Every finding on record at Harris Hill Nursing Facility, L L C

Based on observations, interviews, and record reviews conducted during the survey, the facility failed to ensure developed and prepared menus to meet resident choices including their nutritional, religious, cultural, and ethnic needs were met for one (1) of four (4) dining rooms. Specifically, Resident's #17, #52, and #119 were not served with all the fluids and/or food items listed on their meal tickets and Resident #52 was not provided with their inner lip plate as documented on their meal ticket.The findings include: The policy and procedure titled Dining Rooms/Servery Meal Service revised 3/2011 documented that dietary personnel will assemble each resident's tray according to the menu and any special requests as stated on each diet card in accordance with the diet order. Nursing personnel will be responsible for disbursement of meals beginning with providing appropriate beverages and reviewing the menu with the residents. The tray card, which is labeled with resident's name, diet order, adaptive equipment and feeding status, is placed at the resident's place setting. Designated personnel will visually check each tray for accuracy. The policy and procedure titled Hydration revised 10/2023 documented each resident is provided with sufficient fluid intake to maintain proper hydration and health. The Dietician assesses all residents for fluid needs and adequate fluids to meet hydration needs are provided with each meal. The policy and procedure titled Adaptive Eating Equipment dated 1/1/2000, documented all residents requiring adaptive equipment will be issued the appropriate equipment to promote independence and maintain functional status. The Dietary Department will be responsible for seeing that adaptive equipment was supplied for residents' use at mealtimes.1.Resident #17 had diagnoses of type 2 diabetes mellitus, schizophrenia (mental disorder) and dysphagia (difficulty swallowing). The Minimum Data Set (a resident assessment tool) dated 02/10/2026 documented Resident #17 was severely cognitively impaired, usually understood, and sometimes understands. Required supervision with eating. The current comprehensive care plan dated 02/28/2026 documented at risk for alteration in nutrition, and dehydration. Interventions included: meal plan provides kilocalorie/protein/fluid in excess of needs and meets/exceeds dietary reference intakes for vitamins/minerals; provide preferred fluids via meal plan, adjust as needed; and adjust meal plan as needed. During an observation on 04/16/2026 at 9:12 AM Resident #17's meal ticket documented for two (2) pancakes and two (2) sausages. Resident #17 received scrambled eggs, sausage and toast. During an interview at the time of the observation, Resident #17 stated they would have liked to have received pancakes. Upon surveyor notifying nursing staff that the resident would like pancakes the Dietary Supervisor #1 stated that Resident #17 receives the same breakfast every day, eggs, sausage and toast. Resident #17 was provided with two pancakes and consumed an entire pancake in addition to their eggs, sausage, and toast. During an observation on 04/20/2026 between 8:56 AM and 9:20 AM, Resident #17 meal ticket documented eight (8) ounce coffee, four (4) ounce juice and eight (8) ounce milk. Resident #17 was observed to only be provided with an eight (8) ounce cup of milk. Upon leaving dining room, Resident #17 stated they did not want coffee, but they would have liked to have received juice and did not. 2. Resident #52 had diagnoses of cardiovascular incident (stroke) with hemiplegia (weakness or paralysis), aphasia (difficulty speaking) and dementia. The Minimum Data Set, dated [DATE] documented Resident #52 was severely cognitively impaired and required supervision with eating. The current comprehensive care plan date 03/11/2026 documented Resident #52 was self-performance deficit for eating related cardiovascular incident and interventions included adaptive equipment of inner lip plate. The care plan documented Resident #52 was at risk for alteration in nutrition. Interventions included having a four (4) once mighty shake with meals; meal plan provides kilocalorie/protein/fluid in excess of needs and meets/exceeds dietary reference intakes for vitamins/minerals and adjust meal plan as needed. The care plan also documented Resident #52 was at risk for dehydration related to suboptimal fluid intake with interventions for hydration protocol. During an observation on 04/17/2026 from 8:23 AM to 9:40 AM, Resident #52 was in the dining room for the breakfast meal. Their meal ticket documented two (2) cinnamon pastries, eight (8) ounce water, four (4) ounce prune juice, two (2) eight (8) ounce house juice and four (4) ounce mighty shake. The meal ticket also documented the resident required an inner lip plate. Resident #52 received scrambled eggs, toast, oatmeal (in a bowl) on a regular plate. Resident #52 was drinking an eight (8) ounce chocolate milk. There were no pastries or any other beverages provided. During an observation on 04/17/2026 at 12:35 PM, Resident #52 was in the dining room for the lunch meal. Their meal ticket indicated two eight (8) ounce water, four (4) ounce prune juice, two (2) eight (8) ounce house juice and four (4) ounce mighty shake. Resident #52 was drinking an eight (8) ounce chocolate milk, and no other beverages were provided. During an observation on 04/20/2026 between 8:46 AM and 9:32 AM, Resident #52 was in the dining room for their breakfast meal. Their meal ticket documented two (2) cinnamon pastries and banana with adaptive equipment of an inner lip plate. Resident #52 was served eggs, toast and oatmeal (in a bowl) on a regular plate. There were no pastries or bananas provided. 3. Resident #119 had diagnoses of type 2 diabetes mellitus, cardiovascular incident with hemiplegia, and dementia. The Minimum Data Set, dated [DATE] documented Resident #119 was moderately cognitively impaired, usually understood, and usually understands and required supervision with eating. The current comprehensive care plan dated 01/28/2026 documented Resident #119 was at risk for alteration in nutrition. Interventions included meal plan provides kilocalorie/protein/fluid in excess of needs and meets/exceeds dietary reference intakes for vitamins/minerals. The care plan documented Resident #119 was at risk for dehydration related suboptimal fluid intake. During an observation on 04/14/2026 at 12:07 PM Resident #119 was in the dining room for the lunch meal. Their meal ticket documented they should have received four (4) ounce prune juice, eight (8) ounce chocolate milk, eight (8) ounce coffee and eight (8) ounce house juice. Resident #119 only received eight (8) ounce cup of juice, which they had consumed one hundred percent. No additional fluids were provided. During an observation on 04/20/2026 between 8:50 AM and 9:21 AM, Resident #119 was in the dining room for the breakfast meal. Their meal ticket documented they should have received four (4) ounce prune juice, eight (8) ounce whole milk, eight (8) ounce coffee and eight (8) ounce house juice. Resident #119 only received eight (8) ounce cup of juice. During an interview at the time of the observation Resident #119 was asked by surveyor if they would have liked their milk and coffee and the resident replied yes. During an interview on 04/20/2026 at 9:08 AM, the Dietary Supervisor #1 stated they have been working at the facility for many years, and they are familiar with all the residents, and they know what they like and how they like it. They stated they did not provide Resident #52 with the banana nor pasties because a lot of times they do not eat it. The Dietary Supervisor #1 stated they did not serve Resident #52 meal on an inner plate, but they should have. During an interview on 04/20/2026 at 9:17 AM, Licensed Practical Nurse #6 stated residents should be offered items on their meal tickets. They stated residents should at least be asked, offered beverages on meal tickets to see if they would like them. They stated residents have a choice about what they want to eat and drink. Licensed Practical Nurse #6 stated they were not sure who determined what beverages residents were to receive. During an interview on 4/20/2026 at 9:27 AM, Certified Nurse Aide #3 stated the resident's meal ticket should be looked at to determine what the resident was to receive to eat and drink. They stated it was important for residents to receive what was on their meal ticket for nutrition purposes. They stated if a resident did not receive their drinks indicated on their meal ticket, they could feel parched, their mouth could be dry, they could become dehydrated and could choke if they did not have enough fluids to wash down their food. During an interview on 04/20/2026 at 9:38 AM, Licensed Practical Nurse #4 stated nursing staff should be serving what was indicated on the residents' meal tickets. They stated they would expect all fluids to be offered and that nursing staff typically asked residents what they wanted to drink. They stated the dietician determines preferences and amounts to be served to prevent dehydration and ensure residents were getting enough calories. During an interview on 04/20/2026 at 9:49 AM, Registered Dietician #1 stated they would expect residents to receive food and fluids documented on their meal ticket unless they tell the server they do not want something. They stated substitutions for food and fluids were on the fly, but items on the meal ticket should at least be offered. They stated it was important for residents to receive adequate fluids to prevent dehydration. The Registered Dietician stated residents who were confused should be receiving what was on their meal ticket for hydration purposes, as they cannot communicate what they need. During an interview on 04/21/2026 at 9:17 AM, Occupational Therapist #1 stated Resident #52 utilized only one hand for eating due to their stroke and did not like staff to assist them with eating. They stated Resident #52 was