse #7 applied gloves and cleaned the glucometer (measures blood glucose) for Resident #18. After the glucometer was cleaned, licensed practical nurse #7 removed their gloves and put on another pair of gloves to perform the fingerstick on Resident #18. During an interview on 5/2/2024 at 8:15 AM, licensed practical nurse #7 stated they did not wash or sanitize their hands between administering medications to Resident #68 and Resident #18 or between changing gloves and they should have. They stated they had annual training on infection control and knew the importance of hand hygiene. They stated if hand hygiene was not practiced both residents and staff can become ill from the spread of germs. During an interview on 5/2/2024 at 4:11 PM the Director of Nursing stated all staff were trained annually on infection control. They expected hands to be washed or sanitized after contact with a resident, when soiled, and after removing gloves. If staff did not wash hands between resident contact or after removing gloves it could cause the spread of an infection to the residents, staff, visitors, and families. 10NYCRR 415.19(a)(1-3)(b)(2)

Based on record review and interview during the abbreviated survey (NY00273032), the facility did not provide or obtain radiology or other diagnostic services to meet the needs of its residents for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 did not receive an ordered x-ray timely after a fall. Findings include: The 11/2020 Laboratory, Radiology, and Other Diagnostic Services facility policy documented the facility was to provide diagnostic services with quality and timeliness. The medical provider would be notified and the resident sent out if a test could not be provided in a timely manner. Resident #1 had diagnoses including congestive heart failure, high blood pressure, cardiac pacemaker, chronic obstructive pulmonary disease (COPD), and COVID-19. The 1/20/2021 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition; needed extensive assistance of 2 staff for bed mobility, transfers, dressing, toileting, and hygiene; did not walk during the assessment period; normally used a walker for mobility; was frequently incontinent of bowel and bladder, and had no falls. The 1/13/2021 and 1/14/2021 fall risk assessments documented the resident was at low risk for falls. The 1/13/2021 at 6:51 PM registered nurse (RN) #5's progress note documented the resident arrived to the facility at 2:30 PM. The resident was at the facility for rehabilitation with a plan to return home. The resident had diminished lung sounds and was receiving supplemental oxygen. The resident was receiving a blood thinner and had edema in both arms and legs. The resident was confused at times. The 1/27/21 at 8:46 AM, Director of Nursing (DON) #2's progress note documented the DON was called to assess the resident at 8:00 AM as the resident was observed lying on the floor. The resident had a bloody nose, no alterations in range of motion (ROM), and was alert and answering appropriately. The resident was assisted to bed using a mechanical lift and 4 staff members. There was bruising to the resident's nose and face. The right shoulder appeared protruding with bruising. The resident's baseline neurological checks were within normal limits and the nurse practitioner (NP) was updated. The NP would assess and consider x-rays. The 1/27/2021 at 8:27 AM, licensed practical nurse (LPN) #6's progress note documented the resident's family was notified regarding the resident rolling out of bed that morning. Family requested a call back with the results of the x-ray. The 1/27/2021 at 6:25 PM, NP #7's progress note documented a telephone family conference was done. The resident's condition was declining. The resident was seen that morning after rolling out of bed and was complaining of left shoulder pain and also had a bloody nose. Upon assessment, the nose bleed had stopped and there were no further complaints of shoulder pain. Facial and left shoulder x-rays were to be obtained. The 1/27/2021 physician orders documented to obtain an x-ray of the left shoulder and facial bones. The 1/28/2021 at 8:51 PM, RN #8's progress note documented progress notes were faxed to the x-ray company per their request. The company stated all x-rays requests would require an added progress note faxed to them prior to an x-ray being done. The 1/29/2021 at 7:14 PM, DON #2's progress note documented the x-ray company was called twice to check their estimated time of arrival. The company told the DON that every effort would be made to complete the x-ray that night if not by the next day. The 1/29/2021 at 9:53 PM, LPN #9's progress note documented no technician had come to perform the x-ray. The family was not pleased and spoke with the DON about their concerns. The 1/30/2021 at 9:16 AM, DON #2's progress note documented the x-ray company called and would be at the facility that morning. The 1/30/2021 at 12:52 PM, LPN #10's progress note documented the x-ray was done at that time. The resident's family was at the resident's window during the x-ray and wanted to be notified of the results as soon as possible. The 1/31/2021 at 10:20 AM, LPN #11's progress note documented the resident had facial