Every finding on record at Four Seasons Nursing and Rehabilitation Center

Based on observation, record review, and staff interviews conducted during the abbreviated survey (812190), the facility failed to ensure the resident's right to be treated with respect and dignity which included the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. This was evident in 1 out of 4 residents (Resident #1) sampled for Restraint. Specifically, on 01/30/2024 at 3:18 PM Registered Nurse #1 observed Resident #1's right hand in a mitten and mitten strap tied to the bed frame. Resident #1 was assessed by Registered Nurse Supervisor #1 and Medical Doctor #1 with no redness, discoloration or visible injuries.The Findings are:The facility's policy titled Restraint Use, dated 09/2023, documented the facility promotes and encourages a restraint free environment. Residents have the right to be free from physical or mental abuse, involuntary seclusion and any physical or chemical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms.Resident #1 was admitted to the facility with diagnoses including Chronic Respiratory Failure and ventilator dependent.The Minimum Data Set (a resident assessment tool) dated 11/14/2023 documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 12 associated with moderately impaired cognition.A review of the facility investigation dated 01/30/2024 documented the Director of Respiratory Therapy reported that Respiratory Therapist #1 applied a mitten on Resident #1's right hand on 01/30/2024. The strap of the mitten was tied to the side of the bed. Resident #1 acknowledged removing themself from the ventilator several times that evening (01/30/2024). Resident #1 reported being frustrated of being on the ventilator and going to dialysis. Resident #1 was assessed with no bruising, trauma or any injury. Respiratory Therapist #1 was interviewed and acknowledged placing the hand mitten on Resident #1's hand and tying them to the side of the bed. 911 was called and the incident was reported to them. Respiratory Therapist #1 was suspended and later terminated. Other residents on Respiratory Therapist #1's assignment were assessed for restraint and abuse with no issues. Facility concluded that there is evidence to support Respiratory Therapist #1 applied a hand mitten to Resident #1's right hand and tied it to the bed frame.A review of Resident #1's Behavior Care plan dated 12/30/2023 documented Resident #1 frequently disconnects the respiratory circuit. The interventions are documented to educate Resident #1 on risks associated with disconnecting their respiratory circuit and redirect Resident #1 to watch television or listen to music.A review of Physician's Order dated 01/04/2024 documented apply hand mittens to prevent accidental decannulation. Release mittens every 2-hours x 15 minutes.A review of the Physician's Order dated 01/05/2024 revealed the order for mittens was discontinued, no longer necessary.A psychiatry progress note by Medical Doctor #1 dated 01/15/2024 at 5:13 PM, documented resident has behavior of agitation and pulling off the tubes. Resident #1 is on psychoactive medications. Gradual dose reduction was not attempted at this time; it is clinically contraindicated.A review of a nursing progress notes by Registered Nurse #1 dated 01/30/2024 at 3:18 PM, documented Resident #1 continues to exhibit episodes of inappropriate behavior as evidence by continually attempting to self-decannulate and disconnect the respiratory circuit.A physician's progress notes by Medical Doctor #1 dated 01/30/2024 at 5:27 PM documented tracheostomy care and suctioning performed. No respiratory distress. Resident #1 occasionally disconnect themself from the trach. On Clonazepam (Klonopin, a long-acting benzodiazepine used to treat panic disorder, seizure disorders including epilepsy, and sometimes restlessness) 0.5 milligram table twice daily for anxiety disorder, no adverse reaction noted.Attempts were made to contact Respiratory Therapist #1 but were unsuccessful. A certified letter was mailed out with no response as of today. A review of a statement provided to the facility by Respiratory Therapist #1 dated 01/30/2024, documented they were scheduled to worked on 01/29/2024. Resident #1 was constantly pulling and disconnecting themself from the vent. Resident #1 repeatedly disconnected themself throughout the shift. Around early morning time after finishing their rounds, they placed Resident #1's right hand in a mitten and loop the mitten string around the metal bed frame. They told Respiratory Therapist #2 to give an eye on Resident #1 while they were gone. They did not want Resident #1 to hurt themself. During an interview on 02/06/2026 at 2:18 PM, Registered Nurse #1 stated they worked on the 7:00 AM -3:00 PM shift on 01/30/2024. Registered Nurse #1 stated while they were performing rounds (unsure of time) and observed Resident #1's right hand in a mitten and the string of the mitten was tied to the bed frame. Registered Nurse #1 stated that Resident #1 informed them that someone tied them and they notified Registered Nurse Supervisor #1. Registered Nurse #1 stated they performed a head-to-toe assessment and no invisible injuries, no redness or discoloration observed. Registered Nurse #1 stated that Resident #1 denied pain and discomfort. Registered Nurse #1 stated Resident #1 has been continuously trying to disconnect themself from the vent. Registered Nurse #1 stated Resident #1 was on weaning program and that attempts have been made to wean Resident #1. Registered Nurse #1 stated medical doctor was notified and staff to monitor Resident #1's behavior. Registered Nurse #1 stated the medical doctor was notified and instructed to monitor the resident.During an interview on 02/06/2026 at 12.31 PM, Registered Nurse Supervisor #1 stated they were called to the unit by Registered Nurse #1 on 01/30/2024 at approximately 7:18 AM and was informed that Resident #1's right hand was in a mitten and tied to the bed frame. Registered Nurse Supervisor #1 stated the hand mitten was removed immediately and body assessment was done; there was no visible injury. Registered Nurse Supervisor #1 stated they reported incident to the Director of Nursing. Registered Nurse Supervisor #1 stated Medical Doctor #1 had put an order in for hand mitten on 01/04/2024, however, the order was discontinued on 01/05/2024 as the facility is a restraint free facility. Registered Nurse Supervisor #1 stated Resident #1 was on monitoring. Registered Nurse Supervisor #1 stated the Director of Nursing and medical doctor were aware of Resident #1's behavior and a psych consultation was ordered and implemented. During an interview on 02/06/2026 at 3:15 PM, Respirator Therapist Director #1 stated on 01/30/2024 they received a complaint reporting that Resident #1 was constantly disconnecting themself from the ventilator. Respiratory Therapist Director #1 stated they were informed Resident #1 was observed with right hand mitten, and the mitten strap was tied to the bed frame by Respiratory Therapist #1. Respiratory Therapist Director #1 stated Resident #1 was on trial to be wean off the ventilator. Respiratory Therapist Director #1 stated there was no order for hand mitten. Respiratory Therapist Director #1 stated Respiratory Therapist #1 reported to them on many occasion that Resident #1 continuously trying to disconnect themself from the vent. Respiratory Therapist Director #1 stated they informed the medical doctor #2 and they tried different interventions, but Resident #1 just participated in just a few that they like.During an interview on 02/26/2026 at 4:51 PM, the Administrator stated on 01/30/2024 Respiratory Therapist #1 acknowledged putting a mitten on Resident #1's right hand to protect Resident #1 from pulling out the ventilatory. The Administrator stated Resident #1 was assessed by Registered Nurse Supervisor #1 and Medical Doctor #1 and there were no injuries or trauma. The Administrator stated the facility is restraint free. However, if the medical doctor thinks it is necessary to protect the residents from harm, then they must follow the facility's protocol on restraint. The Administrator stated that all interventions must be in place, physician's order, assessment done, sign consent from resident/family, purpose for the restraint, how long the restraint will last and instruction on releasing it for skin check and comfort. The Administrator stated 911 was called and the incident was reported. The Administrator stated that all staff members received in-service on restraint prior to the incident. The Administrator stated Respiratory Therapist #1 was reported to the board of education.During an interview on 03/04/2026, Medical Doctor #1 stated Resident #1 was well known to them and was very sick, but alert and oriented three times. Medical Doctor #1 stated they were aware of Resident #1's behavior of pulling on the vent and that they have explained to Resident #1 the danger of disconnecting the tube. Medical Doctor #1 stated they try to wean Resident #1 off the vent, and the process was still going on. Medical Doctor #1 stated Resident #1 received dialysis that day and the dialysis staff left the mitten at the bedside that Resident #1 was using during dialysis. Medical Doctor #1 stated they put an order for mitten and during interdisciplinary team meeting the behavior was discussed. Medical Doctor #1 stated the team decided against it and opted to move Resident #1's room closer to the Respiratory Therapist office with frequent monitoring, redirection and encouraged Resident #1 to watch television. Medical Doctor #1 stated Resident #1 family was made aware and also Resident #1 was seen by psych, psychology and psychotherapy. Medical Doctor #1 stated staff members visited Resident #1 and provided emotional support daily and as needed. Based on the corrective actions taken by the facility there was sufficient evidence the facility corrected the identified non-compliance and was in substantial compliance for this specific regulatory requirement on 02/26/2024, prior to surveyors' onsite visit on 02/06/2026.Corrective ActionsOn 01/30/2024, Registered Nurse Supervisor #1 instructed staff to immediately remove mittenOn 01/30/2024, Registered Nurse Supervisor #1 assessed Resident #1 with no signs of injuryOn 01/30/2024, Physician #1 assessed Resident #1 with no injury (medical note dated 01/30/2024 at 5:27 PM)On 01/30/2024, Administrator suspended Respiratory Therapist #1 for applying mittenOn 01/30/2024- 01/31/2024 all Respiratory Therapists received in-service on Abuse Prohibition & Resident Rights.On 01/30/2024 - 02/26/2024, facility audit residents on Ventilator or Tracheostomy who present with behavior of pulling their medical tubingAd_ Hoc Interdisciplinary Team meeting held on 01/30/2024 (attendance sheet/topic received)On 01/31/2024, the Director of Nursing and Director of Respiratory reviewed all residents with vent and trach to determine behavior of attempting to pull trach or vent. Three (3) residents were identified. Residents' charts and care plans reviewed. Respiratory staff and direct care givers were interviewed. Plan of care was determined to be appropriate. Residents did not require mittens. It was determined that intermittent behaviors can be safely managed by staff. None of the three (3) residents have orders for hand mitten and hand mittens were not found in their room. On 01/31/20224, all Respiratory and Nursing staff on affected unit, on all three shifts were re-educated on Restraint Use and Abuse, Neglect, Mistreatment of Residents (Educator - Director of Nursing and Registered Nurse Supervisors). Attendance sheet received.On 01/31/2024, the Administrator, Director of Nursing and Director of Quality Assurance reviewed the policies on Restraint Use, Abuse, Neglect, and Mistreatment. No revision made.On 02/01/2024, a Restraint Audit Tool Policy initiated and revised 02/06/20224Restraint Monitoring Tool reviewedOn 02/02/2024, all other facility staff receive re-education on Restraint and Abuse. (Educator - Director of Quality Assurance/Education or Designee). All new staff are in serviced on the above policies during their orientation period and annually thereafter.On 01/31/2024 - 02/06/2024 an audit tool to monitor compliance with the facility policy on Restraint use has been developed to determine staff compliance with the policy. Using the Restraint Monitoring tool, the Registered Nurse Supervisor together with Respiratory Designee conduct unannounced rounds on all three shifts for one week to determine compliance. Target is 100 percent compliance.If 100 percent compliance is achieved and maintained for a consecutive 2-week period. Auditing and monitoring of compliance with the facility Restraint Policy will be done on 10 shifts per 7-day period (making sure that all three shifts are audited at least once). If 100 percent compliance is achieved and maintained, random auditing and monitoring will be done 7 times monthly for three months.Any non-compliant findings will be reported to the facility Director of Nursing as well as facility Administrator and Director of Quality Assurance immediately. All other findings on the audits will be reported to the Quality Assurance Committee monthly for three months and quarterly thereafter, assuming 100 Percent compliance has been achieved.In-service with lesson plan and signing sheet on Abuse Prohibition and Resident Rights to House-keepers dated 02/06/2024On 02/07/2024, In-service with lesson plan and signing sheet on Abuse Prohibition and Resident Rights to Registered Nurses, Licensed Practical Nurses and Certified Nursing Assistants done. Attendance sheet receivedOn 02/07/2024, Resident #1 received psychotherapy servicesOn 02/09/2024, Respiratory Therapist #1 was terminated via letterOn 02/09/2024, Resident #1's care plan meeting was held. Signing sheet reviewedOn 02/26/2024, Quality Assurance Performance Improvement with attendance sheet receivedOn 02/26/2024, Policy and Procedure on Restraint and Abuse was reviewed and was found to be incompliance. 10 New York Codes, Rules, and Regulations 415.4(a)(2-7)