recommended for an inner lip plate to make it easier for the residents to scoop their food. During an interview on 04/21/2026 at 9:34 AM, the Food Service Director stated they would expect the dietary staff to serve residents what was stated on their meal ticket unless the residents stated they wanted something different. The Food Service Director stated the dietician makes a resident's menu per the resident's preference and what their meal needs were, and the dietary staff should not change that menu without speaking to the dietician. They stated the staff members that were serving the food were responsible for plating the food on the appropriate adaptive equipment. They stated that if the meal ticket documented Resident #52 was to have a scoop plate, then that was what should have been given. During an interview on 04/21/2026 at 11:27 AM, the Director of Nursing stated after review of Resident #52's Kardex (guide used by staff to provide care) in the electronic medical record, that Resident #52 was care planned to have an inner lip plate at meals. They stated they would expect staff to use that adaptive equipment because it was part of the care plan. The Director of Nursing stated they would expect the meal tickets to be followed, unless the residents expressed differently. They stated the standard was for the meal ticket to be followed and for the nursing staff to notify the dietician if the meal tickets needed to be altered. They stated it was important for residents to receive food/fluids as indicated to support their nutritional needs. 10 New York Codes, Rules, and Regulations (NYCRR) 415.14 (c) (3)

Based on observations, interviews, and record reviews conducted during the survey, the facility did not ensure that the resident's person-centered care plan was implemented to meet the resident's medical and nursing needs for one (1) (Resident #19) of one (1) resident reviewed for positioning. Specifically, Resident #119 did not to have their foot buddy (a device that is strapped to the calf and foot pedals of a wheelchair to prevent legs/feet from slipping behind or off of the wheelchair pedals) in place as per their care plan.The findings include:The policy and procedure titled Interdisciplinary Care Planning dated 09/2025 documented that a comprehensive care plan and Kardex (guide used by staff to provide care) must always be current and accurately reflect the resident's status. The Care plan/Kardex must always be reviewed by staff prior to initiating resident care.The policy and procedure titled Positioning-Seating Devices dated 07/19/2023 documented cushions, wedges, bolsters and other corrective devices for seating are properly applied after assessment and implementation by the Rehabilitation Department. Special seating and/or positioning needs are described in the comprehensive care plan. The policy documented the procedure for wheelchair positioning was to support feet by placing them on foot pedals or by use of adaptable cushions and positioning devices are placed as described in the comprehensive care plan.Resident #119 had diagnoses of that included, cardiovascular incident (stroke) with hemiplegia (paralysis on one side of the body), and dementia. The Minimum Data Set (a resident assessment tool) dated 04/14/2026 documented Resident #119 was moderately cognitively impaired, usually understood, and usually understands others. The current comprehensive care plan dated 01/28/2026 documented Resident #119 had self-performance deficit related to activity intolerance, limited mobility and limited range of motion. Interventions included to be out of bed to wheelchair and positioning devices out of bed included a foot buddy. The Kardex dated 04/20/2026 documented Resident #119 was dependent on wheelchair mobility and was to have a foot buddy when out of bed in the wheelchair.Review of interdisciplinary progress notes dated 12/04/2025 to 04/19/2026 revealed there was no documented evidence Resident #119 refused and did not tolerate the use of the foot buddy.During observations on 04/14/2026 at 9:51 AM and 3:10 PM; 04/16/2026 at 9:20 AM; 04/17/2026 at 8:41 AM, 9:32 AM and 10:29 AM, Resident #119 was either in the dining room or sitting in front of the community television in their wheelchair without the foot buddy in place on their wheelchair. Resident #119 was noted to position/move both their legs behind the wheelchair foot pedals.During observation on 04/14/2026 at 9:40 AM and 04/17/2026 at 12:18 PM there was a foot buddy observed on the floor next to the resident's nightstand in their room.During an interview on 04/17/2026 at 1:21 PM, Certified Nurse Aide #3 stated they would know what type of adaptive equipment a resident would need by looking at the Kardex that hangs behind a resident's bathroom door or in their closet. Certified Nurse Aide #3 stated they were responsible for Resident #119's care on 04/14/2026 and 04/17/2026. After review of Resident #119's Kardex in the resident's room they stated that Resident #119 was to have a foot buddy applied to the leg rests on their wheelchair. Certified Nurse Aide #3 pointed to the foot buddy that was next to the resident's nightstand. They stated Resident #119 utilized the foot buddy because the resident does not keep their feet on the foot pedals or places their feet behind the foot pedals and tends to cross their legs at their ankles. Certified Nurse Aide #3 stated they must have forgot to apply Resident #119's foot buddy.During an observation and interview on 04/17/2026 at 1:35 PM, Licensed Practical Nurse #4 reviewed Resident #119's Kardex and stated the resident was to utilize a foot buddy to keep the resident's legs from falling through the wheelchair pedals. Resident #119 was in their wheelchair in front of the community television and Licensed Practical Nurse #4 stated the resident did not have their foot buddy in place. During an interview on 04/21/2026 at 9:20 AM, the Director of Therapy stated they reevaluated Resident #119 for the use of the foot buddy on 04/17/2026 per the request of nursing. They stated the foot buddy remained appropriate for the Resident to help them keep their feet on the footrest and they would not fall behind the pedals. The Director of Therapy stated they would have expected Resident #119 to have the foot buddy in place and for staff to follow their plan of care.During an interview on 04/21/2026 at 11:46 AM, the Director of Nursing reviewed Resident #119's care plan and stated Resident #119 was planned to have a foot buddy on their wheelchair and would have expected staff to apply it as it was a recommendation from therapy.10 New York Code Rules Regulations 415.11 (c)(1)

Based on observations, interviews, and record reviews conducted during the survey, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for two (2) (Unit A and Unit D) of four (4) unit servery refrigerators. Specifically, the unit servery refrigerators contained unlabeled, out-of-date food and drink items, and personal food was stored with residents' food. In addition, Unit A servery floor was soiled with food debris/dried spills and Unit D's refrigerator's handle was sticky with an unknown substance, and the front was soiled with food debris. The findings included: The policy titled Food Receiving and Storage revised on 12/2012 documented all opened items will be labeled and dated and discarded after three (3) days once they were opened. All Non-Potentially Hazardous Foods (PHF) or Time/Temperature Control for Safety (TCS) food items will be labeled and dated and discarded after five (5) days once opened. The policy titled Food Preparation, Service and Distribution revised on 10/2022 documented the facility will assure safe and sanitary food preparation, and distribution to prevent foodborne illness. 1.During an observation of the Unit D servery area and refrigerator/freezer on 04/14/2026 at 9:49 AM the following was observed: -the handle of the refrigerator was sticky with an unknown substance and the front of refrigerator had streaks of food debris.-one (1), clear plastic bag of sliced cold cut bologna, dated 04/07/2026.-one (1), clear plastic bag of sliced cold cut ham, dated 04/07/2026.-one (1), clear disposable plastic container of egg salad, undated.-one (1), clear disposable plastic container of sliced tomatoes, undated.-one (1), clear plastic bag of sliced cold cut turkey, dated 04/09/2026-one (1), clear plastic bag of sliced cheese, dated 04/07/2026.-two (2), 64-ounce clear pitchers of juice, undated. 2.During an observation of the Unit A servery and refrigerator/freezer on 04/17/2026 at 10:30 AM the following was observed: -food debris, crumbs, along back wall, and under stainless steel counter. Floor tacky with dried spills. Buildup of a black substance on floor in front of refrigerator.-one (1), 16.9 fluid ounce bottle unopened, unlabeled personal iced tea.-one (1), 16 ounce (one pound) of margarine opened, used and undated.-one (1), 64-ounce clear pitcher of orange juice with tape labeled on lid 4/14-one (1), 64-ounce clear pitcher of apple juice with tape labeled on lid 4/14-one (1), half gallon of milk opened, and undated with sell by date of April 17, 2026.-one (1), half gallon of chocolate milk opened and undated with sell by date of April 23, 2026.-one (1), clear disposable plastic container of egg salad dated 04/13/2026.-slices of cheese wrapped in clear plastic wrap dated 04/13/26.-one (1), clear disposable plastic container of fresh fruit (melon, grapes) dated 04/14/2026. -two (2), eight (8) ounce cups of juice with lids and straws, undated in door of refrigerator. -one (1), clear plastic baggie undated, unlabeled with bagels in drawer of refrigerator.-one (1), clear plastic baggie undated, unlabeled with raisin bread in drawer of refrigerator.-two (2), clear plastic baggies undated, unlabeled with English muffins in drawer of refrigerator.-three (3), eight (8) ounce cups of chocolate milk with lids and straws, undated in door of refrigerator.-three (3), 16.9 fluid ounce, frozen, plastic water bottles unlabeled in the freezer.