and shoulder x-rays on 1/30/2021. The shoulder x-ray was negative for fracture. Facial x-ray showed incomplete visualization. The 1/31/2021 at 11:05 AM, LPN #11's progress note documented a phone conference was done with family informing them of resident's condition. When interviewed on 7/11/2023 at 1:16 PM, NP #7 stated the resident was admitted to the facility with multiple respiratory issues and became COVID-19 positive shortly after admission. Around the time of the resident's fall, it was a problem obtaining x-rays for residents at the facility. The local hospital did not want the facility sending a resident for x-rays due to the pandemic. NP #7 stated that if the radiology service was unable to come to the facility within 6 hours and could not give a definitive time of service, staff were to call the medical provider and the resident would be sent to the local hospital to obtain the x-ray. That procedure was implemented shortly after this incident. When interviewed on 7/11/2023 at 2:40 PM, Assistant Director of Nursing (ADON) #3 stated the expectation of the x-ray being completed within 4 hours of receiving the order. If it was not done, the ADON expected staff to contact a medical provider for the resident to be sent to a local hospital to have it done. The resident's x-ray was not done timely as it took 3 days for completion. When interviewed on 7/11/2023 at 2:47 PM, Corporate RN #4 stated regular x-rays contained a lot of variables. If ordered as a precaution, the timeline for completion was 24 hours. The x-ray should be done with 4 hours if ordered STAT (immediate). RN #4 stated it was not acceptable for it to take 3 days to rule out a fracture post fall. A conversation with a medical provider should have occurred to obtain the x-ray in a more expedient manner. 483.50(b)(2)(1)(11)

Based on observation, interview and record review during the recertification survey conducted 2/22/22-2/28/22, the facility failed to store and label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration dates when applicable for 2 of 4 medication carts and 2 of 2 medication storage rooms reviewed. Specifically, the North medication cart had resident-specific medications that were not labeled, discharged resident medications were in a bag labelled with a current resident's name, and staff drinks were stored in the bottom drawer of the medication cart. The South medication cart had unlabeled and expired vials of insulin, and house stock medications requiring refrigeration were on the cart. The North medication storage room had refrigerated medications unlabeled and outdated beyond the manufacturer expiration date. Findings include: The facility policy Storage and Maintenance of Medications dated 10/2020, documented: - All drugs and biologicals are to be stored in the locked designated cabinets for this purpose and shall be stored under proper temperature controls. - All medications, except those requiring refrigeration, shall be kept in locked medication carts and cabinets. - Refrigerated medications are kept in closed and labeled containers, with internal and external medications separated. - Only drugs (and supplies necessary for their administration) are to be kept in the medication cabinets and carts. - Medications with shortened expiration dates (i.e., insulin, injections, ophthalmic drop etc.) must be dated when opened. - Medications must be checked regularly for expiration dates and deterioration. - Medications no longer in use are returned to the pharmacy and are destroyed or credited where applicable in accordance with State and Federal regulations. The facility policy Emergency Pharmacy Service and Emergency Kits revised on 8/2020, documented emergency needs for medication are met by using the facility approved emergency medication supply or by special order from the provider pharmacy. The emergency supply along with a list of supply contents and expirations dates are maintained in the medication room, or in accordance with facility policy and state regulations. The following observations of the North medication room on 2/24/22 at 10:39 AM included: - An opened bottle of [MEDICATION(S)] ([MEDICATION(S)]) in the refrigerator was not labeled with the date opened. - Two,10 milliliter (ml) opened, partially used, and undated vials of [NAME]-COV (a combination medication used for the treatment and prevention of COVID-19) which included a label that read discard unused portion. - A box with 3 Dulcolax ([MEDICATION(S)]) suppositories, with a manufacturer expiration date of 1/2022. - A house stock bottle of Tylenol (pain reliever) 500 milligram (mg) tabs with a manufacturer expiration date of 12/2021. During the observation licensed practical nurse (LPN) #4 stated all nurses were responsible for making sure there were no expired medications. The LPN stated expired medications had the potential to make a resident sick if administered. During an observation of the North medication cart on 2/24/22 at 11:05 AM, there was a plastic bag with Resident #43's name that contained [MEDICATION(S)] eye ointment (antibiotic) and Refresh lacri-lube (lubricating eye ointment) that were individually labelled for a resident who had been discharged from the facility. In the bottom