Based on observation, record review, and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, review of the weekend staffing and the Payroll Based Journal Staffing Data Report revealed low weekend staffing.The facility Payroll Based Journal Staffing Data Report for the Quarter 4 2025 dated July 1 - September 30 documented that excessively low weekend staffing triggered on the report. The facility Payroll Based Journal Staffing Data Report for the Quarter 1 2026 dated October 1 - December 30 also documented that excessively low weekend staffing triggered on the report. The facility's policy and procedure titled Staffing, Sufficient and Competent Nursing dated 01/2026, stated the facility provides sufficient number of staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. The policy also stated staffing numbers, and the skill requirements of direct care staff are determined by the needs of the residents based on each resident assessment, residents care plans, and the facility assessment. The policy further stated factors considered in determining appropriate staffing ratios and skills include an evaluation of the disease, conditions, physical or cognitive limitations of the resident population, and acuity. The facility document titled Facility Assessment-Targeted Nursing stated facility staffing is census based, which fluctuates based on admission/discharges. The facility units include the following: 2nd Floor-Rehabilitation, 3rd Floor-Dialysis Residents, 5th Floor Trach/Ventilator, and 4th, 6th, and 7th floors Long Term Care. On team entrance to the facility for the Recertification survey on 02/24/2026, the facility census was 266 residents. The Facility assessment dated [DATE] documented par levels for nursing staff as follows:Day Shift (7:00 AM - 3:00 PM): 2nd Floor (bed capacity of 46): three (3) Licensed Nurses, five (5) Certified Nursing Assistants. 3rd Floor (bed capacity of 45): two (2) Licensed Nurses, five (5) Certified Nursing Assistants. 4th Floor (bed capacity of 45): three (3) Licensed Nurses, four (4) Certified Nursing Assistants. 5th Floor (bed capacity of 43): three (3) Licensed Nurses, five (5) Certified Nursing Assistants. 6th Floor (bed capacity of 45): two (2) Licensed Nurses, four (4) Certified Nursing Assistants. 7th Floor (bed capacity of 45): two (2) Licensed Nurses, four (4) Certified Nursing Assistants. Evening Shift (3:00 PM - 11:00 PM): 2nd Floor: three (3) Licensed Nurses, four (4) Certified Nursing Assistants. 3rd Floor: two (2) Licensed Nurses, four (4) Certified Nursing Assistants. 4th Floor: two (2) Licensed Nurses, four (4) Certified Nursing Assistants. 5th Floor: two (2) Licensed Nurses, four (4) Certified Nursing Assistants. 6th Floor: two (2) Licensed Nurses, four (4) Certified Nursing Assistants. 7th Floor: two (2) Licensed Nurses, four (4) Certified Nursing Assistant. Night Shift (11:00 PM - 7:00 AM): 2nd Floor: three (3) Licensed Nurses, three (3) Certified Nursing Assistants. 3rd Floor: two (2) Licensed Nurses, three (3) Certified Nursing Assistants. 4th Floor: one (1) Licensed Nurses, three (3) Certified Nursing Assistants. 5th Floor: two (2) Licensed Nurses, three (3) Certified Nursing Assistants. 6th Floor: one (1) Licensed Nurses, three (3) Certified Nursing Assistants. 7th Floor: one (1) Licensed Nurse, three (3) Certified Nursing Assistant. Review of the actual weekend staffing schedule from July 1st, 2025, through September 30th, 2025, documented the following:On Saturday July 5th, 2025, on the day shift, the 2nd floor was short of one (1) Licensed Nurse, and the 3rd and 5th floors were short of one (1) Certified Nursing Assistant. On the evening shift, the 2nd and 5th floors were short of one (1) Licensed Nurse and one (1) Certified Nursing Assistant, and the 4th floor was short of two (2) Licensed Nurses. On the night shift, the 2nd floor was short of one (1) Licensed Nurse and the 4th, 5th, 6th, and 7th floors were short of one (1) Certified Nursing Assistant. On Sunday July 6th, 2025, on the day shift, the 2nd and 5th floors were short of one (1) Licensed Nurse, and one (1) Certified Nursing Assistant. On the evening shift, the 2nd and 5th Floors were short of one (1) Licensed Nurse, and one (1) Certified Nursing Assistant. On the night shift, the 3rd, 5th, and 6th floors were short of one (1) Certified Nursing Assistant. On Saturday July 12th, 2025, on the day shift, the 2nd, 4th, and 5th floors were short of one Licensed Nurse, and the 5th floor was short of one (1) Certified Nursing Assistant. On the evening shift, the 5th floor was short of one (1) Certified Nursing Assistant. On the night shift, the 2nd and 5th floors were short of one (1) Licensed Nurse, and the 5th, 6th, and 7th floors were short of one (1) Certified Nursing Assistant. On Sunday July 13th, 2025, on the day shift, the 2nd, 4th, and 5th floors were short of one (1) Licensed Nurse, and the 3rd and 5th floors were short of two (2) Certified Nursing Assistants. On the night shift, the 4th, 5th, 6th, and 7th floors were short of one (1) Certified Nursing Assistant. On Saturday July 19th, 2025, the day shift, the 2nd, 4th, and 5th floors were short of one (1) Licensed Nurse, and the 3rd and 5th floors were short of one (1) Certified Nursing Assistant. On the evening shift, the 5th floor was short of one (1) Certified Nursing Assistant. On the night shift, the 5th, 6th, and 7th floors were short of one (1) Certified Nursing Assistant. On Sunday July 20th, 2025, on the day shift, on the 2nd, 4th, and 5th floors were short of one (1) Licensed Nurse, and two (2) Certified Nursing Assistants. On the night shift, the 2nd floor was short of one (1) Licensed Nurse, and the 5th, 6th, and 7th floors were short of one (1) Certified Nursing Assistant. On Saturday July 26th, 2025, on the day shift, the 2nd, 4th and 5th floors were short of one (1) Licensed Nurse, and the 5th floor was short of one (1) Certified Nursing Assistant. On the evening shift, the 2nd and 4th floors were short of one (1) Licensed Nurse, and the 5th floor was short of one (1) Certified Nursing Assistant. On the night shift, the 3rd, 4th, 5th, and 6th floors were short of one (1) Certified Nursing Assistant, and the 7th floor was short of two (2) Certified Nursing Assistants. On Sunday July 27th, 2025, on the day shift, the 3rd floor was short of two (2) Certified Nursing Assistants; the 4th floor was short one of (1) Licensed Nurse and one (1) Certified Nursing Assistant, and the 5th floor was short one of (1) Licensed Nurse and three (3) Certified Nursing Assistants.On the evening shift, the 2nd and 5th floors were short of one (1) Licensed Nurse, and the 4th and 5th floors were short of two (2) Certified Nursing Assistants. On the night shift, the 2nd floor was short of one (1) Licensed Nurse, the 3rd floor was short of two (2) Certified Nursing Assistants, and the 5th, 6th and 7th floors were short of one (1) Certified Nursing Assistant. On Saturday August 2nd, 2025, on the day shift, the 2nd, 4th, and 5th floors were short of one (1) Licensed Nurse.On the evening shift, the 2nd and 5th floors were short of one (1) Licensed Nurse, and the 5th floor was short of one (1) Certified Nursing Assistant. On the night shift, the 2nd and 7th floors were short of two (2) Certified Nursing Assistants, and the 3rd, 4th, 5th and 6th floor were short of one (1) Certified Nursing Assistant. On Sunday August 3rd, 2025, on the day shift, the 2nd, 4th, 5th, and 7th floors were short of one (1) Licensed Nurse, and the 2nd, 4th, and 5th floors were short of one (1) Certified Nursing Assistant. On the evening shift, the 4th floor was short of one (1) Licensed Nurse. On the night shift, the 2nd, 3rd, and 5th floors were short of one certified Nursing Assistant, and the 6th floor was short of two (2) Certified Nursing Assistants. On Saturday August 9th, 2025, on the day shift, the 2nd, 4th, 5th, and 6th floors were short of one (1) Licensed Nurse, and the 2nd and 5th floors were short of one (1) Certified Nursing Assistant. On the evening shift, the third 3rd floor was short of one (1) Certified Nursing Assistant, and the 5th floor was short of two (2) Licensed Nurses and two (2) Certified Nursing Assistants. On the night shift, the 2nd floor was short of one (1) Licensed Nurse, the 5th floor was short of two (2) Licensed Nurses, and the 6th and 7th floors were short of one (1) Certified Nursing Assistant. On Sunday August 10th, 2025, on the day shift, the 2nd and 4th floors were short of one (1) Licensed Nurse, and one (1) Certified Nursing Assistant, and the 5th floor was short of two (2) Licensed Nurse and one (1) Certified Nursing Assistant. On the evening shift, the 2nd floor was short of one (1) Licensed Nurse. On the night shift, the 2nd floor was short of one (1) Licensed Nurse, and the 6th floor was short of one (1) Certified Nursing Assistant. On Saturday August 16th, 2025, on the day shift, the 2nd and 5th floors were short of one (1) Certified Nursing Assistant (1), the 3rd floor was short of two (2) Certified Nursing Assistant, and the 5th floor was short of one (1) Licensed Nurse. On the evening shift, the 2nd floor was short of one (1) Licensed Nurse. On the night shift, the 2nd floor was short of one (1) Licensed Nurse, and the 4th, 5th, 6th and 7th floors were short of one Certified Nursing Assistant. On Sunday August 17th, 2025, on the day shift, the 2nd, 5th, and 7th floors were short of one (1) Licensed Nurse, and the 2nd and 5th floors were short of one (1) Certified Nursing Assistant. On the evening shift, the 2nd floor was short of one (1) Licensed Nurse. On the night shift, the 2nd and 3rd floors were short of one Licensed Nurse, the 5th floor was short of two (2) Licensed Nurses, and the 3rd, 4th, and 6th floors were short of one (1) Certified Nursing Assistant. On Saturday August 23rd, 2025, on the day shift, the 2nd and 4th floors were short of one (1) Licensed Nurse, the 5th floor was short of two (2) Certified Nursing Assistants, and the 6th and 7th floors were short of one (1) Certified Nursing Assistant. On the night shift, the 2nd, 5th, and 6th floors were short of one (1) Licensed Nurse and one (1) Certified Nursing Assistant. On Sunday August 24th, 2025, on the day shift, the 2nd and 5th floors were short of one (1) Licensed Nurse, the 4th floor was short of two (2) Licensed Nurses, the 2nd, 3rd, 4th, 6th, and 7th floors were short of one (1) Certified Nursing Assistant, and the 5th floor was short of two (2) Certified Nursing assistants. On the evening shift, the 2nd floor was short of one (1) Licensed Nurse. On the night shift the 2nd and 3rd floors were short of one (1) Licensed Nurse, and one (1) Certified Nursing Assistant, and the 5th floor was short of one (1) Certified Nursing Assistants. On Saturday August 30th, 2025, on the day shift, the 2nd and 5th floors were short of one (1) Licensed Nurse and one (1) Certified Nursing Assistant. On the evening shift, the 3rd and 5th floors were short of one Certified Nursing Assistant. On the night shift, the 5th, 6th and 7th floors were short of one certified Nursing Assistant. On Sunday August 31st, 2025, on the day shift, the 2nd and 5th floors were short of one (1) Licensed and one (1) Certified Nursing Assistant, and the 3rd floor was short of one (1) Certified Nursing Assistant. On the evening shift, the 2nd, 3rd, 5th, 6th and 7th floors were short of one (1 ) Certified Nursing Assistant. On the night shift, the 3rd, 4th, 5th, and 7th floors were short of one (1) Certified Nursing Assistant. On Saturday September 6th, 2025, on the day shift, the 2nd floor was short of one Licensed Nurse and one (1) Certified Nursing Assistant. On the evening shift, the 2nd floor was short of one (1) Licensed Nurse. On the night shift, the 2nd floor was short of one (1) Licensed Nurse. On Sunday September 7th, 2025, on the day shift, the 2nd and 5th floors were short of one (1) Licensed Nurse, fourth Floor: two (2) Licensed Nurses. On the evening shift, the 2nd floor was short of one (1) Licensed Nurse and two (2) Certified Nursing Assistants. On the night shift, the 3rd floor was short of one (1) Certified Nursing Assistant. On Saturday September 13th, 2025, on the day shift, the 5th and 4th floors were short of one (1) Licensed Nurse, and the 5th floor was short of two (2) Certified Nursing Assistants. On the evening shift, the 5th floor was short of one (1) Licensed Nurse. On Sunday September 13th, 2025, on the day shift, the 2nd and 5th floors were short of one (1) Licensed Nurse and one (1) Certified Nursing Assistant. On the evening shift, the 2nd floor was short of one (1) Licensed Nurse. On Saturday September 20th, 2025, on the day shift, the 2nd and 5th floors were short of one (1) Licensed Nurse and one (1) Certified Nursing Assistant. On the evening shift, the 2nd floor was short of one Licensed Nurse. On Sunday September 27th, 2025, on the day shift, the 2nd, 4th and 5th floors were short of one (1) Licensed Nurse, and the 2nd and 5th floors were short of one (1) Certified Nursing Assistant. On the evening shift, the 2nd floor was short of one (1) Licensed Nurse, and the 3rd and 6th floor were short of one (1) Certified Nursing Assistant. On Saturday September 28th, 2025, the 2nd, 4th and 5th floors were short of one (1) Licensed Nurse, and the 2nd and 5th floors were short of one (1) certified Nursing Assistant. On the evening shift, the 7th floor was short of one (1) Certified Nursing Assistant. During an interview on 03/03/2026 at 12:27 PM, Registered Nurse #1 stated they are a supervisor, and work on the 3rd, 4th, and 5th floors. Registered Nurse #1 also stated the 2nd, 3rd and 5th floors are a priority when it comes to staffing and must have five (5) Certified Nursing Assistants on the day shift. Registered Nurse #1 further stated the rest of the units can work with four (4) Certified Nursing Assistants on the day shift. Registered Nurse #1 stated staff report that on weekends they are working with less than the required number of Certified Nursing Assistants and nurses at times. Registered Nurse #1 also stated due to chronic staff call outs, which are often late, it becomes difficult to replace the absent staff. Registered Nurse #1 further stated staffing has improved since the new Director of Nursing came to the facility. Registered Nurse #1 stated the facility is tracking and disciplining staff who call out chronically, or are no call, no shows. Registered Nurse #1 also stated it is not easy for a floor that needs five (5) Certified Nursing Assistants to work with three, but staff get the work done. During an interview on 03/03/2026 at 10:24 AM, Certified Nursing Assistant #6 stated the staffing is not good, especially on the weekends. Certified Nursing Assistant #6 also stated they work on the Trach/Vent unit, and at times missing even one Certified Nursing Assistant can make a difference. Certified Nursing Assistant #6 further stated staffing can be much better. Certified Nursing Assistant #6 stated when working with less than the required staff, they must work together to get the care done, because most of the residents on the unit are two plus person assist. Certified Nursing Assistant #6 also stated they have worked in this facility for four years and the staffing is poor, although it recently has gotten better because the state inspectors are here. During an interview on 03/03/2026 at 9:48 AM, Licensed Practical Nurse #9 stated the staffing, especially on the weekends, is not good for the Certified Nursing Assistants. Licensed Practical Nurse #9 also stated at times on the weekends missing one or two Certified Nursing Assistants for the unit makes it difficult for them to administer care, especially when two-person assistance is needed. Licensed Practical Nurse #9 further stated the nurses then must do other duties, including dining room monitoring, help with feeding, help with patient care if two people are needed to administer care, or even do patient care to assist the Certified Nursing Assistants to complete their tasks. Licensed Practical Nurse #9 stated they must assist especially if short two Certified Nursing Assistants, and as a result their nursing work is not done timely, as patient care is important. Licensed Practical Nurse #9 also stated staffing has improved since the new Director of Nursing came to the facility, and there have been talks with the union about staffing but not much has changed. During an interview on 03/03/2026 at 8:58 AM, the Administrator stated they were aware of the one-star staffing rating and excessively low staffing on the weekend for the facility in the past. The Administrator also stated once the current Director of Nursing came to the facility, the Director has been aggressive in bringing in staff by working with multiple agencies, recruitment of staff, advertisements and monthly orientation to staff the facility. The Administrator stated the staffing has improved and continues to improve. During an interview on 03/02/2026 at 10:27 AM, the Director of Nursing stated they took over the position in May 2025 and did a review of the staffing par levels for the facility and did not like the staffing pattern. The Director of Nursing also stated immediately started working with four (4) different agencies to correct the staffing pattern. The Director of Nursing further stated the facility had an issue with staffing, but they believe the issue is now corrected. The Director of Nursing stated they have monthly orientation to bring in new staff, and this has significantly improved the staffing for the facility at present. The Director of Nursing also stated they could not work with the previous staffing pattern and corrected this to improve the staffing as it is today. During an interview on 03/02/2026 at 10:15 AM, the Staffing Coordinator stated the current staffing has improved and stated that during the summer months from July to September staff were on vacation, many staff called out on the weekends, and staff often called out when they are scheduled to work. The Staffing Coordinator also stated there are par levels for each unit which are given to them by the Director of Nursing. The Staffing Coordinator further stated they placed the staff on the unit based on the par levels, and if census is low, they will change the levels to lower the number of staff needed or do not replace a staff who calls out. The Staffing Coordinator stated at times there may be extras on the floor due to residents on one-to-one supervision, or increased census. The Staffing Coordinator also stated there are also Paid Unit Assistants who help to monitor the dining room, feed the residents, or do one to one supervision. The Staffing Coordinator further stated the facility continues to work with some staffing agencies; however, staffing is a constant struggle due to the staff call outs on the weekends. The Staffing Coordinator stated the supervisors will call staff to see who is available to work, as well as ask staff if they want to work overtime to replace the call outs or to replace the no calls, no shows. The Staffing Coordinator also stated the facility uses a lot of overtime, and staff call out more on the weekends than on the weekdays. Union staff are required to pay back the weekend they called out on, but this does not work because they are usually scheduled to work the next weekend anyway. The Staffing Coordinator further stated that despite working with multiple agencies, the no call, no shows, and call outs contributed to the less-than-optimal staffing. During an interview on 03/02/2026 at 9:26 AM, Certified Nursing Assistant #7 stated staffing on the weekend is not good and the facility does try to give enough staff. Certified Nursing Assistant #7 also stated they work short at times at the weekend and when they work short, they will leave the residents in bed or will put off showers for another day. Certified Nursing Assistant #9 further stated staff work together to get the work done, but multiple residents will be left in bed due to the shortage of staff. During an interview on 03/02/2026 at 9:36 AM, Licensed Practical Nurse #6 stated good staffing depends on the day. Licensed Practical Nurse #6 also stated they work every other weekend, and on the weekends, staff call out and the unit often works short. Licensed Practical Nurse #6 further stated if the unit is supposed to have five (5) Certified Nursing Assistants, the unit would have four (4) or sometimes three (3) because of call outs. Licensed Practical Nurse #6 stated the staff will take residents who need monitoring for falls out of bed, and some residents will remain in bed because of the shortage of staff. During an interview on 03/02/2026 at 9:49 AM, Certified Nursing Assistant #8 stated the staffing is very bad, especially on the weekends and at times work with three (3) staff for 45 residents. Certified Nursing Assistant #8 also stated the staffing has been very bad, especially this winter. Certified Nursing Assistant #8 further stated staff works the best they can, and they make sure the residents eat, and are not wet and stated when short residents may not be taken out of bed. Certified Nursing Assistant #8 stated there is so much to do when working with only three (3) staff so some residents will be taken out of bed, such as those who are at risk of falls as they will try and get out of bed on their own, and the other residents will remain in bed. Certified Nursing Assistant #8 also stated when working short the nurse will help by feeding the residents and monitoring the dining room. 10 New York Codes, Rules, and Regulations 415.13(a)(1)(i-iii)