-one (1), eight (8) ounce aluminum can of ginger-ale opened, unlabeled in freezer. During an interview on 04/17/2026 at 10:48 AM, Dietary Aide #1 stated food/drink items labeled/dated in the refrigerator were good for four (4) to five (5) days. They stated they were responsible for checking dates to make sure items did not need to be thrown away. They stated food/drink items dated 04/16/20 would be good until Monday, 04/20/2026. They stated unless drink items were dated, no one would know when they were poured. They stated everything should be dated, so everyone knows when it was from and when it should be gotten rid of. They stated personal items should not be stored in the servery refrigerator. Dietary Aide #1 stated the pitcher of orange juice dated 04/14/2026 did not look good, and they would stay away from using something dated from over three (3) days old. They were not sure how long milk containers were good for once opened and dated but should be dated to make sure they were not serving residents something old. Dietary Aide #1 stated the floors were supposed to be swept between meals and mopped every night. They stated the floor was not free of food debris and the floor needed to be mopped. They stated it was important to keep the servery clean for sanitation purposes. They stated debris builds up fast, was unsanitary and could attract rodents. During an interview on 04/17/2026 at 11:07 AM, Dietary Supervisory #1 stated the dietary supervisors should be checking that the dietary aides were checking dates and discarding food/drink items. They stated anything open was supposed to be dated, so they knew when it needs to be discarded. They stated food/drink items once opened, were good for three (3) days, three-day survival. They stated there should be no personal items stored in the refrigerator and should be labeled if it belongs to a resident. Dietary Supervisory #1 stated there should be no food debris, spills on floor and that there needs to be a better job done of sweeping and mopping the floor. During an interview on 04/17/2026 at 11:33 AM, the Food Service Director stated the dietary supervisors were responsible for checking the refrigerators/freezers in the serveries to make sure nothing was expired and that all food/drink items were dated, labeled every morning. They stated it was important that everything was dated, labeled to prevent food borne illness. During an interview on 04/21/2026 at 10:48 AM, Dietary Aide #2 stated it was important for food/drink items to be dated when they were opened because they only have a three (3) to five (5) day shelf life. After the three (3) to five (5) day shelf life they were disposed of because of bacterial growth. Dietary Aide #2 stated it was important to keep food prep areas clean to keep pests away. During an interview on 04/21/2026 at 11:51 AM, the Director of Nursing stated food is supposed to be labeled and dated when opened to make sure expired items were not being used. During an interview on 04/21/2026 at 1:01 PM, the Food Service Director stated cleaning of the servery areas was dietary and housekeeping's responsibility and that the dietary supervisors should ensure the dietary aides were completing what was required to maintain a clean, sanitized servery. They stated the serveries were supposed to be swept three times a day, after each meal, and mopped every night. They stated hygiene was key in every step because they would not want to eat out of someplace that was dirty. During an interview on 04/21/2026 at 1:12 PM, the Administrator stated all food/drinks should be labeled and dated to prevent any issues with spoilage that could cause complications to residents. They stated they expected a clean environment. 10 New York Codes, Rules, and Regulations (NYCRR) 415.14 (h)

Based on observation, interviews, and record reviews conducted during the survey, the facility failed to ensure that each resident was treated with respect and dignity, cared for in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality for one (1) (Resident #111) of five (5) residents reviewed for dignity. Specifically, two (2) staff members were in Resident #11's room on their personal cell phones, while the resident was calling out for assistance versus engaging with and assisting the resident.The findings include:The policy and procedure titled Personal Cell Phone/Electronic Device Use dated 08/22/2023 documented the use of a personal cell phone and other electronic devices while at work may present a hazard or distraction to the user and/or co-employees. The policy documented all personal cell phones were required to be completely turned off while at work. Employees may use personal cell phones only during lunch in designated areas in the facility. The policy added for emergency use; employees should notify their immediate supervisor.The policy and procedure titled Dignity, Respect and Privacy in Treatment and Care date 10/2023 documented the resident has a right to be treated with dignity, respect, privacy and security. The policy documented that Dignity means that in their interactions with residents, staff carries out activities that assist the resident to maintain and enhance his/her self-esteem and self-worth.Resident #111 had diagnoses that included cognitive communication deficit, heart failure, and chronic obstructive pulmonary disease (chronic lung disease). The Minimum Data Set (a resident assessment tool) dated 03/16/2026 documented the resident had moderate cognitive impairment, understands and was understood by others.The comprehensive care plan dated 03/26/2026 documented that Resident #111 had a potential for alteration in psychosocial well-being/mood related to medical condition, adjustment to subacute rehabilitation and confusion at times. Interventions included to respect and listen to expression of feelings and establish trust.The Kardex Report (a guide used by staff to provide care) dated 04/20/2026 documented Resident #111 was the minimal assistance of one staff member for activities of daily living. The Kardex documented for Resident #111's leisure time activities were to provide 1:1 visits, and transport them to and from activities as desired. During an observation on 04/17/2026 at 11:25 AM, Resident #111 was in their room sitting in their wheelchair yelling out for assistance. Resident Assistant #1 was standing about three feet away from Resident #111, facing the window with their back turned partially away, they had their cellular phone in their hand taping the screen with their finger as if they were texting. At this time, Resident Assistant #1 stated that they could not find Resident #111's certified nurse aide. Resident Assistant #2 was also in the room sitting in a recliner chair behind Resident #111, and the residents back was to Resident Assistant #2. Resident Assistant #2 also had their cellular phone in their hand, and the screen was lit up.During an interview on 04/17/2026 at 11:35 AM, Resident Aide #1 stated they were assigned to Resident #111 to keep them company and busy in attempts to lower the resident's anxiety. Resident Aide #1 stated they were on their cellular device because they were receiving a call from their own family member that was important and personal. They stated the facility policy was that staff were not supposed to have their phones on them because it can cause the staff members to comminute with others on the phone instead of keeping their attention on the residents. Resident Aide #1 stated it was disrespectful to be on their phone in front of a resident.During an interview on 04/17/2026 at 11:40 AM, Resident Assistant #2 stated they were assigned to keep Resident #111 entertained because the resident did not like to be alone. Resident Assistant #2 stated that they were sitting in Resident #111's recliner behind the resident and they did have their personal phone on because they were shutting off an alarm that was ringing on their phone. Resident Assistant #2 stated they were educated on personal cell phone use, and that staff could keep their phones with them when they were working but the facility did recommend staff keep them in their lockers. Resident Assistant #2 stated staff should not be on their phones in front of residents because it was disrespectful, it was a distraction while working.During an interview on 04/17/2026 at 1:44 PM, Licensed Practical Nurse #9 stated they had asked Resident Assistant #1 and #2 to sit with Resident #111 because the resident tended to have behaviors. Licensed Practical Nurse #9 stated that Resident Assistant #2 should not have been sitting in a recliner behind Resident #111 and both Resident Assistant #1 and Resident Assistant #2 should have been engaging with Resident #111. Licensed Practical Nurse #9 stated that neither resident assistants should have been using their personal cellular phones. They stated that personal cellular phone use should not be used in resident care areas and should be used discreetly elsewhere. Licensed Practical Nurse #9 stated personal cellular phone use in resident care areas was a dignity issue, and it was just rude.During an interview on 04/21/2026 at 10:15 AM, Social Worker #2 stated Resident Assistant #1 and #2 should have been engaging with the resident, especially if the resident was calling out for assistance. Social Worker #2 stated staff should not be using their personal cellular phones in resident care areas because it was a dignity issue toward the residents and personal matters should not be conducted in front of the residents.During an interview on 04/21/2026 at 11:40 AM, the Director of Nursing stated staff were not use their personal cell phones in resident care areas. They stated if staff receive an urgent phone call, then the call should be taken in another area away from the residents. The Director of Nursing stated that Resident Assistant #1 and Resident Assistant #2 should have been giving their attention to Resident #111.During an interview on 04/21/2026 at 11:59 AM, the Administrator stated facility staff should not be using their personal cellular phones in resident care area and the facility takes that situation very seriously. The Administrator stated when staff were on their personal cellular phones in front of residents in resident care areas it did not create a home-like environment, because staff were guests in the residents' environment and the staff work where the residents live.10 New York Codes, Rules, and Regulations 415.3 (a)