drawer of the North medication cart there were two bottled energy drinks that belonged to staff. At the time of the observation LPN #4 stated they had agreed to store the drinks for another staff member that morning. They also stated it was not appropriate to have personal food or drinks in the medication cart because of potential infection control issues. During an observation of the South medication cart on 2/24/22 at 12:02 PM with LPN #8, there were two opened insulin [MEDICATION(S)] ([MEDICATION(S)]) 10 ml vials not labeled with the opened date. LPN #8 stated insulin vials were only good for 28 days once opened. They stated the two [MEDICATION(S)] insulins should be disposed of. There was one box of 12 Tylenol 650 mg suppositories, labeled keep refrigerated. At the time of observation, LPN #8 stated they were supposed to be in the medication refrigerator and was not sure why or how long the suppositories were in the medication cart. When interviewed on 2/25/22 at 3:38 PM, the Director of Nursing (DON) stated the medication rooms were audited by the DON and Assistant Director of Nursing (ADON), but there was no set scheduled audit time. All residents' medications should be stored separately, and eye drops should be separate from eye ointments. Staff food and drinks were never allowed on the medication carts as this was poor nursing practice and an infection control issue. All medications, including insulin vials, should be labeled with the date they were opened. Insulin was good for 28 days. The DON stated they were not sure if the Tylenol suppositories should be kept in the medication cart or the medication room refrigerator and would have to check with the pharmacist. 10NYCRR 415.18(d)(e) (2-4)

Based on observation, record review and interview during the recertification survey conducted 2/22/22- 2/28/22, the facility failed to ensure the right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate for 1 of 1 resident (Resident # 19) reviewed. Specifically, Resident #19 had [MEDICATION(S)] gel (a nonsteroidal anti-[CONDITION(S)] topical medication) at their bedside and there was no documented evidence the interdisciplinary team had assessed the resident's ability to safely self-administer the medication. Findings include: The facility policy Medication Administration reviewed 2/2019 documented all medications were to be administered by licensed nursing staff. No medications are to be left at bedside except as noted (see 'Self-Administration of Medications). The undated facility policy Self-administration of Medications documented it was the policy of the facility that those residents deemed capable who desire to self-administer their medications, and residents preparing for discharge be permitted to do so after appropriate counseling, and with the specific order of the resident's physician. Resident #19 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition and required limited assistance with personal hygiene. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order did not include instructions for the resident to self-administer the medication. The comprehensive care plan (CCP) initiated 4/22/21 documented the resident had a self-care performance deficit related to activity intolerance, fatigue, pain, and limited mobility. The resident required limited assistance of one with personal hygiene. The CCP initiated 5/20/21 documented the resident had back pain and was at risk to develop increased pain or have pain not be controlled. Interventions included to administer analgesia. There was no documented evidence the resident had a plan in place to self-administer medications The 2/2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The following observations were made: - on 2/22/22 at 10:30 AM, the resident was observed rubbing ointment on their left foot. They stated it was brought to their room and left by the nurse. It was in a small medication cup, and the resident stated it was [MEDICATION(S)]. The resident stated it was recommended by podiatry, and they had been using it for a long time for pain. - on 2/23/22 at 10:03 AM, the resident was observed putting [MEDICATION(S)] on their left foot. They stated staff brought it in a medication cup and left it. They stated they used it twice a day, in the morning and night and they put it on themself. The resident stated they sometimes had to ask staff for it because they did not bring it. When interviewed on 2/28/22 at 12:02 PM, licensed practical nurse (LPN) # 4 stated they administered the [MEDICATION(S)] to the resident that morning. They stated medications were not to be left in the resident's room. They stated there was a medication cup in the room with [MEDICATION(S)] in it, but they disposed of it because residents were not supposed to self-administer medications. Medications should not be left at the bedside, as a resident may not apply correctly, or another resident may get it. They were not aware of any residents on the unit that were able to self-administer their own medications. The LPN stated if the resident was able to administer their own medication, it would be documented in the medication administration record. When interviewed on 2/28/22 at 12:18 PM, LPN #5 stated there were