Based on observation, record review and interviews conducted during the Recertification survey, the facility did not ensure that infection control protocols were followed. This was evident for one (1) of one (1) resident (Resident #8) reviewed for Respiratory Care out of 38 sampled residents. Specifically, Resident #8 was being maintained on contact precautions and Certified Nursing Assistant #6 did not don appropriate Personal Protective Equipment (PPE), including gown and gloves, when entering their room and also failed to perform hand hygiene prior to exiting the room. The findings are:The facility policy titled Infection Prevention and Control Guidelines revised on 08/2025 stated the facility establishes and maintains an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. The policy also stated hand hygiene is to be done before and after entering an isolation precaution setting. The policy further stated Contact Precautions requires the use of appropriate Personal Protective Equipment (PPE), including a gown and gloves upon entering the contact precaution room. Prior to leaving the contact precaution room the Personal Protective Equipment is removed, and hand hygiene is performed. Resident #8 was admitted to the facility with diagnosis that includes Candida Auris and Multidrug-Resistant Organism.A Physician's Order dated 01/05/2026 documented Resident #8 is on contact isolation precautions for Candida Auris. On 02/26/2026 at 09:00 AM, a sign was observed on the front of the Resident #8's room door that indicated Contact Isolation and that gloves, and gowns are required prior to entering the room. A compartment holder that contained blue gowns and gloves, and masks was observed on the door.On 02/26/2026 at 09:00 AM, Certified Nursing Assistant #6, who was holding a container of wipes, entered Resident #8's room without first donning personal protective equipment. Certified Nursing Assistant #6 was then observed handing Resident #8 a wipe and then exited the room without performing hand hygiene. Certified Nursing Assistant #6 was then observed donning a blue gown and entered another resident room without performing hand hygiene. On 02/26/2026 at 09:05 AM, Certified Nursing Assistant #6 was interviewed and stated they did observe the Contact Isolation sign on Resident #8's room door. Certified Nursing Assistant #6 further stated they were only handing Resident #8 a wipe and stated they know that they should have put on the personal protective equipment before going into the room. On 02/26/2026 at 09:10 AM, Registered Nurse #1, the Nursing Supervisor for the unit, was interviewed and stated the facility process for infection control when entering a room where a resident is on contact precautions is that staff are to knock on the door to make sure it is okay for them to enter and then they are to put on Personal Protective Equipment (PPE) that includes a gown, gloves, and mask. Registered Nurse #1 also stated that before staff leave the room, they have to remove the Personal Protective Equipment and wash their hands. On 02/26/2026 at 09:30 AM, the Infection Control Preventionist was interviewed and stated they had heard what had occurred and are in the process of in-servicing the staff. The Infection Control Preventionist also stated staff are supposed to wear a gown when entering the residents' room on contact precautions to prevent spreading infection from one resident to another resident. 10 New York Code, Rules, and Regulations 415.19 (a)(1-3)(b)1

Number of residents sampled: 5Number of residents cited: 2 Based on observation, interviews, and record review conducted during the Recertification survey conducted, the facility did not ensure residents unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. This was evident for two (2) of 5 (five) residents (Resident #86 and Resident #253) reviewed for Activities of Daily Living out of 38 total sampled residents. Specifically, Resident #86 and Resident #253 were unable to cut their own fingernails and did not receive staff assistance to do so. The findings are:The facility policy titled Activities of Daily Living (ADL) last reviewed 11/12/2025 stated the facility is to ensure that all residents receive assistance with Activities of Daily Living. It also documented Activities of Daily Living include, but is not limited to grooming 1). Resident #86 had diagnoses which included hemiplegia and hemiparesis following cerebral infarction (weakness on one side of the body after a stroke) affecting the right dominant side, and muscle weakness. The admission Minimum Data Set 3.0 assessment dated [DATE] documented Resident #86 had severely impaired cognition, did not reject care, and required partial/moderate assistance of staff for personal hygiene. On 02/24/2026 at 11:22 AM, Resident #86 was observed with fingernails that were approximately a half inch long beyond their fingertips. Resident #86 was interviewed and stated they were not able to cut their fingernails and required assistance. Resident #86 also stated no staff had provided them with the necessary assistance to cut their fingernails since their admission to facility in late November 2025. Resident #86 further stated their child would cut their fingernails when they were in the community. During multiple observations from 02/24/2026 at 11:22 AM to 03/02/2026 at 9:47 AM, Resident #86 was observed having their fingernails uncut. Resident #86 stated no staff asked or offered the necessary nail care to them during the period. The comprehensive care plan Activities of Daily Living All Tasks - Total Assistance initiated 11/28/2025 documented Resident #86 requires total assistance in all tasks related to weakness and debility following hospitalization. On 03/03/2026 at 9:29 AM, Certified Nursing Assistant #1 was interviewed and stated Resident #86 was alert and oriented and did not refuse care. Certified Nursing Assistant #1 also stated they observed Resident #86 had long fingernails recently. Certified Nursing Assistant #1 further stated they asked Resident #86 one (1) time about three (3) weeks ago if they wanted fingernails to be cut and Resident #86 refused. Certified Nursing Assistant #1 stated they did not ask Resident #86 about cutting fingernails since then. Certified Nursing Assistant #1 also stated the fingernails were not that long three (3) weeks ago. Certified Nursing Assistant #1 further stated they should have asked Resident #86 to cut fingernails regularly when the fingernails grew beyond the fingertips. Certified Nursing Assistant #1 further stated nail clippers available at the nursing station. On 03/02/2026 at 10:32 AM, Licensed Practical Nurse #4 was interviewed and stated the certified nursing assistants were responsible for cutting the fingernails for residents. Licensed Practical Nurse #4 also stated Resident #86 was transferred to the unit for one (1) month now. Licensed Practical Nurse #4 further stated they did not pay attention to Resident #86's fingernails when administering medications. Licensed Practical Nurse #4 made an observation of Resident #86's fingernails, which were approximately a half inch long beyond their fingertips, with the State Surveyor. Licensed Practical Nurse #4 stated the certified nursing assistant should have cut Resident #86's fingernails and that there are nail clippers for residents available at the nursing station. 2). Resident #253 had diagnoses which included Alzheimer's disease. The admission Minimum Data Set 3.0 assessment dated [DATE] documented Resident #253 had moderately impaired cognition, did not reject care, and required partial/moderate assistance for personal hygiene. On 02/24/2026 at 10:38 AM, Resident #253 was observed with fingernails that were approximately a half inch beyond their fingertips. Resident #253 was interviewed and stated they required staff to cut their fingernails for them and had not had their fingernails cut for a few weeks. Resident #253 also stated they wanted their long fingernails to be cut. During multiple observations from 02/24/2026 at 10:38 AM to 03/02/2026 at 9:50 AM, Resident #253 was observed with uncut fingernails. Resident #253 stated no staff asked or offered the necessary nail care to them during the period. The comprehensive care plan titled Activities of Daily Living/Rehab: Functional Abilities (Self-care) initiated 12/16/2025 documented Resident #253 had self-care limitations related to metabolic encephalopathy (change in brain function due to changes in the body) and Alzheimer's disease and required partial/moderate assistance for personal hygiene.On 03/02/2026 at 10:04 AM, Certified Nursing Assistant #2 was interviewed and stated Resident #253 was alert and able to make needs known. Certified Nursing Assistant #2 also stated they checked fingernails for residents when providing care. Certified Nursing Assistant #2 further stated they were able to cut fingernails for residents. Certified Nursing Assistant #2 stated fingernails were considered long when they grew beyond fingertips. Certified Nursing Assistant #2 also stated they observed Resident #253 had fingernails about half inch beyond their fingertips. Certified Nursing Assistant #2 further stated they did not ask Resident #253 if they wanted their fingernails to be cut or offered nail care because they were busy with other things. On 03/02/2026 at 10:13 AM, Licensed Practical Nurse #5 was interviewed and stated they did not recall if Resident #253 had long fingernails when they administered medications to them. Licensed Practical Nurse #5 also stated they were not sure if Certified Nursing Assistant should cut fingernails for residents. On 03/02/2026 at 11:18 AM, Registered Nurse #2 was interviewed and stated it was the responsibility of the certified nursing assistant to check fingernails during resident care and cut the fingernails when they were long. Registered Nurse #2 also stated nail clippers were available for each resident at nursing station. Registered Nurse #2 further stated the fingernails were considered long when they were beyond the fingertips. On 03/02/2026 at 12:35 PM, the Director of Nursing was interviewed and stated the certified nursing assistant was responsible for providing basic fingernail care including cutting long fingernails. The Director of Nursing also stated the fingernails were considered long when they grew beyond the fingertips unless the residents wanted the long nails. 10 New York Code, Rules, and Regulations 415.12(a)(3)