Based on observations, interviews, and record reviews conducted during the survey, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for three (3) (Residents #8, #32 and #58) of seventeen (17) residents reviewed for quality of care. Specifically, weights were not obtained daily as ordered by the physician (#8), lack of identification and documentation of a bruise (#32) and medications that were left at the bedside for self-administration without a physician's order (#58).The findings include:The policy and procedure titled Weight Monitoring dated 5/2013 documented that a weight record was used to monitor changes in weight on a weekly or monthly basis. Weekly or more frequent weight checks may be indicated for residents with anorexia, dehydration, obesity, edema, significant changes, or certain medication regimens. Weight frequency will be increased as deemed necessary by Nursing, Dietary, or a Physician. Consistent monitoring of weight gain or loss provides guidance for appropriate intervention in conjunction with the dietician.The policy and procedure titled Documentation of Pressure Ulcer and Chronic Wounds revised 6/23 documented a Skin Inspection is completed weekly on shower day. Skin was non-remarkable unless otherwise noted. Skin Inspection Requirements: inspect all skin surfaces (including heels and elbows), in order do a thorough skin inspection, resident must be turned side to side in bed or if able stand for inspection.The policy and procedure titled Self-Administration of Medications revised on 11/23/2021 documented that each resident is given a detailed explanation of the medications that they may self-administer, the reason for the medication, what to expect, and the possible side effects within their cognitive ability to understand The self-administration of medication is monitored by the Team Leader and the nurse is to document on the electronic medication administration record after the self-administered medications, the time and effect of the medication. Continued approval of the self -administration of medication by the resident is dependent on the resident's compliance with physician orders and facility procedures.1.Resident #8 had diagnoses of congestive heart failure (heart cannot pump blood well enough to meet the body's needs), chronic obstructive pulmonary disease (lung disease that makes breathing difficult), respiratory failure, and a history of pulmonary edema (fluid around the lungs). The Minimum Data Set (a resident assessment tool) dated 02/10/2026 documented Resident #8 was cognitively intact, able to understand and be understood by others, had no behavior or rejection of care, and was prescribed diuretics (medication that helps decrease swelling and increase urination).The current comprehensive care Plan dated 02/10/2026 documented to monitor for edema. The resident was at risk for altered nutrition related to congestive heart failure, with interventions including a no added salt diet, daily weights, and reporting weight gains of three (3) pounds in 24 hours or five (5) pounds in seven (7) days. The resident was also at risk for dehydration related to diuretic therapy, and fluid restrictions, with interventions including a 1500 milliliter fluid restriction.The Kardex (a guide used by staff to provide care) dated 04/20/2026 documented a 1500 milliliter fluid restriction and a no added salt diet. The Kardex did not document weight monitoring was needed.Review of a physician's order dated 11/05/2025 and renewed on 02/16/2026 documented Resident #8 was to be weighed daily on day shift, with parameters of a three (3) pound gain in 24 hours or a five (5) pound gain in seven (7) days to update provider.Review of weights in the electronic medical record documented on 02/11/2026 Resident #8 weighed 211.6 pounds and on 02/13/2026 weighed 217.2 pounds, an increase of 5.6 pounds in two (2) days.Review of weights in the electronic medical record documented on 03/11/2026 Resident #8 weighed 211.6 pounds and on 03/14/2026 weighed 217.9 pounds and an increase of 6.3 pounds in three days. There was no documentation evidence the provider was notified.A dietician progress note dated 04/15/2026 documented weights over the past month ranged 208.9-219.4 lbs. Fluid restriction, ace wraps, and Bumex (diuretic) continued per order.Review of daily weights in the treatment administration orders for April of 2026 revealed weights were not obtained on 04/04/2026, 04/06/2026, 04/07/2026, 04/08/2026, 04/09/2026, 04/12/2026, 04/13/2026, and on 04/16/2026. There was no documented evidence as to why Resident #8's weight was not obtained on these days and/or the provider was made aware the weights were not obtained.During an interview on 04/17/2026 at 10:38 AM, Certified Nursing Aide #9 stated they did not weigh Resident #8 and had not been told to do so.During an interview on 04/17/2026 at 10:52 AM, Licensed Practical Nurse #10 stated Resident #8 was weighed daily due to congestive heart failure and fluid retention. They stated they were not aware that Resident #8 had not been weighed multiple times in the months of February, March and April. They stated the team leader should have ensured daily weights were completed.During an interview on 04/20/2026 at 9:54 AM, Licensed Practical Nurse #2 Team Leader stated Resident #8 required daily weights due to congestive heart failure. They stated the rationale was to identify fluid overload, exacerbation of congestive heart failure, pleural edema (fluid that accumulates in the lung tissues), and avoidable hospitalization. They stated they were on vacation during the missed weights in April and did not notice they were not completed. They verified 10 days in the treatment administration record for February and 11 days for March that Resident #8 was not weighed as ordered. Additionally, they verified the provider was not notified of parameters ordered for weight monitoring on 02/13/2026 and 03/14/2026 and should have been.During an interview on 04/20/2026 at 10:25 AM, Certified Nursing Aide #1 stated they had not weighed Resident #8. They stated they usually weighed the resident after lunch and would notify the nurse and place the weight in the weight book. They stated they had worked with this resident every day and sometimes would jot their weight down on a scrap piece of paper and give it to the nurse. They stated Resident #8 never refused weights and did not know why daily weights were important.During an interview on 04/20/2026 at 10:29 AM, Licensed Practical Nurse #2 Team Leader stated it was their responsibility to ensure daily weights were completed.During an interview on 04/20/2026 at 11:19 AM, the Registered Dietician stated their role was to monitor weight changes in residents with congestive heart failure. They stated Resident #8 was expected to be weighed daily and missed weights could delay identification of fluid overload. They stated they meet monthly with the provider to review weights, and the provider would decide if orders needed to be adjusted. They were unable to provide a daily log sheet for Resident #8 but provided weekly and monthly weight sheets for Resident #8. They stated if they needed their daily weight they would look in their electronic medical record and print them out. They stated they did review weights daily and thought the weights were missed due to resident refusal.During an interview on 04/20/2026 at 11:47 AM, the Director of Nursing stated all staff should have known Resident #8 required daily weights. They stated there was a system in place for missed orders and nursing managers should have populated a missed medication/treatment report. They stated missed weights could inhibit identification of fluid overload and congestive heart failure exacerbation. They stated staff were expected to follow physician orders, document, follow parameters, and contact the provider as needed. They stated if the weights were not completed daily, for consecutive days of three (3) or more days, they would expect the provider to be notified by the unit manager or the team leader.During an interview on 04/20/2026 at 1:16 PM, Nurse Practitioner #1 stated Resident #8 had multiple comorbidities that required to be carefully monitored, including daily weights, shortness of breath, and swelling. They stated missed weights could impair clinical judgment regarding fluid status and overall medication management but would also rely on other symptoms. They considered Resident #8 at moderate risk for congestive heart failure exacerbation.During an interview on 04/21/2026 at 9:41 AM, the Medical Director stated Resident #8 had been stable but daily weights were an important component to monitor congestive heart failure. They stated they expected staff to monitor weights daily and follow parameters for notifying the physician.2.Resident #32 had diagnosis that included dementia, protein-calorie malnutrition, and reduced mobility. The Minimum Data Set, dated [DATE] documented Resident #32 had severe cognitive impairment, understood, and usually understands others. Resident #32 required substantial/maximal assistance with personal hygiene, bathing, and dressing.The current comprehensive care plan dated 04/01/2026 documented to monitor skin changes daily during care, skin and feet check with daily care, document weekly on shower day.The Order Summary Report printed 04/20/2026 documented an active order that was started on 07/15/2025 for bath/shower every evening shift every Tuesday with complete Skin Inspection; clean/trim nails.Review of the Treatment Administration Record dated 04/1/2026 - 04/30/2026, documented order for 3-11 bath/shower every evening shift every Tuesday, complete Skin Inspection that was signed off as