no residents assessed for self-administration of medications on the unit. Prior to being able to self-administer medication a resident should be educated and assessed to make sure they were able to administer the medication properly and safely. The resident had not been assessed for self-medication administration. LPN #5 stated they took the [MEDICATION(S)] in to Resident # 19 and applied the [MEDICATION(S)] on affected areas and the resident rubbed it in themself. When interviewed on 2/28/22 at 1:01 PM the Director of Nursing (DON) stated prior to self-administration of medications, the resident must be assessed for the ability to perform the task competently and safely. If the resident was not assessed there was the possibility of the resident not self-administering appropriately, or another resident could pick up the medication if it was left at the bedside. The resident did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . 10NYCRR 415.3(e)(1)(vi)

Based on record review and interview during the recertification survey conducted 2/22/22-2/28/22 the facility failed to provide the appropriate liability and appeal notices to Medicare beneficiaries for 3 of 3 residents (Residents #222, 223 and 224) reviewed. Specifically, Residents #222, 223 and 224 were discharged to home and the facility did not provide the residents with Notice of Medicare Non-Coverage (NOMNC) CMS- (Centers for Medicare and Medicaid Services) for Medicare Part A as required. Findings include: The CMS form instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS- (expiration date 8/31/23) documents a Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. The facility policy Medicare Cut Letters revised 2/2019 documents the Minimum Data Set (MDS) Coordinator will work with the financial coordinator to give residents Medicare cut letters in a timely fashion. A NOMNC, form CMS- , shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if resident is leaving the facility or remaining in the facility. Resident #222 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) dated [DATE] documented it was a planned discharge and was a SNF (skilled nursing facility) Part A PPS (Prospective Payment System) discharge assessment. The resident's cognition was moderately impaired. Resident #223 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was cognitively intact. Resident #224 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's cognition was moderately impaired. There was no documented evidence Residents #222, 223 and 224 were provided with NOMNC CMS- at least two calendar days before Medicare covered services ended. During an interview with the Administrator on 2/28/22 at 9:45 AM, they stated the facility got behind in sending the NOMNC CMS- forms to the residents being discharged home as the MDS Coordinator was out for an extended period of time last year. During an interview with the MDS Coordinator on 2/28/22 at 9:50 AM, they stated they did not send Residents #222, 223 and 224 their NOMNC CMS- forms. They were out of work for an extended period last year, no other staff took over sending out the NOMNC CMS- forms and they were trying to get caught up. They had been in this position for [AGE] years and it must have slipped under the radar. They stated most residents wanted to be discharged from the nursing home and rarely want to appeal the cut letter. 10 NYCRR 415.3(g)(2)(iii)

Based on observation, record review, and interview during the recertification survey conducted 2/22/22-2/28/22, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (resident #275) reviewed. Specifically, Resident #275 was administered oxygen without a medical order. Findings included: The facility policy Oxygen Therapy reviewed 8/2021 documented a physician's order was required to initiate oxygen therapy, except in an emergency situation. The physician's order shall include the following: liter flow rate, administration device (i.e., nasal cannula etc.), duration of therapy, and SPO2 (oxygen saturation levels) as applicable. Resident #275 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognition and received oxygen therapy. Physician orders did not document oxygen administration. The 2/7/22 unsigned Nursing Comprehensive Assessment documented the resident's oxygen (O2) saturation (amount of oxygen in blood stream) was 96%, had diminished lung sounds and was receiving 1 liter (L) of O2 as needed via a mask. The comprehensive care plan (CCP) did not include the use of O2. Observations of Resident #275 included: - on 2/23/22 at 9:46 AM, the resident had a portable oxygen tank on the back of their wheelchair that was running at 3 L via a nasal cannula. - on 2/23/22 at 1:05 pm, the resident was eating lunch in their room with oxygen being administered at 3 L via nasal cannula from an oxygen concentrator. - on 2/24/22 at 9:10 AM, the resident was in bed receiving oxygen via nasal cannula at 3 L from an oxygen concentrator. The February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing progress notes dated 2/23/22-2/24/22 did not document the use of O2. When interviewed on 2/28/22 at 12:06 PM, licensed practical nurse (LPN) #4 stated that the resident was supposed to be on oxygen because they had been hospitalized