Based on observation, record review, and staff interview conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles. This was evident for one (1) prescription eye drop bottle on Unit 6 and one (1) prescription eye drop bottle on Unit 3 observed during the Medication Storage task. Specifically, two (2) opened (Latanoprost) prescription eye drops currently being used were not dated when opened. The findings are: The facility policy titled Policy on Storage of Over-The-Counter Medications on Units approved June 2008, stated that it is the policy of the facility that all medications deliver to the medication units will be stored according to federal and state guidelines. The facility policy included information on the storage of controlled substances, refrigerated medication storage, the emergency box, and over-the-counter medications but did not include policies related to prescription eye drops. The Xalatan Package Insert for Xalatan latanoprost ophthalmic solution dated August 2011 documented once a bottle is opened for use, it may be stored at room temperature up to 25 C (77 F) for 6 (six) weeks. On 03/02/2026 at 10:04 AM, during the Medication Storage task, an observation was made on Unit 6 of Resident #220s Latanoprost 0.005% prescription eye drops with an expiration date of 09/2027. The eye drops were open and in use but were not dated with an open date.Licensed Practical Nurse #1 was interviewed immediately and stated that they do not ever label eye drops when they open them and that they use the printed expiration date on the eye drop bottle to determine when to dispose of it.On 03/03/2026 at 09:51 AM, during the Medication Storage task, an observation was made on Unit 3 of Resident #102's Latanoprost 0.005% prescription eye drops with an expiration date of 10/2028. The eye drops were open and in use but were not dated with an open date. Licensed Practical Nurse #2 was interviewed immediately and stated that they do not label eye drops in the facility with open dates because the eye drops used in the facility are safe to use until the printed expiration date on eye drop bottle. Licensed Practical Nurse #2 also stated they did not know when the Latanoprost eyedrops were opened.On 03/03/2026 at 12:00 PM, Registered Nurse #4 was interviewed and stated that the nurse who opens the eye drops is responsible for labeling them with the open date. Registered Nurse #4 also stated nurses receive annual training related to this, and that they also verbally remind the nurses who they supervise. On 03/03/2026 at 12:48 PM, Registered Nurse #1 was interviewed and stated that all eye drops must be labeled with an open date by the person who opens them because some eye drops have their own expiration dates that differ from the bottle's expiration date, based on their stability and shelf life. Registered Nurse #1 also stated the pharmacy department reviews the carts on the unit daily to ensure compliance. Registered Nurse #1 further stated that they also try to review the cart each shift to ensure compliance. On 03/03/2026 at 12:56 PM, the Director of Pharmacy was interviewed and stated that the Latanoprost prescription eye drops require an open date to be labeled on the prescription bottle because they must be discarded after six (6) weeks of opening them. The Director of Pharmacy also stated they do unit evaluations at least once per month where they review the medication carts, including eye drop medications, and they had not previously identified unlabeled Latanoprost eyedrops to be an occurring concern on the units. On 03/03/2026 at 01:00 PM, the Director of Nursing was interviewed and stated that the Latanoprost prescription eye drops should be labeled with an open date, so staff know when to dispose of them. The Director of Nursing also stated nurses receive quarterly in-service education related to medication storage, including education on eye drop storage and labeling. 10 New York Code, Rules, and Regulations 415.18(e)(1-4)

Based on observations, interviews, and record review conducted during the Recertification survey from [DATE] to [DATE], the facility did not ensure food was stored in accordance with professional standards for food service safety. This was evident during kitchen observation and in 1 (7th floor) of 6 pantries. Specifically, 1) the kitchen walk-in refrigerator contained expired food items, and 2) the 7th floor pantry contained expired milk and undated, unlabeled food. The findings are: The facility policy titled Food Storage dated ,d+[DATE] documented perishable food items opened or prepared shall clearly be marked at the time of preparation and shall be discarded 48 hrs after the date opened. The facility policy titled Food Brought for Residents from the Outside dated ,d+[DATE] documented that all cooked or prepared food brought in for a resident and stored in the facilities refrigerator will be discarded after 48 hrs/2 days. Food or beverages brought in from the outside will be labeled with the resident's name, room number, and date. Employees are not to store their food in any refrigerators used by residents. 1) On [DATE] at 06:14 AM, the kitchen walk-in refrigerator was observed with 1 container labeled Chili Beans with a use-by date of [DATE], 1 undated container of chopped celery, carrots, and onions, 1 container labeled Chopped Chicken with use-by date of [DATE], 1 container labeled Meat Loaf' with use-by date of [DATE], 1 container labeled Fish with a use-by date of [DATE], 1 container labeled Chicken Parts for Soup with a use-by date of [DATE], and 1 container labeled Baked Chicken Breast with a use-by date of [DATE]. On [DATE] at 02:56 PM, the Dietary Supervisor was interviewed and sated the kitchen walk-in refrigerator contained expired food items. The cook and the dietary aides were not supposed to write dates on food that was leftover from meals at the end of the day. The proper procedure was for kitchen staff to attach stickers with a use-by date onto the plastic wrap of the leftover foods. Leftover food should be disposed of within 2 days. The Dietary Supervisor was responsible for discarding the leftovers from the refrigerator. 2) On [DATE] at 8:03 AM, Licensed Practical Nurse #1 and Registered Nurse #1 were present during observation of the 7th Floor pantry refrigerator. The refrigerator was observed with 1 unlabeled and undated beef patty ion a plastic bag, and 1 half pint of skim milk with an expiration date of [DATE]. On [DATE] at 08:03 AM, Licensed Practical Nurse #1 was interviewed and stated all food in the pantry refrigerator should be labeled, dated, and discarded after 3 days. On [DATE] at 8:05 AM, Registered Nurse #1 was interviewed and stated the pantry refrigerator was checked every 3 days and expired food were discarded. Nursing Supervisors were responsible for checking the pantry refrigerators once weekly. On [DATE] at 8:07 AM, the Dietary Supervisor was interviewed and stated they made daily rounds to check for unlabeled and undated food in refrigerators that needed to be discarded. On [DATE] at 03:13 PM, the Director of Food Service was interviewed and stated Housekeeping was responsible for checking the pantry refrigerators daily and discarding expired or undated, unlabeled food. The Dietary staff were only responsible for checking refrigerator temperatures and placing resident nourishments in the fridge. The Director of Food Service stated the kitchen walk-in refrigerators had a strict policy that leftover food was only kept for 48 hours and then discarded. The expired items in the walk-in refrigerators might have been left from the weekend. On [DATE] at 11:35 AM, the Director of Housekeeping was interviewed and stated Housekeeping was responsible for cleaning pantry refrigerators every Saturday and discarded expired and unlabeled items. 10 NYCRR 415.14(h)

Based on record review and interviews conducted during the Recertification and Abbreviated Survey (NY00325860, NY00304996) from 02/08/2023 - 02/15/2023, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation of abuse was made, to the administrator of the facility and to the State Survey Agency. This was evident in 4 residents (#57, #133, #150 and #165) of 38 total sampled residents. Specifically, 1.) On 10/05/2023, Resident #57 alleged they were hit by another resident. The facility reported the allegation to the New York State Department of Health on 10/11/2023. Additionally, The Administrator was made aware of the allegation on 10/10/2023. 2.) On 11/04/2022 at 11:05 PM, Resident #165 alleged Resident #133 hit them on their left eye. The facility reported the allegation to the New York State Department of Health on 11/05/2022 3:05 PM. The findings are: A facility policy titled Abuse, Involuntary Seclusion, Exploitation, Neglect, Misappropriation of Property and Injuries of Unknown Origin with revision date of 01/30/2024 stated the facility will ensure that all alleged violations involving abuse, neglect, exploitation, or misappropriation of property, are reported immediately, but not later than 2 hours after the allegation was made. Internal Reporting Employees must always report any abuse or suspicion of abuse immediately to the Administrator, Director of Nursing, Grievance Officer, and Supervisor. Resident # 57 was admitted to the facility with diagnoses of Mild Intellectual Disability, Atrial Fibrillation, and Deep Vein Thrombosis. The quarterly Minimum Data Set with Assessment Reference Date of 09/14/2023 documented that Resident #57 had moderately impaired cognition, no behaviors. Resident #150 was admitted to the facility with diagnoses of Dementia with other Behavioral Disturbance, Alzheimer's Disease, and Cerebral Ischemia. The quarterly Minimum Data Set assessment with Assessment Reference Date of 07/26/2023 documented that Resident #150 had intact cognition and had behavioral symptom not directed toward others that occurred in 1 to 3 days. An Accident/Incident Report form dated 10/07/2023 documented that Resident #57 was noted with redness to right chin, when Resident was asked, they stated they do not know. An undated Certified Nursing Assistant Accident/Incident Report form documented they were told by the housekeeping staff that Resident #57 stated they were punched by their roommate. A written statement by Licensed Practical Nurse #1 dated 10/12/2023 2:49 PM documented on the morning of 10/05/2023 they were told by the porter that Resident #57 was bleeding from the mouth and Resident stated they were hit. It was documented that Licensed Practical Nurse #1 immediately went to the Resident and provided mouth care and then reported the alleged incident to the supervisor. A written statement by Registered Nurse #1 who was the supervisor dated 10/12/2023 6:00 PM documented that on 10/05/2023, they were called by the nurse on duty who informed them that Resident #57 was bleeding from the mouth as per porter. Nurse on duty stated that porter reported that their roommate may have hit Resident #57. The Nursing Home Facility Incident Report for complaint NY00325860 documented that the allegation was reported to the New York State Department of Health on 10/11/2023 at 5:02 PM. It was documented that the Administrator was first made aware of the incident on 10/10/2023 at 11:30 am. Resident #133 was admitted to the facility with diagnoses of Dementia, Anxiety, and Major Depressive Disorders. The Minimum Data Set assessment dated [DATE] and the most recent assessment dated [DATE] documented Resident #133 had moderately impaired cognition. Resident #165 was admitted to the facility with diagnoses of Dementia, Major Depressive Disorder, and Schizoaffective disorders. The Minimum Data Set assessment dated [DATE], and the most recent MDS assessment dated [DATE] documented Resident #165 had moderately impaired cognition. An Accident/Incident Report form dated 11/04/2022 11:05 PM documented Resident #165 stated their roommate hit them in the left eye. Left eye was noted with purple discoloration. The report form documented that the incident was reported to the Department of Health on 11/05/2022. The facility Summary of Investigation dated 11/10/2022 documented there was alleged altercation between Residents #165 and #133. Resident #165 stated during interview that their roommate hit them because they wanted to turn off the light. Resident #133 stated during interview that it was Resident #165 who hit them in the face and that they only defended themselves. The altercation was unwitnessed. The facility summary concluded that based on the facility investigation, there was no evidence to support any policy or care plan violation. There was no evidence that either resident intended to harm each other. The Nursing Home Facility Incident Report for complaint #NY00304996 documented that the allegation was reported to the New York State Department of Health on 11/05/2022 at 03:05PM. During an interview on 02/14/2024 at 10:57 AM, the Quality Assurance Director, stated they were responsible for reporting allegations of abuse and other reportable incident to the Department of Health. They stated they were not around when the incident on 11/04/2022 occurred and that they communicated it with the Director of Nursing. The Quality Assurance Director stated that according to the Director of Nursing, there was a computer glitch on the day of the incident and that it was later submitted on 11/05/2022. The Quality Assurance Director also stated during an interview on 02/14/2024 at 4:43 PM that they were following the New York State protocol of investigation and that they have 5 days to report the allegations. During an interview on 02/14/2024 at 11:01 AM, the Director of Nursing stated they were not made aware on 10/05/2023 of the allegation between Residents #57 and #150. They were made aware a couple of days later when Resident #57's bruising on the chin became apparent, and that was when a full-blown investigation was initiated. The Director of Nursing stated that nursing supervisors are required to immediately report any allegation of abuse and begin an investigation. They stated that the nursing supervisors have access to the Nursing Home Facility Incident Report system, and once they are notified of any allegation of abuse, supervisors are then given a go ahead to report the incident themselves. The Director of Nursing also stated during an interview on 02/14/2024 at 11:50 AM that an allegation of abuse must be reported to the Department of Health within 2 hours from the time they were made aware. They stated that for the incident on 11/04/2022, they attempted to submit the report timely but had a technical issue. During an interview on 02/13/2024 at 8:14 AM, the Administrator stated they were first made aware of the allegation that Resident #57 was hit by Resident #150 a few days later when Resident #57 had some right-side facial bruising that became apparent. They immediately started the investigation and reported the allegation to the New York state Department of Health on 10/11/2023. 10 NYCRR 415.4(b)