completed by Licensed Practical Nurse #7 on 04/14/2026.Quality Improvement Skin Inspection for Resident #32 dated 04/13/2026 documented no skin issues.During an observation on 04/14/2026 at 12:46 PM, Resident #32 was sitting in their wheelchair in the dining room eating lunch and the resident had an approximate three (3) inch long, multicolored bruise over their entire left elbow. Resident #32 was unable to state what happened.During a telephone interview on 04/15/2026 at 11:00 AM, Resident #32's emergency contact stated they were not aware of any recent injuries or bruises to Resident #32.During an observation on 04/16/2026 at 11:05 AM, Resident #32 was sitting in their wheelchair with left arm along their left side and holding their left elbow with their right hand. Resident #32 was wearing long sleeves and bruise was unable to visualize at that time.During an interview and observation on 04/16/2026 at 4:28 PM-4:35 PM, Certified Nurse Aide #4, who was assigned to Resident #32 during day shift stated they provided morning care to Resident #32 and got them out of bed that morning. They stated they had not observed any bruise recently to Resident #32 skin. Resident #32 was lying in bed and upon Certified Nurse Aide #4 pushing left sleeve up on shirt, bruising to left elbow was present. Certified Nurse Aide #4 stated the bruising to Resident #32's left elbow looked recent, and they should have noticed it during hands on care but had overlooked it.During an interview on 04/16/2026 at 4:37 PM, Licensed Practical Nurse #7 stated nursing staff should be inspecting residents' skin on their shower days and during routine care.During a telephone interview on 04/17/2026 at 12:30 PM, Certified Nurse Aide #5 stated they gave Resident #32 their shower on Tuesday, 04/14/26 during the evening shift. They stated the date 04/13/26 on the skin inspection sheet was incorrect. Certified Nurse Aide #5 stated they did not recall seeing any bruises on Resident #32's left elbow. They stated if they had seen any bruising they would have reported it to the nurse immediately.During a follow up interview on 04/17/2026 at 1:49 PM, Licensed Practical Nurse #7 stated they recalled completing the skin check on Resident #32 on Tuesday, 04/14/2026, while they were in the shower room. They stated the lighting in the shower room was poor and if Resident #32's bruise to their left elbow was there, they must have missed it. Licensed Practical Nurse #7 stated they should have noticed the bruising because they were checking skin head to toe.During an interview on 04/17/2026 at 3:50 PM, Licensed Practical Nurse #4 Unit Coordinator stated skin inspections were expected to be completed on the resident's shower day, and any issues should be brought to them or a nursing supervisor's attention as soon as possible. They stated they expected the nurse to complete the skin inspection to be visualizing the resident's skin to identify any skin issues, including bruises.During an interview on 04/17/2026 at 4:41 PM, the Director of Nursing stated their expectation was that a head-to-toe assessment for any skin disruptions (rash, bruising, skin tears) was completed during the resident's weekly skin inspection to ensure skin integrity was being maintained. They stated resident skin should also be checked during hands on care as well. The Director of Nursing stated Resident #32's bruise to their left elbow should have been observed during their skin inspection on 04/14/26, if it was present, and did not know why it was not.3.Resident #58 had diagnoses that included diabetes mellitus, dementia, and osteoarthritis (a condition that affects your joints). The Minimum Data Set, dated [DATE] documented Resident #58 was cognitively intact, was understood and understood by others.The current comprehensive care plan dated 03/20/2026 documented Resident #58 was independent for decision making skills. Interventions included but not limited to able to self-administer medications as ordered/stored at bedside. The comprehensive care plan was not revised until 04/20/2026 to specifically include Tylenol may be self-administered as ordered and stored at bedside.The Nursing Self Medication Administration Data Collection Tool dated 04/09/2026 documented the tool would be reviewed by the Interdisciplinary Team to determine if self-administration was clinically appropriate and would document their decision on the resident's care plan. If applicable, there would be a written order from the attending physician for the specific medications which could be self-administered. Further review of the Data Collection Tool documented Resident #58 was deemed safe for medication self-administration and the specified medications included inhalers and artificial tears (eye drops used for dry eyes).During intermittent observations on 04/14/2026 at 9:33 AM, 04/15/2026 at 9:31AM, and 04/20/2026 at 9:04 AM, Resident #58 was observed to have a bottle of Extra Strength Tylenol 500 milligram tablets located on their bedside table.During an observation and interview on 04/17/2026 at 8:50 AM, Resident #58 was observed in their room, and the same bottle Extra Strength Tylenol was observed on the resident's bedside table. Resident #58 stated their family had supplied the medication and they took two (2) pills every night for pain. Resident #58 stated the nursing staff was aware they had their own bottle of Tylenol and that they took the medication at night. Resident #58 stated it was documented on their care plan to have the medication at bedside.The Order Review Report dated 04/01/2026 - 04/30/2026 revealed a physician order for Acetaminophen (Tylenol) Tablet 500 milligrams, give two (2) tablets by mouth every eight (8) hours as needed for pain. The order start date was documented as 03/20/2026 and did not indicate Resident #58 may self-administer or keep the medication at bedside.Review of the Medication Administration Record dated 04/1/2026- 04/30/2026 revealed there was no documented evidence that Resident #58 had the ability to self-administer Tylenol prior to 04/20/2026 and there were no PRN (as needed) doses of Tylenol signed as administered by the nursing staff.During an interview on 04/20/2026 at 9:13 AM, Licensed Practical Nurse #8 stated residents that were allowed to self-administer medications would have a physician's order in the electronic medical record. Licensed Practical Nurse #8 reviewed Resident #58's medication administration record and stated they did not have a current order to self-administer or keep any medication at bedside. They stated Resident #58 was alert and oriented and believed they used to have an order to self-administer their inhalers and Tylenol in the past but did not have a current order. They stated they were not aware Resident #58 had a bottle of Tylenol on their bedside table and would notify their Unit Coordinator because there needed to be an order.During an interview on 04/20/2026 at 9:24 AM, Licensed Practical Nurse #4 Unit Coordinator stated if a resident wanted to self-administer a medication, they would need to be evaluated for their knowledge of the medication and if they could safely administer a medication. They stated if the evaluation determined a resident could self-administer medications it would be documented on their care plan and did not need a physician's order. Licensed Practical Nurse #4 Unit Coordinator stated Resident #58 was care planned to self-administer and store medications at bedside. They stated all questions on the Self Medication Administration Data Collection Tool completed on 04/09/2026 for Resident #58 were answered as yes which indicated the resident was able to safely self-administer medications and could keep medication bottles at the bedside.During an interview on 04/20/2026 at 9:43 AM, the Medical Director stated they would expect to be notified by the nursing staff if a resident wanted to self-administer medications. They stated a resident would need to have an assessment completed prior to allowing them to self-administer medication to determine if self-administration was safe and any over-the counter medications would need to be stored in a locked box in their room. The Medical Director stated there needed to be a physician's order for residents to self-administer any medication including eye drops, inhalers, and Tylenol. They stated if a resident had their own supply of Tylenol at bedside, they would expect the nurses to educate the resident to inform staff when the medication was taken and document the dose that was self-administered. They stated the nurses would need to ensure residents were not exceeding the maximum dose of three (3) grams of Tylenol in 24 hours.During an interview on 04/20/2026 at 11:17 AM, the Director of Nursing stated when a resident expressed the desire to self-administer medication, a self-medication administration evaluation tool was completed by the nursing team. They stated the evaluation was geared to medications being stored in a resident's room, their ability to open bottles and to safely administer the medication. The Director of Nursing stated there would need to be a physician order obtained for the medication that was to be self-administered, the order would indicate it was the residents' own supply and may be self-administered. They stated a self-medication evaluation tool had been completed for Resident #58 and indicated they were able to self-administer and store medications at bedside. The Director of Nursing stated Resident #58 needed to have a physician order in place to have their own supply of Tylenol stored at bedside and did not. They also stated there were no active physician orders to self-administer any medications. The Director of Nursing stated Resident #58's Tylenol order needed to be updated to indicate may self-administer, additionally they would expect the nurses to verify and document when Resident #58 self-administered medication to know how much was being consumed.During an interview on 04/21/2026 at 11:18 AM, the Administrator stated residents who were deemed appropriate to self-administer medications would be able to do so to promote a homelike environment. They stated Resident #58 was evaluated and deemed appropriate to self-administer medications, however the nursing staff should have obtained a physician order to self-administer Tylenol. The Administrator stated it was expected that whenever staff found medications in a resident room, they would notify the unit coordinator to ensure an evaluation was completed, the care plan was updated, and that a physician order was obtained.10 New York Codes, Rules, and Regulations 415.12