with COVID-19. They stated it should be in the electronic Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Oxygen required a medical order and should not be given if it was not needed. They stated the resident has been on oxygen since admission. When interviewed on 2/28/22 at 12:11 PM, registered nurse (RN) #12 stated they had performed the admission assessment for Resident #275 on 2/7/22. The resident was admitted wearing oxygen due to a history of COVID-19 infection. The admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical provider could add or remove orders. A nurse supervisor or medication nurse was supposed to double check for accuracy of orders for admissions. The RN stated oxygen required a medical order and should not be administered without an order. The RN was not sure if oxygen was listed on the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] When interviewed on 2/28/22 at 12:49 PM, physician #9 stated that oxygen required a physician order. The physician stated oxygen should not be administered if it was not needed. In an emergency, with an RN assessment, oxygen could be administered while a call was being made to a provider. When interviewed on 2/28/22 at 12:56 PM, the Director of Nursing (DON) stated that oxygen required orders by a medical provider. Those orders should include flow rate, method of administration, and routine tubing changes. The DON stated on admission, physician orders were put in the computer by nursing, then a second review of admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 10 NYCRR 415.12(k)(6)

Based on observation and interview during the recertification and abbreviated surveys (NY 216) conducted 2/22/22-2/28/22 the facility failed to post on a daily basis at the beginning of each shift, the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, in a prominent location readily accessible to residents and visitors for 4 of 4 days reviewed. Specifically, the current daily resident census and nurse staffing schedules were posted in the administrative hall on a wall near the staff time clock in a dimly lit area that was not readily accessible to residents and visitors. Findings include: The daily resident census and nurse staffing information was observed posted on the wall above eye level in the dimly lit administrative hallway on: - 2/22/22 at 10:50 AM. - 2/23/22 at 10:00 AM. - 2/24/22 at 10:15 AM. - 2/28/22 at 9:10 AM. During an interview with staff scheduler #3 on 2/28/22 at 9:39 AM, they stated they assigned staff to the nursing schedule then posted it on the wall by the visitor bathrooms across from the scheduling and Administrator's office. They stated they had always posted it there and were not aware it should be posted in a more readily accessible location for visitors and residents. During an interview with the Administrator on 2/28/22 at 9:41 AM, they stated the nursing staff schedule used to be posted on the wall outside the copy machine room. They did not recall when it started being posted in the current location. The Administrator stated the hall where the staffing was posted was not frequented by visitors or by residents. 10 NYCRR 415.13

Based on observation, interview, and record review during an abbreviated survey (#NY 714), the facility did not ensure residents were free from accident hazards and received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents. Specifically, Resident #1 had a physician order for pudding thick consistency liquids, the resident was served thin consistency liquids and was left unsupervised to eat in their room for an hour and forty minutes. When the resident was next observed by staff, they were coughing up liquids, experienced shortness of breath, and passed away shortly after consuming the thin consistency liquids. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. Finding include: The undated Resident Diets policy documented the physician ordered a diet upon admission and nursing staff completed a non-verbal communication form that was sent to Nutritional Services. The Director of Nutritional Services and/or the Diet Technician validated the meal ticket for accuracy. Upon serving the meal, nursing staff checked the meal tickets to ensure accuracy of the food and fluids provided. The [DATE] Coronavirus (COVID-19) Disease: Communal Dining policy documented the following: - All communal dining was suspended. - In-room service was provided to residents who had been assessed to be capable of feeding themselves. - Residents who were at high-risk of choking and those at-risk of aspiration were to be identified, as they could cough and create droplets. Ideally, these residents would eat in the room to avoid the spread of droplets or ensure social distancing of 6 feet or more with a few residents as possible in the nearby area. The [DATE] Accepting Admissions and Re-admissions from Hospitals During COVID-19 Pandemic policy documented new admissions who were COVID-19 negative or unknown and asymptomatic were recommended to be in a private room with limited contact with other residents if possible. Resident #1 was admitted to the facility on [DATE] with diagnoses including stroke and dysphagia (difficulty swallowing). The [DATE] Registered