Based on record review and interviews conducted during the Recertification Survey, the facility failed to ensure that services provided met professional standards of quality. This was evident for 1 (Resident #402) of 38 total sampled residents. Specifically, Licensed Practical Nurse #4 did not notify the physician when Resident #402 refused to take Carvedilol 25 milligrams and Hydralazine 50 milligrams on multiple occasions. In addition, Licensed Practical Nurse #5 held Carvedilol 25 milligrams and Hydralazine 50mg without a physician's order. The findings are: The New York State Education Law Article 139, Section 6902 stated the practice of the profession of nursing includes the executing of medical regimens prescribed by a licensed physician. It further states that nursing regimen shall be consistent with and shall not vary any existing medical regimen. Resident #402 was admitted to the facility with diagnoses of End Stage Renal Failure, Major Depressive Disorder, Hypocalcemia, Hypertension. The admission Minimum Data Set assessment dated [DATE] documented Resident #402's cognitive status was moderately impaired. A physician's order dated 01/24/2024 included Carvedilol 25 milligram tablet, give 1 tablet by oral route 2 times daily with food for hypertension and Hydralazine 50 milligram tablet, give 2 tablets (100 milligrams) by oral route 3 times daily with food for hypertension. The electronic Medication Administration Record dated 02/01/2024 - 02/12/2024 documented that Hydralazine 50 milligram tablet was not administered on 02/03/2024 10:00 AM, 02/03/2024 2:00 PM, and on 02/11/2024 6:00 PM; Carvedilol 25 milligram was not administered on 02/03/2024 8:00 AM. License Practical Nurse #4 documented Refused as the reason for not administering the medication. Further review of the electronic Medication Administration Record revealed that Hydralazine 50 milligram was not administered on 02/06/2024 2:00 PM, 02/08/2024 2:00 PM, and 02/09/2024 2:00 PM; Carvedilol 25 milligram was not administered on 02/08/2024 8:00 AM. Licensed Practical Nurse #5 documented Below Normal Parameters as the reason for not administering the medication. A nurse's note dated 02/03/2024 2:00 PM documented Resident refused all medications and treatment provided on tour. Education was given but not successful. A nurse's note dated 02/11/2024 11:14 PM documented Resident refused scheduled medication. Resident stated they were tired and wanted to sleep. A review of the Nurses' Progress Notes did not reveal documentation that the physician was notified of the missed medications and that medications were put on hold. A review of the Physician's Progress Notes did not reveal documentation that the physician was informed of the missed and held medications. A review of the Physician's Orders did not reveal orders to hold Hydralazine 50 milligram and Carvedilol 25 milligram due to below normal parameters. During an interview on 02/13/2024 at 11:57 AM, Licensed Practical Nurse #4 stated Resident #402 was alert and oriented, and often refused medications. They stated they tried to re-offer the medications and Resident would still refuse. Licensed Practical Nurse #4 stated they did not notify the physician because they believed that Resident #402 was able to make decisions on their own. During an interview on 02/14/2024 at 01:53 PM, Licensed Practical Nurse #5 stated they held the Carvedilol and Hydralazine because Resident #402's blood pressure was too low. They stated they did not inform Resident #402's physician about putting the medications on hold. During an interview on 02/14/2024 at 02:29 PM, Registered Nurse #4, who was a Supervisor stated that the physician or the Nurse Practitioner must be notified when a resident refuses to take a medication. The Registered Nurse Supervisor stated they were not aware that Resident #402 was refusing their medications. During an interview on 02/15/2024 at 9:58 PM, the Nurse Practitioner stated they were not informed that Resident #402 refused their medications and that medications were put on hold. During an interview on 02/13/2024 at 02:48 PM, the Attending Physician stated they have not received information from nursing that Resident #402 was refusing medications and that medications were put on hold. During an interview on 02/14/2024 at 02:45 PM, the Director of Nursing stated they reviewed Resident #402's medical record and noted that medications were not administered on several occasions. The Director of Nursing stated that the Registered Nurse Supervisor and the Attending Physician must be notified when medications are not administered. 10 NYCRR 415.11(c)(3)(i)

Based on observation, interview, and record review conducted during the recertification survey, the facility failed to ensure that all drugs and biologicals were stored in locked compartments consistent with state or federal requirements and professional standards of practice. This was evident for 1 (3rd Floor) of 7 units. Specifically, a large bag containing discontinued medications was observed under a desk on 3rd floor nurses' station. Additionally, stock medications were stored on the 3rd floor nurses' station cabinet and were not locked. The findings are: A facility policy titled Medication Storage dated 06/2021 documented that it is the policy of the facility that all medications delivered to the facility are stored according to the federal and state guidelines. The policy documented that over-the-counter medications may be stored in the medication carts or a locked cabinet within the nursing station. On 02/08/2024 at 08:00 AM, a large clear plastic bag was observed under the 3rd floor nurses' station counter. The clear plastic bag had several envelopes containing residents' medications. There was no nursing staff present at the nurses' station at the time of this observation. On 02/08/2024 at 08:05 AM, stock medications were observed stored on the 3rd floor nurses' station cabinet. The cabinet was not locked. A housekeeping staff was observed opening the same cabinet and placed a stack of napkins and paper towels inside. On 02/08/2024 at 08:19 AM, a Pharmacy Technician came and removed the large bag of medications from the nurses' station. During an interview on 02/09/2024 at 10:47 AM, Licensed Practical Nurse #3 stated that their unit does not have a medication room. They stated that medications for return to the pharmacy were kept under the nurses' desk until a pharmacy staff comes to pick them up. During an interview on 02/09/2024 at 11:01 AM, the Director of Nursing stated all units does not have a medication room and stated they need to start locking up all medications after the State Surveyor brought it to their attention. 10 NYCRR 415.18(e)(1-4)

Based on record review and interviews conducted during the Recertification and Abbreviated Survey (NY00325860) from 02/08/2024 - 02/15/2024, the facility failed to ensure that all allegations of abuse, including injuries of unknown origin, were promptly investigated. This was evident for 2 (Resident #57 and Resident #150) of 39 total sampled residents. Specifically, on 10/05/2023, Resident #57 alleged they were hit by another resident. The facility initiated the investigation on 10/07/2023. The findings are: A facility policy titled Abuse, Involuntary Seclusion, Exploitation, Neglect, Misappropriation of Property, and Injuries of Unknown Origin with revision date 01/30/2024, documented it is the policy of this facility that reports of abuse are promptly and thoroughly investigated. Resident # 57 was admitted to the facility with diagnoses of Mild Intellectual Disability, Atrial Fibrillation, and Deep Vein Thrombosis. The quarterly Minimum Data Set with Assessment Reference Date of 09/14/2023 documented that Resident #57 had moderately impaired cognition, no behaviors. Resident #150 was admitted to the facility with diagnoses of Dementia with other Behavioral Disturbance, Alzheimer's Disease, and Cerebral Ischemia. The quarterly Minimum Data Set assessment with Assessment Reference Date of 07/26/2023 documented that Resident #150 had intact cognition and had behavioral symptom not directed toward others that occurred in 1 to 3 days. Review of the Nursing Home Facility Incident Report submitted to the New York State Department of Health on 10/11/2023 at 5:02 PM, documented that on 10/05/23 at approximately 7:25 AM, Resident # 57 was observed by the porter with small amount of blood coming from inside their mouth while Resident was sitting in the hallway. Resident #57 stated they hit me and pointed to the room where roommate was located. [NAME] reported same to the assigned Certified Nursing Assistant who immediately informed the charge nurse. An Accident/Incident Report form dated 10/07/2023 documented that Resident #57 was noted with redness to right chin, when asked Resident stated they do not know. An undated Certified Nursing Assistant Accident/Incident Report form documented they were told by the housekeeping staff that Resident #57 stated they were punched by their roommate. A written statement by Licensed Practical Nurse #1 dated 10/12/2023 2:49 PM documented on the morning of 10/05/2023 they were told by the porter that Resident #57 was bleeding from the mouth and Resident stated they were hit. It was documented that Licensed Practical Nurse #1 immediately went to the Resident and provided mouth care and then reported the alleged incident to the supervisor. A written statement by Registered Nurse #1 dated 10/12/2023 6:00 PM documented that on 10/05/2023, they were called by the nurse on duty who informed them that Resident #57 was bleeding from the mouth as per porter. Nurse on duty stated that porter reported that their roommate may have hit Resident #57. The facility Investigation Summary dated 10/16/2023 signed by the Administrator documented based on chart review, interviews with staff, and review of video surveillance there was insufficient credible evidence to substantiate conclusively that Resident #150 hit Resident #57. During an interview on 02/12/2024 at 8:38 AM, Registered Nurse #1 stated they received a call from the nurse that Resident #57 was bleeding from their mouth. Registered Nurse #1 stated there was no broken skin around their mouth and there was no gum bleeding but observed caries. Registered Nurse #1 stated Resident #57 would not speak but gestured with their hand that they got hit. Registered Nurse #1 stated it was not until a few days later when Resident #57 had some signs of bruising on their chin area that they realized they should have reported the allegation to the Administration. During an interview on 02/14/2024 at 11:01 AM, the Director of Nursing stated they were not made aware on 10/05/2023 of the allegation. They were made aware a couple of days later when Resident #57's bruising on the chin became apparent, and that was when a full-blown investigation was initiated. The Director of Nursing stated that an investigation should have been immediately initiated by the supervisor on 10/05/2023. During an interview on 02/13/2024 at 8:14 AM, the Administrator stated they were first made aware of the allegation that Resident #57 was hit by Resident #150 a few days later when Resident #57 had some right-side facial bruising that became apparent. They immediately started the investigation and reported the allegation to the New York state Department of Health on 10/11/2023. 10 NYCRR 415.4(b)(3)

Based on observations, record review, and staff interviews conducted during the Recertification survey (TQIS11), the facility did not ensure that food was stored in safe and sanitary manner to prevent food contamination. Specifically, the emergency food storage area was observed with rodent droppings on the elevated plastic stands, the food boxes, and on the plastic covering wrapped around the boxes. In addition, a mouse was observed coming out of an open cereal box. This was evident during the Kitchen Observation facility task. The findings are: 1) The facility policy titled Emergency Three Day Food/Water/Supply/Disaster Meal Plan, effective 1/2022, documented items consistent with the emergency/disaster menus will be in the facilities at all times and all foods are stored safely in accordance with local, state and federal guidelines. On 01/18/2022 at 09:59AM, an observation was made during the initial tour of the Emergency Food storeroom. There were black droppings on the elevated plastic stands and boxes of multiple emergency food items- boxes of Passover matzo crackers, reduced calorie apple pie, and an open box of corn flakes. Inside the corn flakes box, there were droppings on the inner plastic bag of corn flakes. There were droppings on the plastic wrapping covering the thick it cinnamon French toast puree and puree spinach. A dead fly was on the elevated plastic stand next to two boxes of brown sugar. On 01/18/2022 at 10:13AM, during an additional observation of the Emergency Food storage a live rodent jumped out of the corn flakes box after the Dietary Aide picked up the box off of the elevated shelf. The Dietary Aide stepped on the rodent and killed it. On 01/18/2022 at 10:11AM, the Dietary Aide in charge of the Emergency Food storeroom was interviewed and stated they have been in charge of the storeroom for 5 years. They stated that they clean up when the room is messy or has spills. The Dietary Aide stated the room is cleaned every 3 months, and there is no cleaning record. The Dietary Aide stated if they see droppings when the exterminator comes, they are cleaned up. An additional interview was conducted with the Dietary Aide for the storeroom on 01/20/2022 at 09:48 AM who stated the emergency storeroom should be kept clean for sanitation to prevent mice. Dietary staff should sweep and rotate items in the food storage room. The Dietary Aide stated the food with droppings observed earlier was thrown away, and no more mice have been found. The Dietary Aide stated the exterminator set up a trap, and this is the first time they have seen a mouse. On 01/18/2022 at 10:19AM, the Food Service Supervisor (FSS) was interviewed and stated the dietary staff have noticed the droppings. The FSS stated staff have cleaning assignments and clean once a week. The FSS stated it happens, and the facility addresses it. There are renovations going on downstairs. An additional interview was conducted with the Food Service Supervisor on 01/20/2022 at 10:58 AM who stated it is important that the storeroom is cleaned because the bacteria in the droppings can make residents sick. The droppings carry diseases. The FSS stated he/she is in communication with the exterminator and maintenance. The exterminator came back, and maintenance has the report. On 01/21/2022 at 02:03PM, The Director of Housekeeping was interviewed, and they stated that they received a request from the FSS for service. Glue boards and bait station were placed in the 3 -day emergency food supply area. The Director stated they recommended the area be cleaned. The containers were checked for holes where mice were getting in . The maintenance container behind the emergency food container was also treated and no other vermin were noted. The Director stated when the exterminator visits, he/she is given the service slips and does a weekly plan of action with Environmental Care. When the exterminator comes in on Thursdays and they see the Director of Housekeeping first and review the book at the front desk where environmental complaints are logged. Pests need to be kept to a minimum and if possible, none at all. The Director stated they are proactive when they get a complaint from a resident, family, or staff to maintain hygiene and safety. Rodents can transfer bacteria. Two weeks ago was the last time the emergency food area was inspected by the Director of Housekeeping. Environmental checks of the emergency food storage is done at least monthly, and they check 2 floors per month. The Director stated the facility gets complaints and there is activity on the glue boards and roaches here and there, but it is kept to a minimum. On 01/21/2022 at 2:38PM, the Director of Environmental Care (DEC) was interviewed and stated they are present when the exterminator comes on Thursdays, and occasionally, he/she does rounds with the exterminator and informs them of any concerns. The DEC stated they have been in the facility for 18 to [AGE] years and have never seen rodents in the building. The facility tries to stay on top of it, and the exterminator helps. The DEC stated they make rounds and send staff to seal any holes observed. In the fall, maintenance staff check radiators and sinks and caulk and foam to prevent rodents from coming in when it is cold outside. The DEC stated the facility does not have issues like other facilities do. If rodents enter the building, they could breed and multiply. The DEC stated they try to be proactive with the pest control program. 415.14 (h)