Based on record review and interviews conducted during the Standard survey completed on 6/28/24, the facility did not ensure that the facility's infection prevention and control program included antibiotic use protocols and a system to monitor antibiotic use for one (Resident #12) of one resident reviewed. Specifically, Resident #12 received prophylactic Rifampin and Bactrim (antibiotics) since 10/18/22 and there was no ongoing monitoring by the Antibiotic Stewardship Program including laboratory tests, communication, or appointments with the Infectious Disease Physician. The finding is: Review of the policy and procedure titled Antibiotic Stewardship Program dated 5/2017, documented that the antibiotic stewardship program promotes the appropriate use of antimicrobials, improves patient outcomes, reduces microbial resistance, and decrease the spread of infections caused by multidrug-resistant organisms. The goal of antibiotic stewardship is to optimize the treatment of infections and clinical outcomes while minimizing unintended consequences of antibiotic use. The facility has a quality assessment and assurance committee that will review the antibiotic and resistance data. The Administrator, Medical Director, Director of Nursing Services, and Consultant Pharmacist are responsible for antibiotic stewardship in the facility. The Consultant Pharmacist reviews every antibiotic that is prescribed in the facility under the Drug Regimen Review and will report to the quality assessment and assurance committee on antibiotic use, agents, dose, and duration of use. Resident #12 was admitted with diagnoses including peripheral neuropathy (disorder affecting the nervous system), intraspinal abscess (swelling, inflammation, and collection of infected material in or around the spinal cord), and glaucoma (progressive eye disease that can cause vision loss). Review of the Minimum Data Set (a resident assessment tool) dated 4/16/24 documented Resident #12 was cognitively intact and received antibiotics. The comprehensive care plan dated 4/23/24 documented Resident #12 had a risk for infection related to long term prophylactic antibiotic use for a history of a paraspinal abscess (infection around the spinal cord). Interventions included to monitor for signs and symptoms of infection and administer antibiotics per physician orders. Infectious disease consults and recommendations were not included in the planned interventions. Review of the infectious disease consult dated 5/18/23 documented that Resident #12 had been tolerating chronic suppressive antibiotics since 4/2022 for an abscess in the epidural space of thoracic (middle section of spine) spine. The Infectious Disease Physician recommended continued treatment with Bactrim and Rifampin for indefinite therapy. Blood work that was requested to be done at three-month intervals was not done and was reinforced to be done as soon as possible. It would not be unreasonable to stop the Rifampin after 18-24 month use if no toxicity was noted on blood work. The plan was discussed with Licensed Practical Nurse #3, Unit Manager. Review of a handwritten Physician Verbal Telephone Orders dated 5/18/23 at 3:00 PM, documented by Licensed Practical Nurse #3, Unit Manager, revealed a physician's order for an erythrocyte sedimentation rate (blood test to measure inflammation in the body), c-reactive protein (blood test to identify inflammation), complete blood count (blood test to diagnose and monitor diseases), basic metabolic panel (blood test to monitor chemical balance and metabolism) in the morning, and every 3 months. Review of the infectious disease consult dated 7/20/23 documented continued surveillance of laboratory tests specifically, complete blood count, comprehensive metabolic panel, sedimentation rate, and c-reactive protein were to be obtained every 3 months. The infectious disease consult documented that the plan was discussed with Licensed Practical Nurse #3, Unit Manager. The next follow up appointment would be in 6 months. There were no additional infectious disease consults after 7/20/23. Review of the Order Review Report printed by the facility on 6/27/24, documented a physician's order with start date of 10/18/22 for Rifampin Capsule 300 milligrams give one capsule by mouth every twelve hours and Sulfamethoxazole-Trimethoprim (Bactrim) tablet 800-160 milligrams give one tablet by mouth every twelve hours for an intraspinal abscess. There was no documented physician's order for the six month follow up appointment with the infectious disease provider, erythrocyte sedimentation rate, c-reactive protein, complete blood count, basic metabolic panel every 3 months. Review of the provider's Medical Visit Notes from 7/21/23 through 6/18/24 documented Resident #12 continued Rifampin and Bactrim prophylaxis per infectious disease recommendations. There was no documentation for lab monitoring related to antibiotic use. Review of Resident #12's medical record including laboratory reports and nursing progress notes from 11/1/23 through 6/19/24 revealed no documentation that the recommended labs including a c-reactive protein, and erythrocyte sedimentation rate were drawn every three months and communicated to the infectious disease provider or that the resident was seen by the Infectious Disease Physician. Review of the monthly Pharmacy Drug Regimen Review dated 7/2023 through 6/2024 documented no irregularities or recommendations made for continued antibiotic therapy. Review of the Infection and Antibiotic Tracking Tool dated April 2024 to June 2024 provided by the facility, documented Resident #12 was on prophylactic antibiotics per infectious disease with an onset date of 10/18/22 for a skin and soft tissue infection. The white blood cell count column was blank and there were no documentation labs were monitored or communicated with the infectious disease provider. During a telephone interview on 6/26/24 at 3:24 PM, the Medical Assistant for the Infectious Disease Physician stated Resident #12 was seen last on 7/20/23. The last documented complete blood count, comprehensive metabolic profile, c-reactive protein, erythrocyte sedimentation rate results received from the facility were from 8/25/23. There were no further lab results communicated to their office as recommended. Resident #12 had an upcoming appointment in July 2024 and should have been seen in January 2024 for a six month follow up and was unaware why the appointment never occurred. During a telephone interview on 6/26/24 at 3:46 PM, the Infectious Disease Physician stated Resident #12 received Bactrim and Rifampin for history of methicillin-resistant staphylococcus aureus, bacteremia, discitis (inflammation between the discs of the spine), and osteomyelitis (bone infection). Frequent blood chemistries and infection markers monitored for presence of infection and antibiotic resistance. Follow up appointments were to be scheduled by the facility every 6 months to re-evaluate the need of the continued long-term use of the medications. Lab tests were not completed every three months as they recommended. During an interview on 6/27/24 at 12:55 PM, Licensed Practical Nurse #3, Unit Manager stated they reviewed the infectious disease consults and attended tele med visits with Resident #12 and should have informed the Infection Preventionist of the recommendations for tracking purposes. They were responsible to ensure labs and appointments were completed, documented, and communicated to infectious disease. The recommended labs were not completed since August 2023. Resident #12 should have had a complete blood count, comprehensive metabolic panel, c-reactive protein, and erythrocyte sedimentation rate drawn in November 2023, February 2024, and April 2024. There was no documented evidence the blood work was completed and faxed to infectious disease. Licensed Practical Nurse #3, Unit Manager stated they were not involved in the facility antibiotic stewardship program and that was something the Director of Nursing/Infection Preventionist should monitor. During an interview on 6/27/24 at 3:41 PM, the Director of Nursing/Infection Preventionist stated Resident #12's antibiotics were documented on the facility infection and antibiotic tracking tool. Criteria, trends, and stop dates were discussed during monthly meetings. Resident #12 was stable from a medical standpoint, was followed by infectious disease and therefore, not discussed at their monthly meetings. The Director of Nursing/Infection Preventionist stated they were not aware that labs or scheduled appointments with infectious disease were recommended for Resident #12. Unit Managers reviewed recommendations with providers and documented changes in the medical record. A physician's order would be written, and they would have expected some kind of communication from Licensed Practical Nurse #3 Unit Manager. Standing lab orders for Resident #12 should have been documented in the lab book on the unit and the unit clerk should have made sure appointments were scheduled. The blood work should have been drawn, documented, and faxed to infectious disease for effective monitoring. During a telephone interview on 6/27/24 at 4:16 PM, the Pharmacy Consultant stated Resident #12 was on long term antibiotic therapy for discitis. They reviewed provider notes, diagnostics, consults, and physician orders during the monthly regimen review. The Pharmacy Consultant was unaware of the infectious disease consult dated 7/20/23 and the recommended labs for Resident #12. The Pharmacy Consultant stated effective antibiotic monitoring included review of labs and continued communication with infectious disease. During an interview on 6/28/24 at 12:58 PM, the Administrator stated they expected the unit manager to document a note in the medical record about the infectious disease recommendations for labs and appointments. The Administrator stated unit managers were responsible to follow up with consult recommendations, update providers and follow the orders once approved. The Administrator stated if the resident had been stable, they would not necessarily have been reviewed during the monthly antibiotic stewardship meetings. They would have just been monitored for a change in status which included monitoring for sepsis, pain, decline in status and lab work if ordered. During a telephone interview on 6/28/24 at 1:30 PM, the Medical Director stated they participated in the antibiotic stewardship program in the facility which were reviewed during quality assurance meetings. They did not review Resident #12. The Medical Director stated prophylactic antibiotics were tracked under the antibiotic stewardship program and expected recommendations of infectious disease be followed when approved by the provider. This ensured for effective monitoring. 10 NYCRR 415.12(l)(1)