Nurse Supervisor (RNS) #4's progress note documented the resident was admitted to the facility at 5:00 PM and was alert to person but confused otherwise. The [DATE] Physician's verbal order documented the resident was to receive a regular diet, pureed texture, and extremely thick/pudding liquid consistency due to a stroke. The [DATE] Dietary Communication Form completed by Licensed Practical Nurse (LPN) #6 documented puree/pudding. The ,d+[DATE] Certified Nurse Aide (CNA) Documentation Report (documentation of care provided, completed by LPN #6) documented the resident was dependent on one staff person for eating dinner on [DATE]. The resident did not have written CNA care instructions initiated on [DATE]. The [DATE] Medical Orders for Life Sustaining Treatment (MOLST) documented the resident was a DNR (do not resuscitate, do not attempt chest compressions if the heart stops beating), DNI (do not intubate, insert a breathing tube), do not send to the hospital, and comfort measures. The [DATE] RNS #4's progress note at 11:34 AM documented she was paged to the resident's room at 10:36 AM. The resident was unable to answer questions, was coughing and exhibited respiratory distress. Respirations were labored and rapid at 36 per minute. Oxygen was applied at 3 Liters (L) and the resident's saturation (level of oxygen in blood) was 84%. The RNS called the nurse practitioner who ordered a chest x-ray and oxygen. The resident's respirations then slowed and ceased, and the resident expired. The [DATE] Incident Report documented: - The resident was admitted to the facility on [DATE] at 5:00 PM and their diet order was Regular diet, pureed texture, extremely thick/pudding thick liquids consistency. - The diet order was communicated with the kitchen and the kitchen could not print meal tickets on the weekends, so the resident's meal ticket was handwritten and documented puree/pudding on half a sheet of paper. - Temporary Nursing Assistant #1 prepared Resident #1's meal tray and thought the diet order meant pureed food with chocolate or vanilla pudding. Temporary Nursing Assistant #1 did not know the resident required thickened liquids. Temporary Nursing Assistant #1 served the resident the meal tray in the resident's room and left the resident to eat unsupervised. - At 10:36 AM, licensed practical nurse (LPN) #2 entered the resident's room and noticed the resident was having difficulty breathing. The resident had a breakfast tray and 3 empty cups in front of them at that time. - LPN #3 and RNS #4 were notified. The resident became hypoxic (lack of oxygen in the blood), supplemental oxygen was provided, and the resident declined and expired 10 minutes later. - Temporary Nursing Assistant #1's statement documented the meal ticket did not document pudding-thick liquids, she left the resident alone in the room with the meal tray to eat, and she was told the resident aspirated on the liquids and passed away. - RNS #4 and LPN #3's witness statements documented the resident had three empty cups on the bedside table and one had a small amount of thin liquids remaining in the bottom of the cup. - The report documented the resident received the incorrect fluid-consistency and staff were disciplined. The timeline review of camera footage outside of the resident's room on [DATE] documented: - Temporary Nursing Assistant #1 entered the resident's room at 8:51 AM with a breakfast tray and left the room at 8:53 AM. - LPN #3 entered the resident's room at 10:33 AM, exited the room at 10:37 AM, returned with an oxygen tank, exited the room at 10:38 AM, and re-entered the room with LPN #2. - RNS #4 entered the room at 10:39 AM. - The timeline summary documented staff were seen near the nurse's station outside of the resident's room from 8:53 AM to 10:33 AM and no one entered the room during the time the resident had the breakfast tray in their room. The [DATE] Nurse Practitioner (NP) #5's progress note documented the resident was admitted to the facility on [DATE] after hospitalization following a stroke. The NP was notified on [DATE] that the resident was having abnormal lung sounds and [CONDITION(S)]. Staff applied 3 L of oxygen and the resident's oxygen saturation increased to 84%. The NP ordered a chest x-ray and to apply oxygen. The resident's breathing slowed, became tachypneic (abnormally rapid breathing), the resident lost consciousness, then breathing and heartbeat stopped. There was no documentation in the NP's note the resident received the wrong fluid consistency. During an interview on [DATE] at 1:51 PM, LPN #6 stated she was working the night the resident was admitted ([DATE]), she called the kitchen for a dinner tray stating the resident was on a pureed, pudding thick liquid diet. She filled out the Dietary Communication Form but could not recall if she wrote puree, pudding-thick or just puree, pudding. She stated that the kitchen always called if there were any questions. She stated the dietary staff created the meal tickets from the Dietary Communication Form that nursing sent to them. She stated the facility policy was that if a resident was on any altered consistency diet, they could not eat alone in the rooms as there was a greater risk to have problems due to