Based on observation, record review and staff interview conducted during the recertification survey (TQIS11), the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. Specifically, a mouse was observed in the emergency food storage area. In addition, mouse droppings were observed on food boxes and the plastic stands. This was evident for the Kitchen Observation facility task. The finding is: The facility policy titled Pest Control Program and Exterminating Policy and Procedure effective 9/1/2016 documented the facility will maintain a robust and comprehensive pest control and maintenance program to control pests, insects and rodents in the facility and its environments. Despite good housekeeping and constant vigilance, pest still may enter the facility. They may be carried in packages or in sacks of food; they may enter thru an open window; they may be brought in by patients and visitors. Efforts to control pests must be constant to reduce the threat of infection and disease that accompanies them. The best way to control pest is to eliminate the sources that attract them. Rats and mice are among the most destructive pests. Rats destroy food; destroy property and cause fires. Rats spread many diseases: [CONDITION(S)], Plague, Dysentery and [CONDITION(S)] amount others. Rodents can be eliminated by using these measures: rodent proofing, depriving the mice and rats of access to food, eliminating shelters and nests, trapping; fumigating; poisoning and observing proper sanitation practices. Under licensed exterminator in premises service will be provided to all service call areas and rounds will be preformed of all baits, traps and high concern areas including kitchen. On 01/18/2022 at 09:59AM, an observation was made during the initial tour of the Emergency Food storeroom. There were black droppings on the elevated plastic stands and boxes of multiple emergency food items- boxes of Passover matzo crackers, reduced calorie apple pie, and an open box of corn flakes. Inside the corn flakes box, there were droppings on the inner plastic bag of corn flakes. There were droppings on the plastic wrapping covering the thick it cinnamon French toast puree and puree spinach. A dead fly was on the elevated plastic stand next to two boxes of brown sugar. On 01/18/2022 at 10:13AM, during an additional observation of the Emergency Food storage a live rodent jumped out of the corn flakes box after the Dietary Aide picked up the box off of the elevated shelf. The Dietary Aide stepped on the rodent and killed it. The Facility Pest Control Log between November 2020 and 1/22/2022 there were reported multiple sightings of rodents in running under a desk, in resident rooms or on unit, day rooms, staff locker room/renaissance room, main dining room, unit nurses stations, lobby, staff longue, admission and patio area were treated preventatively for rodents. The Pest Control Log Book documented in November 2020, the front desk on the 1sr floor reported a mouse running under the desk. On 1/13/2021 a mouse was reported in nursing office. On 2/1/2021, a mouse was reported in room 612. On 2/15/2021, mice were reported in rooms 605, 702, 704 and 706. On 2/18/2021, a mouse and water bugs reported in the dining room. On 2/24/2021, a mouse was reported in room 631. On 3/5/2021, a mouse was reported on the 6th floor nurses station. On 3/8/2021 a mouse was reported running around the 6th floor. On 5/3/2021 a mice was reported in admission. On 5/5/2021 a mice in the female locker room and renaissance room. On 7/29/2021, a mouse was reported in the main dining room. On 8/5/2021, a mouse was reported running around room 202. On 8/23/2021, mice were reported in room 315, 3rd floor and 4th floor. On 8/31/2021, a mouse was reported in room 616. On 9/21/2021 a mice was reported in room 701,702 and 704. On 10/6/2021 a mice was reported in room 209, On 10/30/2021 a mouse was reported in room 731. On 11/4/2021, a mouse was reported in the lobby. On 12/2/2021, a mouse was reported in the staff longue area. On 12/8/2021, a mouse was reported in room 603. On 12/9/2021, a mouse was reported on the patio. On 12/13/2021, a mouse was reported in the 2nd floor day room and Room 411. There were corrective actions documented in response to the entries. The exterminator service report slips documented on 1/13/2022 the kitchen was treated for target pests roach and mice and on1/20/2022 that 10 glue boards were placed in the food storage area. Kitchen service report slips documented that on 12/2/2021,12/9/2021, 12/16/2021 t the area was treated for roach and mice. On 01/18/2022 at 10:11AM, the Dietary Aide (DA #1) in charge of the Emergency Food storeroom was interviewed and stated they have been in charge of the storeroom for 5 years. They stated that they clean up when the room is messy or has spills. The Dietary Aide stated the room is cleaned every 3 months, and there is no cleaning record. The Dietary Aide stated if they see droppings when the exterminator comes, they are cleaned up. An additional interview was conducted with the Dietary Aide for the storeroom on 01/20/2022 at 09:48 AM who stated the emergency storeroom should be kept clean for sanitation to prevent mice. Dietary staff should sweep and rotate items in the food storage room. The Dietary Aide stated the food with droppings observed earlier was thrown away, and no more mice have been found. The Dietary Aide stated the exterminator set up a trap, and this is the first time they have seen a mouse. On 01/18/2022 at 10:19AM, the Food Service Supervisor (FSS) was interviewed and stated the dietary staff have noticed the droppings. The FSS stated staff have cleaning assignments and clean once a week. The FSS stated it happens, and the facility addresses it. There are renovations going on downstairs. An additional interview was conducted with the Food Service Supervisor on 01/20/2022 at 10:58 AM who stated it is important that the storeroom is cleaned because the bacteria in the droppings can make residents sick. The droppings carry diseases. The FSS stated he/she is in communication with the exterminator and maintenance. The exterminator came back, and maintenance has the report. On 01/21/2022 at 02:03PM, The Director of Housekeeping was interviewed, and they stated that they received a request from the FSS for service. Glue boards and bait station were placed in the 3 -day emergency food supply area. The Director stated they recommended the area be cleaned. The containers were checked for holes where mice were getting in . The maintenance container behind the emergency food container was also treated and no other vermin were noted. The Director stated when the exterminator visits, he/she is given the service slips and does a weekly plan of action with Environmental Care. When the exterminator comes in on Thursdays and they see the Director of Housekeeping first and review the book at the front desk where environmental complaints are logged. Pests need to be kept to a minimum and if possible, none at all. The Director stated they are proactive when they get a complaint from a resident, family, or staff to maintain hygiene and safety. Rodents can transfer bacteria. Two weeks ago was the last time the emergency food area was inspected by the Director of Housekeeping. Environmental checks of the emergency food storage is done at least monthly, and they check 2 floors per month. The Director stated the facility gets complaints and there is activity on the glue boards and roaches here and there, but it is kept to a minimum. On 01/21/2022 at 2:38PM, the Director of Environmental Care (DEC) was interviewed and stated they are present when the exterminator comes on Thursdays, and occasionally, he/she does rounds with the exterminator and informs them of any concerns. The DEC stated they have been in the facility for 18 to [AGE] years and have never seen rodents in the building. The facility tries to stay on top of it, and the exterminator helps. The DEC stated they make rounds and send staff to seal any holes observed. In the fall, maintenance staff check radiators and sinks and caulk and foam to prevent rodents from coming in when it is cold outside. The DEC stated the facility does not have issues like other facilities do. If rodents enter the building, they could breed and multiply. The DEC stated they try to be proactive with the pest control program. On 01/25/2022 at 01:20PM the Director of Nursing (DON) was interviewed and sated that if staff see vermin (roach, mouse for example) they call housekeeping and enter the concern in the maintenance log to have the issue taken care of. If staff upstairs see vermin, they notify maintenance and contact the exterminator to take care of the issue. Rodents are a source of infection and when they come into contact with resident items/food it can lead to an infection. 415.(5) (h)(1),415.5 (h) (1) Emergency water:

Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure an infection prevention and control program designed to provide a safe, sanitary and comfortable environment was maintained. Specifically, (1) residents' hands were not cleaned before consuming meals, and (2) oxygen tubing was observed on the floor. This was evident for 1 of 6 units observed for Dining (Unit 2) and 2 of 4 residents reviewed for Respiratory Care (Resident #113 and Resident #174). The findings are: 1) The facility policy and procedure titled Handwashing/Hand Hygiene, revised 01/2019, documented hands are to be considered contaminated unless just washed in accordance with proper handwashing technique. The policy documented hands should be washed before eating. The handwashing policy only addresses staff handwashing. On 01/19/2022 at 8:48 AM, breakfst was observed on the 2nd floor. A Certified Nursing Assistant (CNA #4) was observed dropping off breakfast trays to the residents in room [ROOM NUMBER], Resident #395 and Resident #183. No hand wipes or assistance with hand hygiene was offered to the residents. CNA #4 returned to the day room, set up a resident's tray, and exited the day room to bring a meal tray to Resident #32 in room [ROOM NUMBER]. Resident #32 was not offered hand hygiene prior to eating. On 01/20/2022 at 11:55AM, residents were observed in the 2nd floor day room during lunch preparation. CNA #4 served lunch to Resident #32 and Resident #395 and did not offer hand hygiene to the residents prior to eating. On 01/20/2022 at 12:06PM, CNA #8 was observed serving lunch to Resident #148, Resident #142, and Resident #82 in their rooms. No hand hygiene was offered to the residents prior to eating. On 01/24/2022 at 12:18PM, CNA #7 observed passing out lunch trays to resident rooms on the 2nd floor. CNA #7 served lunch to Resident #132, Resident #89, and Resident #211. CNA #7 did not offer hand hygiene to the residents. On 01/20/2022 at 02:45PM, CNA #4 was interviewed and stated most times staff make sure the residents hands are cleaned for meal service. Staff give the residents a washcloth with soap to clean their hands before breakfast. CNA #4 stated residents hands should be clean prior to eating to prevent bacteria. On 01/20/2022 at 12:45PM, CNA # 8 was interviewed and stated residents' hands are cleaned with a wash cloth before meals. If the resident is at rehab before lunch, the rehab staff wash their hands prior to the meal. On 01/25/2022 at 10:40AM, CNA #7 was interviewed and stated that hand hygiene should be done at mealtime to avoid the spread of infection. Handwashing is the primary thing to do to prevent spread of germs and the Omicron COVID-19 virus. CNA #7 stated they normally ask the resident if their hands are dirty before meals. On 01/25/2022 at 12:20PM, the Unit Manager (RN #3) was interviewed and stated it is important that staff are doing hand hygiene, and an in-service on hand hygiene was conducted for the staff in response to the survey findings. On 01/25/2022 at 01:10PM, the Director of Nursing (DON) was interviewed and stated he/she conducts rounds to ensure staff are doing hand hygiene and have enough supplies. Staff should make sure proper hand hygiene is done. Alternative means include hand wipes which are readily accessible to all staff. Morning and evening staff were re-inserviced on hand hygiene. When the DOH inspectors come, staff are flustered and get nervous. The DON stated staff should uphold infection control precautions to avoid the transmission of any possible infection. The DON stated there are posted reminders to use the hand rub, and hand wipes are available in the dining room. 2) The facility policy and procedure titled Oxygen Therapy updated 08/31/2021 documented to ensure that the use of cannula, mask, oxygen tubing and other inhalation equipment are in accordance with the acceptable standards of care and manufacturer recommendations. Respiratory Therapy/Nursing documented that assess residents need for oxygen therapy and obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Proper dating of oxygen tubing connectors will be done on every replacement or change. Resident #174 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/19/2022 at 08:18 AM and 11:12 AM resident was observed in bed oxygen via concentrator and nasal cannula and tubing not labeled with date. On 01/20/2022 at 10:25 AM resident lying in bed resting and no date noted on nasal cannula oxygen tubing currently in use. On 01/20/2022 at 03:22 PM the resident was noted sleeping in wheelchair, with oxygen in use. The oxygen tubing was dated 1/20/2022. On 01/21/2022 at 03:44 PM, the resident was observed sitting in a w/c with oxygen via nasal cannula in use. The oxygen tubing, dated 1/20/2022, was touching the floor. On 01/24/2022 at 10:22 AM and 1/25/2022 at 10:09 AM, the resident was observed in bed with oxygen via nasal cannula in use. The oxygen tubing, dated 1/20/2022, was touching the floor. On 1/25/2022 at 10:59 AM resident dressed in wheelchair oxygen via nasal cannula in both nostrils and touching floor on left side of body behind left wheel of wheelchair and CNA # 3 was observed leaving resident room. On 01/25/2022 at 11:13 AM. The Certified Nursing Assistant (CNA # 3) was interviewed and stated that oxygen tubing should not be touching the floor because of dust. On 1/25/2022 at 12:02 PM, the Registered Nurse (RN #4) was interviewed in relation to the oxygen tubing touching the floor and stated they do rounds on the unit 3-4 times during their shift, and they did look at the position of Resident #174's oxygen tubing this morning. If the oxygen tubing is dirty from the floor, it can cause bacteria to enter the nose and lungs and cause pneumonia. Staff should let the nurse know when tubing is on the ground. If they notice tubing on the ground, the nurse should change the tubing and adjust it. On 01/25/2022 at 12:20 PM, the RN Supervisor (RN # 3) was interviewed and stated they do round every hour on the unit and as needed on the 2nd and 5th floors they are covering. They have not noticed Resident #174's oxygen tubing on the floor. If tubing is on the floor take and replace with new tubing that is labeled and dated as well. For infection control, tubing should not be touching the ground. On 01/25/2022 at 1:16 PM, the DON was interviewed and stated oxygen tubing should be changed when on the floor to prevent infection and reiterated with staff. As part of their rounds they look at oxygen tubing and make sure infection control practices are upheld and longer tubing and maintaining resident dignity and quality of life residents, residents intubated in the hospital may need oxygen. 3. Resident # 113 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented resident cognition status was intact and required extensive assistance of 2 persons for bed mobility and transfer. The MDS also documented that the was receiving Oxygen Therapy. On 01/18/2022 at 11:15 AM, 01/19/2022 at 11:37 AM, and 01/20/2022 at 10 AM, Resident # 113 was observed lying in bed receiving oxygen via nasal cannula. Oxygen tubing was observed on the floor near the bedside table. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/24/2022 at 12:23 PM, an interview was conducted with Certified Nursing Aide (CNA) #2. CNA #2 stated that the oxygen tubing is long and sometimes it rolls down to the floor. CNA #2 also stated that sometimes they put them up near the resident's bed and sometimes they forget to put them up. On 01/24/2022 at 12:40 PM, Licensed Practical Nurse (LPN) # 1 accompanied surveyor to the room of Resident #113 and LPN # 1 immediately picked up the oxygen tubing and placed it near the head of the bed. LPN # 1 stated that oxygen tubing should not be on the floor. On 01/24/2022 at 03:34 PM, an interview was conducted Registered Nurse Supervisor (RNS) #2 stated Oxygen tubing should not be in the floor at any time, and if found on the floor, staff should get a new one and discard the one found on the floor. On 01/24/2022 at 03:45 PM, an interview was conducted with the Infection Control Coordinator (ICC) who stated the oxygen tubing at no time should be on the floor. The ICC also stated further that in-service education had been given on Oxygen tubing not to be placed on the floor. On 01/25/2022 at 12:13 PM, an interview was conducted with the Director of Nursing (DON). The DON stated when oxygen tubing is in the floor it must be replaced, and staff must make sure the new one will not touch the floor. The DON also stated that Resident #113 has long oxygen tubing which the resident requests when they are going to therapy. The DON further stated that when the resident comes back from therapy, staff needs to change the tubing to a shorter one that will not touch the floor. 415.19(a) (1-3)