Based on observation, interview and record review conducted during a Standard survey completed on 6/28/24, the facility did not ensure that a resident is free from abuse, neglect or exploitation for one (Resident #71) of five residents reviewed for abuse and neglect. Specifically, a Certified Nurse Aide did not follow Resident #71's care plan when they transferred the resident using a mechanical lift by themselves and the resident sustained an injury to their left lower leg. The finding is: The policy and procedure titled Abuse Prohibition revised on 2/2023, documented that residents have the right to be free from verbal, sexual, physical, mental abuse, mistreatment, neglect, involuntary seclusion, misappropriation of property, and exploitation. The policy and procedure titled Facility Incident, Abuse Investigation and Reporting dated 6/7/23 documented neglect was defined as the failure of the facility or its employees to provide goods and services to a resident that are necessary to avoid physical harm or pain. Resident #71 was admitted to the facility with diagnoses of stroke and hemiplegia (one sided paralysis caused by a brain or spinal cord injury). Review of the Minimum Data Set (a resident assessment tool) dated 4/9/24 documented that the resident was cognitively intact, understood by others, understands others, and was dependent on others for transfers. Review of Resident #71's comprehensive care plan dated 4/16/24 documented that the resident had issues related to transfer due to limited mobility, activity intolerance, limited range of motion, and cerebrovascular accident (stroke). The comprehensive care plan documented that Resident #71 required an assist of two staff members using a sit to stand lift (allows resident to go from a seated position to a standing position during transfers). Review of a Physical Therapy evaluation dated 4/3/24 documented that Resident #71 required a minimum assistance of two staff members with a manual sit to stand lift for transfers between their wheelchair and their bed. Review of a visual/beside Kardex report (a tool used by staff to guide care) dated 4/15/24 for Resident #71 documented that the resident required an assist of two staff members for transfers between the resident's wheelchair and the resident's bed. Review of a nursing progress note dated 5/13/24 at 9:37 PM, documented that a Certified Nurse Aide noticed an area on the back of Resident #71's left calf. The resident stated that Certified Nurse Aide #1 bumped their leg on the bed and that was the cause. The area was assessed and found to be painful to the touch. Review of an incident report dated 5/14/24 at 10:38 AM, documented that the resident received an injury to their lower left leg while they were transferred into bed. The resident description included that the back of their leg hit the bed rail and at first it didn't hurt but the next night it was killing me. Review of a radiology report dated 5/14/24 at 5:47 PM, revealed a vein scan was done due to swelling and pain, findings included a left lower extremity (leg) hematoma (collection of blood under the skin). Review of a Coach and Counseling session dated 5/14/24, signed by Certified Nurse Aide #1, documented that Certified Nurse Aide #1 did not follow the care plan for Resident #71 and used the lift to transfer the resident with one assist. Certified Nurse Aide #1 documented that they were one of the Certified Nurse Aides on the unit and going forward they would get someone to help them with transfers to avoid anything going wrong. During an interview on 6/24/24 at 11:53 AM, Resident #71 stated that they were transferred from their wheelchair to bed and the Certified Nurse Aide hit the back of their leg on the bed. They stated that Certified Nurse Aide #1 was by themselves when they were transferred with the manual sit to stand lift. Resident #71 stated that they had to have Dopplers (a diagnostic test used to check the circulation of the large veins of the leg) to make sure they didn't have a blood clot. An observation during this interview revealed the resident had a slight discoloration on the back of their left calf. During an interview on 6/26/24 at 8:43 AM, Certified Nurse Aide #1 stated that they put the resident to bed by themselves and knew the resident needed a two assist. They stated that there was no one else to help them to put Resident #71 to bed. They stated putting the resident to bed by themselves that it was not following the care plan. During an interview on 6/26/24 at 10:01 AM, Licensed Practical Nurse #1 stated that Certified Nurse Aide #1 broke the care plan by transferring the resident by themselves. Licensed Practical Nurse #1 stated that if the care plan says there needed to be two people to assist a transfer, then there should be two people to assist in the transfer. They stated that they do not recall anyone asking them to help transfer Resident #71 on that night. Licensed Practical Nurse #1 stated that if the care plan wasn't followed then that would be neglect. During an interview on 6/26/24 at 11:28 AM, Licensed Practical Nurse Unit Manager #2 stated that staff not following the care plan and the resident was hurt, would be considered neglect. During an interview on 6/26/24 at 12:38 PM, Director of Nursing stated that they expected their staff to follow the care plan of a resident. They stated that they expected their staff to use ask for help when using a manual sit to stand lift for a resident. The Director of Nursing stated that it would be neglect if the staff member didn't ask for help with a transfer if the care plan required two staff members for a transfer. During an interview on 6/26/24 at 12:49 PM, the Administrator stated that they expected the Certified Nurse Aide to follow the care plan. 10NYCRR 415.4(b)(1)(i)

Based on observation, interview, and record review conducted during a Standard survey completed on 6/28/24, the facility did not ensure a resident was assessed by the interdisciplinary team to determine a resident's ability to safely administer their own medications if clinically appropriate for one (Resident #12) of one resident reviewed. Specifically, Resident #12 was observed with medications in their room and self-administered those medications without being evaluated as to whether they could safely do so. The findings are: The policy and procedure titled Self-Administration of Medications revised on 11/23/21 documented that each resident is given a detailed explanation of the medications that they may self-administer, the reason for the medication, what to expect, and the possible side effects within their cognitive ability to understand. Staff re-evaluates the resident's knowledge by having the resident report their understanding of the information presented to them. The self-administration of medication is monitored by the Team Leader. Continued approval of the self -administration of medication by the resident is dependent on the resident's compliance with physician orders and facility procedures. Resident #12 diagnoses which included peripheral neuropathy (disorder affecting the nervous system), intraspinal abscess (swelling, inflammation, and collection of infected material in or around the spinal cord), and glaucoma (progressive eye disease that can cause vision loss). The Minimum Data Set (MDS- a resident assessment) dated 4/16/24 documented Resident #12 was understood, understands and was cognitively intact. The Comprehensive Care Plan with last review date of 4/23/24, documented for nursing to administer ophthalmic (having to do with the eye) medication per physician's order. Documented in the section titled decision making stated to store medications at bedside for self-administration. During an interview on 6/24/24 at 11:11 AM, Resident #12 stated they self-administered their own eye drops for glaucoma. During observation of Resident #12's room and interview on 6/26/24 at 10:52 AM, revealed one bottle of Latanoprost 0.005% (used to treat glaucoma), one bottle of Dorzolamide HCL 2% (used to treat glaucoma), and one bottle of Refresh Tears 0.5% (used to treat dry eyes) stored in a clear zip lock bag taped onto the over the bed table. Resident #12 stated they administered their own eyedrops daily. Review of the physician Order Review Report dated 6/27/24, documented Latanoprost Ophthalmic Solution 0.005% instill 1 drop in both eyes at bedtime for Glaucoma, Dorzolamide HCL Ophthalmic Solution 2% instill 1 drop in both eyes three times a day and Refresh Tears Ophthalmic Solution 0.5% instill 1 drop both eyes as needed for dry eyes every day. There was no active physician's order for Resident #12 to self-administer medications and that medications were to be left at the bedside. The Medication Administration Record dated 6/2024 documented