swallowing difficulties. During an interview on [DATE] at 11:57 AM, dietary aide #8 stated when she came to work on [DATE], the cook gave her the Dietary Communication Form and instructed her to make the resident's meal ticket. She wrote down exactly what the LPN wrote on the form and she knew that pudding meant pudding thick liquids. She said she could see how pudding could be confusing, especially to someone new. She did not prepare the tray, she prepared the meal ticket. During an interview on [DATE] at 10:57 AM, Temporary Nursing Assistant #1 stated she was a temporary CNA and worked at the facility for about one month prior to the incident with the resident. On [DATE], she was helping pass breakfast trays and the resident had a handwritten meal ticket that said puree, pudding, and did not specify that the liquids needed to be thickened. She poured the resident three drinks of thin liquids that day at breakfast and served the tray. She left the resident in the room alone and did not go back and check on the resident again during the meal. She stated most residents ate outside of their rooms, but the resident was a new admission and was on isolation for 14 days. She stated residents on isolation ate in their rooms. She did not know if there was a policy for residents on altered consistency diets needing to be supervised at meals. During an interview on [DATE] at 12:35 PM, LPN #2 stated that she did not think the resident would be in view of staff if they were eating in their room and staff were at the nurse's station. She stated residents who were at high risk for aspiration had it documented in their care plan and would not be allowed to eat alone in their room. The resident was not care planned to be at high risk for aspiration and she stated the resident was too new for the staff to know if the resident was at high risk or not. The first time she saw the resident was when she was in distress and the resident was coughing out colored liquids that were an orangey-red, and globs of what looked like pureed scrambled eggs. It looked like the food and fluids from the breakfast tray. She did not hear the resident having trouble with the meal prior to that. She stated the CNAs were supposed to round in the rooms during meals. During an interview on [DATE] at 2:12 PM, RNS #4 stated on [DATE] she was called to the resident's unit by LPN #2 and #3. When RNS #4 arrived to the resident's room there was a glass with a little bit of thin liquids in the cup left on the resident's meal tray. The resident was short of breath and coughing and not able to talk to RNS #4. The resident had spoken to the LPN #2 and #3 and said the resident could not catch their breath. RNS #4. RNS #4 immediately called the NP who ordered a chest x-ray. The resident's advance directives documented DNR, DNI, and not to send to the hospital. NP #5 did not want to send the resident to the hospital. RNS #4 said the resident declined quickly. During an interview on [DATE] at 8:13 AM, NP #5 stated on [DATE] she was notified the resident's oxygen saturation dropped and she ordered a chest x-ray. She said the staff did not tell her what caused the resident's oxygen saturation to drop and she could not recall the staff informing her the resident received thin liquids when she required pudding-thick liquids. When the surveyor told the NP the staff reported the resident likely consumed close to three cups of thin liquids, she stated that was a lot of fluid and aspiration could potentially be a possible cause of death. When the resident consumed thin liquids, especially that amount, it could potentially cause harm to the resident. During interviews on [DATE] at 11:11 AM and 11:41 AM, the Assistant Director of Nursing (ADON) stated she completed Temporary Nursing Assistant #1's training. Diet consistencies were not reviewed as part of the temporary CNA training. She stated diet consistencies would be reviewed when the temporary nursing assistant was paired up with a preceptor on the unit. She stated Temporary Nursing Assistant #1 was new to healthcare and did not know that pudding without thick after it meant thickened liquids. The ADON stated that all new admissions were placed on isolation and remained in their rooms for 14 days after admission. They could eat alone in the rooms but should be in eyesight of the staff. The resident's room was by the nurse's station and staff could visualize the resident and they could see the resident in bed from the door. During an interview on [DATE] at 12:41 PM, the Director of Nursing (DON) stated the facility did not have a policy that residents on an altered consistency could not eat in their rooms alone. If a resident was identified to be at high risk for aspiration after an RN or speech therapy assessment, it would be on their care card and on the dashboard in the electronic medical record. If a resident was on aspiration precautions, the resident would not be allowed to eat without supervision. The resident's room was right next to the nursing station and staff were able to see the resident from the hallway. Looking back, the DON said she would not feel comfortable with the resident eating alone in their room and she thought the nurses should have been a little more aware and present while the resident was eating. During an observation on [DATE] at 11:14 AM, the resident's room was directly behind the nursing station down a short hallway and the resident's room could not be seen into while at the nursing station. 10NYCRR 415.12(h)(1)(2)