Based on record review and interviews conducted during the Recertification survey from 1/18/2022 to 1/25/2022, the facility did not ensure that a resident's assessment was accurate. Specifically, the Minimum Data Set (MDS) 3.0 assessment inaccurately documented that a resident received insulin injections. This was evident for 1 out of 2 residents reviewed for Resident Assessment out of an investigative sample of 35 residents (Resident #115). The findings are: The facility policy & procedure titled Resident Assessment Instrument, MDS 3.0 Completion with effective date April 2012 and last updated April 4, 2014 documented under section Person Responsible that it was the duties of MDS Coordinator (R.N.) to Complete assigned assessments and sections via EMR through record review, staff interview and resident observation; and Review completed MDS 3.0 and certify. It also documented under section Responsible Person that MDS Coordinator (R.N.) was to complete section N for Medication in the MDS Assessment. Resident #115 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence that Resident # 115 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Quarterly MDS dated [DATE] documented Resident #115 was rarely/never understood with short and long-term memory problems. It did not document that Resident # 115 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Patient Review Instrument (PRI) dated 11/8/2021 did not document Resident #115 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The hospital discharge paper dated 11/12/2021 did not document that Resident # 115 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician Orders for Re-admitted d 11/12/2021 had only the injection of [MEDICATION(S)] ([MEDICATION(S)]) 5,000 unit/mL injection solution, inject 1 milliliter (5,000 unit) by subcutaneous route every 12 hours starting 11/12/2021. There was no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence that any Comprehensive Care Plan was created for DM. The Medical note dated 11/13/2021 for readmission did not document Resident # 115 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Resident Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/20/22 at 10:57 AM, Resident Care Coordinator (RCC)/Unit Manager (RN # 3) was interviewed. RN # 3 stated they did both the admission and re-admission for Resident #115 on 9/25/2021 and 11/12/2021 respectively and obtained the medication orders from the attending physician. RN # 3 also stated Resident #115 did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/20/22 at 11:45 AM, MDS Coordinator (MDSC) was interviewed. MDSC stated the MDS Assessor reviewed the discharge paper and confirmed with RCC/Unit Manager for the medications a resident was receiving for the MDS assessment. MDSC reviewed the PRI and hospital discharge papers for the re-admission on 11/12/2021 and stated Resident # 115 did not have diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MDSC also stated it was an error to code [MEDICATION(S)] injection as insulin injection in the MDS assessment with reference date 11/19/2021. MDSC stated the MDS Assessor was a professional registered nurse and had to review and sign the MDS assessment after MDS assessment completion. MDSC also stated they would do the modification for the MDS assessment to correct the error of insulin entry. 415.11(b)

Based on observation, record review, and staff interview conducted during the Recertification survey (TQIS11), the facility did not ensure that medication and biologicals were labeled properly with the open date based on professional standards of practice. Specifically, two multi-use insulin vials were not labeled with the open date. This was evident for 1 on 6 units reviewed for Medication Storage (Unit 2). The findings are: The Policy titled Labeling of Pharmaceuticals reviewed on 4/2/2010 documented that floor stock medications shall be labeled with the expiration date. Individual resident prescriptions shall have the expiration date. The Policy titled Insulin Administration, reviewed March 2010, documented all insulin are considered to be floor stock within the facility. The nurse will date the insulin vial once opened then discard within 30 days of opening. On 01/24/2022 at 11:12 AM, an observation of the medication cart on the 2nd floor was conducted with the Registered Nurse (RN #4). A plastic bag labeled with an open date of 1/22/22 contained two open multi-use vials of insulin (one vial of [MEDICATION(S)] R and one vial of Ademalog). The [MEDICATION(S)] R and Ademalog vials were not labeled with open date on the vial. An interview was conducted on 01/24/2022 at 1120AM and 3:06PM with RN#4 who stated when insulin is received from the pharmacy, it is understood that the insulin will be opened and used on the date on the pharmacy label. The nurses to not label the vial with an open date. RN #4 stated the insulin vials should be labeled with an open date on 1/17/22 and 1/22/22. RN #4 stated the Medication carts are checked every 2 weeks to ensure there are no expired medications. On 01/24/2022 at 03:35 PM, an interview was conducted with the Registered Nurse Supervisor (RN#3) who stated open insulin vials should be labeled with open date and expiration date. RN #3 stated the nurses on the unit and the supervisor check the medication on the carts for proper labeling. RN #3 stated he/she checked the cart 2 weeks ago. On 01/24/2022 at 3:50 PM, the Director of Pharmacy was interviewed and stated they check the medication carts at least once a month. Insulin vials should be labeled when opened and discarded within 30 days of opening. Vials should be labeled because the manufacturer cannot guarantee the potency after 30 days once opened. The pharmacy sends and auxiliary label with the insulin that staff can use for dating the medication. Every month, the pharmacist checks all the insulin expiration dates. 415.18 (e) (1-4)

Based on observations, record reviews and interviews conducted during the Recertification survey conducted 1/18/2022 to 1/25/ , the facility did not ensure that necessary environmental maintenance services were provided to maintain a safe, clean, comfortable, and homelike environment. Specifically, a broken wall, an exposed inner wire of the call bell, and a hanging call bell wall plate were observed in residents' living areas. This was evident for 1 of how many resident floors (6th floor). The findings are: The facility policy and procedure for Environment of Care in Maintaining the Physical Environment Policies and Procedures dated as effective 08/23/2010 reviewed and updated 07/21/2021 documented It is the policy of the facility to provide care and services related to physical environment in accordance to State and Federal regulations. The facility is constructed to maintain all essential mechanical, electrical in safe operating condition for the safety of residents, personnel, and the public. All issues/conditions must be entered in logbook for Maintenance. Examples of Maintenance issues include TV, heating, air conditioning problems, call bells problems, holes in the walls etc. Administration, Maintenance and Housekeeping department heads will make Environmental rounds on a regular basis. On 01/18/2022 at 10:20 AM, during the initial tour on the 6th floor, the following observations were made in Room 612 Private: There was a broken/ open wall on top of the resident's bed with an exposed call bell wire coming out of the opening. The call bell plate was hanging off the wall. On 01/19/2022 at 10 AM, 01/20/2022 at 2:30 PM and 01/21/2022 at 11AM the same observations were made in Room 612P. On 01/ 21/ 2022 at 11:05 AM, the Maintenance book was checked from 01/01/2022 to 01/21/2022. There was no documentation noted regarding any issues requiring maintenace in Room 612. On 01/21/2022 at 11:07 AM, an interview was conducted with the Certified Nursing Assistant (CNA #1). CNA #1 stated the open wall in Room 612 was from last week. CNA #1 stated they mentioned this issue to a worker in the maintenance department but forgot the person's name. CNA #1 forgot to write the issue in the maintenance book. On 01/21/2022 at 11:18 AM, an interview was conducted with the Registered Nurse (RN #1). RN #1 stated they did not notice the open wall by the call bell, and they seldom work on that side of the unit. On 01/21/2022 at 3:04 PM, the Director of Maintenance was interviewed and stated maintenance did not fix the open wall because they were not informed about it. Maintenance workers make rounds, and the open wall should have been repaired and covered for safety. On 01/21/2022 at 3:14 PM, the Director of Environment of Care was interviewed and stated, we do not have enough manpower to check all corners of the facilty. The hanging call bell wall plate should have been fixed. The Director of Environment of Care immediately inspected the open wall, inspected the wires inside the open wall and attached the hanging wall plate using a moderate hand pressure against the wall. 415.5(h)(2)