Based on observation, interview and record review conducted during the standard survey, it was determined for 5 of 7 exit discharge pathways (North Unit, South Unit, physical therapy, administrative, and main dining room), the facility failed to ensure Administrative staff administered the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Specifically, the Administrative staff failed to maintain a system for 5 of 7 exit discharge pathways to ensure they were clear of impediments, and accessible at all times, to provide occupants with a safe access to the public way. Refer to K38. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety of the 74 residents at the facility. The Immediate Jeopardy was removed on 3/6/2014, prior to the survey exit. Findings include: On 3/4/3014 at 1:47 PM, in an interview with a maintenance staff member, he stated he had received no instruction on how far someone needed to get away from the building in an emergency. He stated he believed the goal was to just be able to get out of the building. When interviewed on 3/4/2014 between 2 PM and 2:20 PM, the facility Administrator stated the facility exits/doorways need to be kept clear of snow, as well as the path to the parking lot, and the path around the building. The Administrator stated the Director of Environmental Services was responsible for snow removal. During the interview the Administrator went outside the North Unit exit with the surveyor, she stated the path was not clear enough to get multiple residents out of the building. After reviewing the condition of the South Unit egress with the surveyor, the Administrator stated she did not think the path was ever cleared to the public way. She stated she had not done any audits regarding the paths being maintained clear to the public way. After reviewing the 3 - 4 inches of packed snow on the sloped path to the parking lot from the administrative and dining room egress doors, she stated the path was treacherous. As the Administrator visualized the South unit egress with the surveyor, she stated staff would use blankets and mats to drag the residents through the paths, as it was part of the facility fire evacuation plan. The Administrator stated staff had not practiced that. When interviewed on 3/4/2014 at 2:25 PM, the Director of Nursing (DON) stated staff had not been trained "recently" on the use of floor mats/blankets to evacuate residents. She stated she would try to get the residents out to the front of the building, and the fire chief would direct staff/administration regarding resident movement. When interviewed on 3/4/2014 at 3:30 PM, the DON stated she was not aware there was a problem with snow blocking exit doors, and was not sure how long a path needed to be cleared. On 3/4/2014 at 3:30 PM, in a follow up interview, the Administrator stated she was aware the path to the public way needed to be kept clear. The Administrator stated she visually checked, when she came in the facility from the parking lot, that the paths were clear, and there were video cameras that showed if the paths were clear as well. She stated she did not walk around the building every day to ensure the paths were clear. She stated it was the responsibility of the Director of Environmental Services to check the paths every day, he did all the snow removal around the building, and he would let her know if there were concerns. The Administrator stated the Director of Environmental Services told her that morning he had planned to plow the paths that day. On 3/4/2014, between 3:41 PM and 3:47 PM, a surveyor and the Director of Environmental Services observed the north side discharge path to the public way. The discharge path was was approximately 28 - 30 inches wide and contained an 18 - 20 inch snow drift. The remaining path along the outside of the building to the parking lot contained approximately 4 - 6 inches of snow that varied in depth. The surveyor documented the path was difficult to traverse by walking on the snow covered surface. The Director of Environmental Services stated he still had snow that needed to be removed in this area. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed prior to survey exit on 3/6/2014 based on the following corrective actions taken by the facility: - Ensured the egress paths were clear and accessible to the public way. - Developed a system to adequately maintain and monitor facility egress paths to ensure they were clear and accessible to the public way. - Revised policies and procedures to address maintenance of egress paths in a clear and accessible manner. - Educated the majority of facility staff on roles and responsibility regarding the maintenance of egress paths in a clear and accessible manner, and ensured remaining staff will be trained prior to returning to duty. - Quality assurance monitoring was initiated, by administrative staff, to ensure compliance with the new/revised policy and procedure. 10NYCRR 415.26(a)