Based on observation, record reviews, and staff interviews during the recertification survey, the facility did not ensure that a resident maintained acceptable parameters of nutritional status. Specifically, the facility did not effectively monitor a resident after they were started on tube feeding after a [DEVICE] placement. As a result, the resident, who was already underweight, had further weight loss. This was evident for 1 out of 6 residents reviewed for nutrition. (Resident #48). Finding is: The facility's policy titled Enteral Nutrition Therapy (Tube Feeding) documents tube feedings via PEG (Percutaneous Endoscopic [DEVICE]), gastric, and jejunostomy tubes are used to provide adequate nutrition and hydration for residents who are unable to take liquid or food by normal means. Feedings are initiated and monitored by licensed nursing staff that have been trained to perform tube feeding procedures. A physician order [REDACTED]. Resident # 48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 Assessment ((MDS) dated [DATE] documented the resident had long and short term memory problems with severely impaired cognitive skills for daily decision making. The resident required limited assistance with Activities of Daily Living (ADLs), and the resident was on a mechanically altered, therapeutic diet. The resident had no difficulty chewing or swallowing. The Significant Change MDS dated [DATE] documented the resident was unable to complete a Brief Interview for Mental Status. The resident had a feeding tube and received 51% or more calories through tube feeding. The resident received 501 cc /day or more fluids through tube feeding. The Comprehensive Care plan (CCP) for nutrition was initiated on 2/20/19. The CCP identified the resident with dysphagia, a BMI (Body Mass Index) of 13.22 (underweight), and status [REDACTED]. The CCP for tube feeding was initiated on 2/20/19. The CCP identified the resident as at risk for aspiration from tube feeding. Interventions included obtain dietary intervention for feeding regimen evaluation and re-evaluation as needed. Physician's progress note dated 12/24/19 documented the resident had weight loss and will start [MEDICATION NAME], monitor more closely. Physician's progress note dated 1/21/19 documented the resident was not eating well and family was refusing PEG placement. The resident weight loss, and the physician's plan was to start [MEDICATION NAME] and monitor the resident closely. A Dietary note dated 2/6/19 documented: late entry for December, the resident had a 11% weight loss in 6 months. Resident is spoon fed by staff. Resident continues on NCS diet, blenderized consistency. Per MD family refused PEG placement. Resident is on Ensure Clear 8 oz four times a day and Proform 30 ml once a day. Resident is on weekly weights. Resident receives high calories foods on tray. Residents needs are being met with 1950 calories and 56 grams protein daily. Resident is at risk for altered nutrition and hydration status related to Anorexia, Dementia, Dysphagia, and altered oral intake trend. A second Dietary note dated 2/6/19 documented: Quarterly weight note with impaired skin integrity. Estimated needs 1050-1225 calories/day, protein 42-56 grams/day, 1050-1225 ml/day fluids. Resident weight 77 lbs and BMI 13.22. Resident lost significant weigh of 10 lbs in 6 months. A Dietary note dated 2/8/19 documented that the resident was pocketing food and was referred to Speech Language Pathology (SLP). The Physician's progress note dated 2/11/19 documented the family agreed to PEG placement and a consultation for placement was ordered. The Dietary note dated 2/11/19 documented the family agreed to PEG placement for enteral nutrition support. The Physician's progress note dated 2/18/19 documented the resident had weight loss and would be sent for PEG placement. The review of the physician's orders [REDACTED]. A Dietary note dated 2/19/19 documented the resident was placed on IV fluids: Sodium Chloride 0.45% @ 100 ml/hour for five days for Anorexia. The resident was medically cleared for PEG placement on 2/19/19. A Dietary note dated 2/20/19 documented the resident is status [REDACTED].@ 40 ml/hour providing 960 calories. Per Nurse Practitioner, the rate was decreased due to the resident having a new PEG. The note documented the dietician will adjust new feeding as needed. On 2/22/219 an order for [REDACTED]. The Physician's progress note dated 3/18/19 documented the resident had weight loss after PEG placement. A review of the physician's orders [REDACTED].@ 40 ml/hour renewed on 3/18/19. A Dietary note dated 4/12/19 documented a late entry for 3/11/19. The note documented the resident had a significant weight change and new GT placement. The resident had 16% weight loss over 6 months and a current BMI of 12.98. A second Dietary note dated 4/12/19 documented the resident had further weight loss of 20% weight loss in 6 months and a PEG was placed. The note documented the resident's tube feeding formula was changed to [MEDICATION NAME] 1.2 Cal @ 60 ml/hour providing 1200 calories. physician progress notes [REDACTED]. The review of the physician's orders [REDACTED].@ 60 ml/hour on 4/15/19. The resident's weight records documented that the residents' weight was the following: on 12/7/18- 80 lbs, on 1/4/19- 78.2 lbs, on 2/1/19 77 lbs, on 3/1/19- 75.6lbs, and on 4/10/19- 72 lbs. There was no documented evidence in the medical record that the resident's continued weight loss after PEG placement was addressed in (MONTH) after it was identified. The resident's tube feeding orders were not re-evaluated and the resident continued to lose weight into April. As of 4/10/19, the resident a 4.76% weight loss since 3/1/19. On 05/31/19 at 09:57 AM, an interview was conducted with the Certified Nursing Assistant (CNA). The CNA stated that every first to fifth of the month the aids do monthly weights. The CNA stated that she can see if a resident is losing weight. The CNAs report weights to the nurse on duty. The CNA reported the resident is very slender and when transferring her you could tell she lost weight. The weight loss was reported to the nurse during weekly weight monitoring. On 05/31/19 at 10:09 AM, an interview with the Licensed Practical Nurse (LPN) was conducted. The LPN stated the resident was diagnosed with [REDACTED]. The LPN stated residents' weights are done monthly, but for someone like Resident #48, weights are done weekly to monitor more closely. The LPN stated that the CNAs will weigh residents, record the weights, and give them to her. If there is a discrepancy of weights, the LPN will let the dietitian know. The LPN stated if there is a 5#(pound) difference they put reweigh and the dietitian will come and get the weight with the resident. For this resident, the LPN was not aware if the dietitian was notified about the weight loss. The LPN stated that dietary decides the formula and rate of a tube feed. The LPN stated that after a PEG tube is placed, dietary comes daily to see if a resident is tolerating the feeding. The LPN stated that after tube feeding is started, they put residents on weekly weights. The LPN stated if a resident's weight is going down after tube feeding, we mention it to the doctor and dietary to reassess the formula. The LPN could not answer why the resident had continued weight loss and the tube feed formula was not updated. The LPN could not clearly state if the weight loss was mentioned to the Physician (MD) or dietitian. On 05/31/19 at 10:26 AM, an interview with the Registered Dietitian (RD) was conducted. The RD stated that she was the regional manager and not the covering dietitian. The RD stated that prior to recommending tube feeding the dietitians try and figure out why the resident isn't eating- get food preferences, get speech evaluation, get psych consult, fortified foods, put supplements in between meals to focus on meals as main source. The RD stated they monitor closely with weekly weights to see if the interventions are effective. RD stated that if the interventions don't work they will recommend tube feeding. The RD stated that for tube feeds the dietitians will calculate the rate and needs of the resident. The RD stated that if the doctor is recommending that the resident get a rate that is lower than estimated needs she would speak to the doctor about her recommendations for increasing the rate, especially if a resident is losing weight we want to address the weight loss. The RD stated that after a PEG placement, the resident should be seen to evaluate the rate and then monthly thereafter. The RD stated she cannot speak to why there were no dietary notes or assessments in the month of (MONTH) or why the tube feed order wasn't clarified. The RD stated the dietitian should have made recommendations to increase the tube feed after the resident was losing weight post PEG placement. On 05/31/19 11:50 AM, an interview with the Nursing Supervisor was conducted. The supervisor stated that the nurse practitioner and doctor followed the resident and recommendation for consult for PEG placement. The supervisor stated that the resident didn't come back from PEG placement with a tube feed order. The supervisor stated the tube feed order comes from the doctor and then nursing will put it in the system. The supervisor stated that the nurse practitioner wanted to see if the resident could tolerate the tube feeding before giving a higher rate. The supervisor stated that after the order the RD is supposed to come and make their recommendations to the doctor. The supervisor further stated that after one month the RD is consulted to see if we should increase the calories of the tube feeding. The supervisor stated that the dietitian will send nursing an email for tube feed if anything was changed. The supervisor stated that if nursing does not get an email from the RD they assume that the rate is ok and there is no issue. There was no follow-up about the tube feeding rate between nursing and dietary staff. On 06/03/19 at 10:13 AM an interview with the Medical Doctor (MD) treating the resident was conducted. The MD stated the residents family took a while to agree to tube feeding placement, but once they agreed the resident was sent out for consult. The MD stated that when the resident returned from her PEG placement she was started on the feeding tube. The MD stated that usually the RD will calculate the recommendation for the tube feeding formula and rate and then he signs off on the order for it to start. The MD stated that the rate of the feeding is started low and then in 2-3 weeks, if the resident is tolerating the feeding, the RD recalculates. The MD stated that he expects the resident to gain 5 lbs in the first month after a PEG is placed. The MD stated that the PEG was placed on 3/18/19 despite documentation indicating the PEG was placed on 2/19/19. The MD stated that the resident has been gaining weight since the PEG placement despite an initial weight loss of 5 lbs over about a month. The MD was not aware of the weight loss status [REDACTED]. A review of the record did not reveal the revaluation of the tube feeding formula and rate by the MD, dietitian, or nursing in a timely manner, resulting in weight loss in a resident that was already underweight. The RD was not able to identify why the resident did not have recommendation to increase the tube feeding earlier. 415.12 (i)(1)

Based on observation, and interview during the recertification survey, the facility did not ensure that infection control practices were maintained. Specifically, two nurses were observed performing finger stick glucose testing without cleaning the glucometer machine between resident use. This was evident during observations conducted during the Medication Administration Observation. The findings are: On 09/07/2017 at 10:47 AM, the Registered Nurse (RN) was observed performing blood glucose testing (finger-stick) on resident # 347 in room [ROOM NUMBER] A. The RN removed the glucometer from a small blue plastic box in the top drawer of the medication cart. The nurse placed a test strip into the device and performed the test on the resident. The RN removed and discarded the test strip and then placed the glucometer back into the box in the medication cart without cleaning the glucometer machine. On 09/07/2017 at 11:50 AM, the RN was again observed performing blood glucose testing (finger-stick) on resident # 380 in room [ROOM NUMBER] A. The RN was not observed cleaning the glucometer with an antiseptic wipe prior to performing the blood glucose testing. The nurse placed a test strip into the device and performed the test on the resident. The LPN then removed and discarded the test strip and placed the glucometer back into the box in the medication cart. On 09/07/2017 at 11:53 AM, the Licensed Practical Nurse was observed performing blood glucose testing (finger-stick) on Resident # 401 in room [ROOM NUMBER] B. The RN was not observed cleaning the glucometer with an antiseptic wipe prior to performing the blood glucose testing. The nurse placed a test strip into the device and performed the test on the resident. The LPN then removed and discarded the test strip and placed the glucometer back into the box in the medication cart. The nurses did not sanitize the glucometer machine after performing the finger stick tests before returning the device to the medication cart. There were no sanitizing wipes observed on the medication cart for cleaning the reusable glucometer. On 09/07/2017 at 7:07 PM, the LPN was interviewed and stated that he received training on infection control at least once a year. The LPN stated that the glucometer is supposed to be cleaned with an alcohol swab or antiseptic -wipe before and after use. The LPN also stated that he thought that he had cleaned the glucometer before using it on another resident. The LPN also stated that the glucometer should be cleaned before being placed back into the blue box and put back into the cart. On 09/07/2017 at 7:13 PM, the RN was interviewed and stated that the glucometer is cleaned before use with an alcohol swab if she has time. The RN also stated that the glucometer was not cleaned before being used with the resident. The nurse stated that she could not recall when she was last in-serviced on the use of the glucometer. On 09/08/2017 at 11:27 PM, the Resident Care Coordinator/RN Supervisor was interviewed and stated that glucometers are supposed to be cleaned before, after use and in between residents. The glucometers should be cleaned with approved wipes and not alcohol prep pads. The RN Supervisor also stated that random observations are done of staff to ensure that staff are doing the tasks properly. In addition, the supervisor stated that all nurses had been in-serviced but would be re-educated. On 09/08/2017 at 11:48 AM, the Infection Control Coordinator (ICC) was interviewed and stated that Annual Mandatory in-service to all staff and new hires and to staff as needed. The ICC also stated that glucometers should be cleaned and disinfected in-between residents use and should be cleaned with the approved Super Sani Cloth, germicidal wipes or alcohol prep pad. A review of the facility of the policy Cleaning and Disinfecting Non-Critical Resident Care Equipment dated 6/2017 documented reusable items -are cleaned and disinfected or sterilized between residents. 415.19(a)(1-3)

Based on observations and interviews the facility did not ensure that food holding temperatures were maintained to prevent food borne illness. Specifically, the cold and hot food holding and refrigerated temperatures were not maintained within acceptable parameters. This was evident during observations conducted during the Kitchen Tour. The findings are: On 6/21/16 at 11:20 AM, the tray line was observed and the following temperature readings were recorded: Tomato sauce (to serve over stuffed cabbage) 125 F (degrees Fahrenheit). The sauce was in a pan sitting on the unheated counter. Cranberry Juice 53 F and Orange/ pineapple juice 44 F. These were kept in an open reach-in refrigerator, that measured 44 F. There was no air curtain in place. Chilled Apricot 65 F - stored in Styrofoam cups A second observation was conducted on 6/23/16 at 11:00 AM. The following temperature readings were recorded: Cranberry Juice 44 F and Apple juice 45 F - stored in the open reach-in refrigerator. Fruit cocktail 50 F -stored in a Styrofoam cup placed in a plastic tub over ice. On 6/23/16 at 11:05 AM the Food service director ( FSD) was interviewed and stated that she was aware of the cold food temperatures not meeting standard and that she tried to bring down the temperature by leaving the foods in a freezer for an hour, realizing that it was not enough. She had recommended plastic cups to be purchased a few months back, which never came and she did not follow up on the request with the purchasing department. The facility policy dated 1/13/10 for 'Food Holding Temperatures' - trayline documents that cold foods are to be maintained at 41 F or below. 415.14 (h)

Based on observations and interviews the facility did not ensure that refuse from the kitchen was disposed of properly. This was evident during observations conducted during the Kitchen Tour. The findings is: On 6/20/16 at 10:15 AM, an observation of the garbage disposal area was conducted and the following observed: The top loading compacter had no door on top. The garbage bags and cardboard boxes were exposed and not fully compacted in. There was a puddle of whitish liquid on the floor to the left side of the compacter and was emitting a foul odor. To the right of the compacter, the floor was scattered with gloves, cardboard boxes, an opened can with a sharp edged lid and tubing. On 6/20/16 at 10:18 AM and 6/23/16 at 11:25 AM, Housekeeping staff were observed loading bags of garbage into the compactor. There was no door noted to enclose the contents of the compactor during operation. On 6/20/16 at 10:23 AM the House keeping staff was interviewed and stated that he has been working in that area for the past 6 years and during that time, there has not been a door on compacter to enclose the contents during operation. On 6/23/16 at 11:30 AM the Director of Environmental services was interviewed and stated that he was aware the garbage has to be contained and covered while transporting but not in the Compacter area and they never had a door for the compacter. On 6/23/16 at 11:30 AM the Director of House Keeping was interviewed and stated that he was not aware the compacter door has to be closed to operate the compacter and also keep the garbage contained. Further he did not think it was necessary to keep the door closed. The facility policy dated 3/16 for Waste Removal does not clearly document how to dispose off garbage into the compactor and how to maintain the surrounding area. 415.14 (h)