Resident #12 had received Latanoprost Ophthalmic Solution 0.005%, Dorzolamide HCL Ophthalmic Solution 2%, and Refresh Tears Ophthalmic Solution 0.5%. Medications were initialed as being administered by nursing staff. There was no documented evidence that Resident #12 could self-administer their eye drops. Review of the electronic medical record (EMR) dated 6/1/24 through 6/26/24 revealed there was no documented evidence Resident #12 was assessed by the interdisciplinary team to self-administer medications. There was no documented evidence there was a Self-Medication Administration Data Collection Tool completed per the facility process. During medication observation and interview on 6/27/24 at 9:45 AM, Licensed Practical Nurse #4 offered Resident #12 their eye drops. Resident #12 stated they administered their own eyedrops and had not taken them yet. Licensed Practical Nurse #4 stated there should have been a physician's order in the electronic medication administration record for self-administration. During an interview on 6/27/24 at 11:20 AM, Licensed Practical Nurse Unit Manager #3 stated there was no assessment tool completed for Resident #12 to self-administer the eyedrops and there should have been. Licensed Practical Nurse Unit Manager #3 stated self-administration should be documented on the comprehensive care plan and there should be a physician's order in place. During an interview on 6/27/24 at 4:16 PM, Pharmacy Consultant stated there was a policy and procedure for self-administration of medications. An evaluation was expected and would determine if the resident had the ability to self-administer medications. During an interview on 6/28/24 at 12:49 PM, the Director of Nursing stated Resident #12 should not have been administering the eyedrops without a Self-Medication Administration Data Collection Tool and without a physician's order. When a resident expressed the desire to self-administer medication including eye drops, the nurse, or unit manager should complete a [NAME] (user defined evaluation) which was then signed by a registered nurse. The assessment would be shared with the provider and a physician's order would be written. The Director of Nursing stated self-administration assessments were reviewed during the quarterly care plan meetings with the interdisciplinary team and as needed if there was a change in condition with the resident. 415.3 (e)(1)(vi)

Based on observation, record review, and interview conducted during a Standard survey started on 9/15/22 and completed on 9/21/22, the facility did not provide food and drink that was at a safe and appetizing temperature. Specifically, two (A wing, B wing) of four resident units reviewed for food temperatures during meals had issues involving food items that were not served at safe and appetizing temperatures. Residents #5, 13, 110, 138, and 467 were involved. The findings are: The facility policy and procedure (P&P) title Food Preparation, Service, and Distribution dated 8/17 documented the facility will assure safe and sanitary food preparation, holding, transport and distribution to prevent foodborne illness. Alternate meal preparation and service areas may include steam tables, where hot prepared foods are held and served, and chilled areas where cold foods are held and served. The facility will avoid the following potential risks to reduce foodborne illness: will not hold foods in the danger zone (temperatures above 41 degrees ( ) Fahrenheit (F) and less than 135 F). Staff will serve hot foods hot and cold foods cold in accordance with resident preference. a. During an interview on 9/15/22 at 9:57 AM, Resident #5 stated the food was always cold since the prior Food Service Director (FSD) left. During an interview on 9/15/22 at 10:16 AM, Resident #13 stated the meals were always late and cold. During an interview on 9/15/22 at 12:24 PM, Resident #138 stated the food was always cold. During an interview on 9/16/22 at 11:18 AM, Resident #110 stated the food was cold on most days and sometimes the vegetables (carrots) were very hard and not cooked. During an observation on 9/20/22 at 12:44 PM, all lunch meals were served to the residents on the A wing. The test tray temperatures were taken by Dietary Aide #1 using the facility's thermometer. The temperatures obtained were as follows: -Beef mushroom steak measured 98 F and tasted lukewarm -Brussel sprouts measured 104 F and tasted lukewarm -Buttered noodles measured 86 F and tasted lukewarm During an interview on 9/20/22 at 12:47 PM, the Dietary Aide #1 stated the hot food should be 135 F and cold food should be 35-45 F. b. During an interview on 9/20/22 at 12:56 PM, Resident #138 had their lunch meal in front of them and stated the food wasn't warm and they didn't like the Brussel sprouts. Resident #138's visitor stated the plates just sit out in the dining room and don't get passed out right away to the rooms. During an observation of the B wing lunch meal on 9/20/22 revealed lunch trays started to be passed from the servery at 12:07 PM. At 12:45 PM, Certified Nurse Aide (CNA) #3 was observed pre-pouring juice into plastic cups, placed covers on them and put all the cups into two plastic containers without ice. At 1:30 PM, CNA #3 placed three plates of food on a table in the dining area. CNA #3 was observed to place two of those plates on trays along with beverages and left the dining area. One plate remained on the table and had a meal ticket on top of it identifying the meal was for Resident #467. At 1:51 PM, CNA #3 arrived back in the dining area and placed Resident #467's plate on a tray with the pre-poured juice, coffee, and a mighty shake and walked down the hall to deliver it to the resident at 1:54 PM. At 1:57 PM, The Licensed Practical Nurse (LPN) #1 Clinical Instructor and CNA #3 were present when temperatures were obtained by the surveyor of Resident #467's meal using the facility's thermometer as follows: -Beef mushroom steak measured 96 F -Buttered noodles measured 84 F -[NAME] sprouts measured 88 F -Chilled pears measured 76 F -Apple juice measured 68 F -Coffee measured 110 F The LPN #1 Clinical Instructor and CNA #3 stated they didn't know what the temperature of the food should be when delivered to the resident and then delivered the tray to Resident #467 at 2:01 PM. During an interview on 9/20/22 at 2:10 PM, Resident #467 was in bed and had their lunch tray in front of them on their overbed table. The resident stated they had tasted the food; it was not warm enough and they didn't like it. The resident also stated the coffee wasn't hot, just warm and they didn't try the juice, but the cup felt cool. During an interview on 9/21/22 at 9:20 AM, with the Administrator present, the Registered Dietician (RD) stated cold foods should be served to residents less than 40 F and hot foods should be higher than 150 F. The RD stated CNA #3 should not have given Resident #467 the food; they should have brought it back to the servery to be refreshed. The RD stated the CNA needed education about what they should be doing because the food should be served as soon as possible once it has been plated from the servery staff. The Administrator stated on the subacute unit the CNAs were responsible to serve meals to their assigned group of residents and they needed to communicate when they needed help. During an interview on 9/21/22 at 10:52 AM, the FSD stated the food temperatures when served to a resident should be over 135 F for hot food and cold items should be below 41 F. The FSD stated CNA #3 should have gotten a different tray for Resident #467 and they shouldn't have been served food at those temperatures, because of the danger zone. 415.14 (d)(2)

Based on observation, interview, and record review conducted during the Standard survey started 9/15/22 and completed on 9/21/22, the facility did not ensure that a resident with an indwelling catheter (foley-tube inserted into the bladder to drain urine), received the appropriate care and services to prevent urinary tract infections (UTIs) to the extent possible for one (Resident #315) of three residents reviewed for urinary catheters. Specifically, issues involved the lack of appropriate urinary catheter care and the lack of maintaining infection control measures for a resident on transmission-based precautions (TBP) and a history of UTIs. The finding is: The facility policy and procedure (P&P) titled Incontinent Care dated 1/1/2000 documented the purpose was to prevent skin breakdown caused by bacteria from urine/feces and to avoid infections and odor. Explain procedure to resident and bring equipment to bedside. Place on a clean barrier. Wash hands and apply gloves. Remove brief, clothing and bed linen and place on soiled barrier. Place clean barrier under resident for incontinent care. Wet washcloth at sink with warm or fill and use basin. Apply soap or spray wet washcloth with Peri wash. Wash perineum, anus, buttocks, abdomen, hips and thighs. Rinse if using soap. Pat dry with a towel. Remove gloves and wash hands. The P&P titled Perineal Care dated 1/1/2000 documented perineal care is provided to clean the perineum and provide comfort. Wash hands before and after perineal care. Wear gloves. For residents with foley catheters; cleanse urethral meatus around the tubing, washing away from the body and down the catheter about 3-4 inches thoroughly removing clots, secretions and drainage. The P&P titled Policy on Hand Washing dated 1/1/2000 documented proper handwashing technique is used for the prevention of transmission of infectious diseases. All personnel working in the long-term care setting are required to wash their hands when: hands are visibly soiled; before and after direct resident contact with resident skin, before and after assisting a resident with toileting; after handling soiled or used linens, dressings, bedpans, catheters and urinal, and after removing gloves. 1. Resident #315 was readmitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 7/28/22 documented Resident #315 had intact cognition and an indwelling catheter. The Comprehensive Care Plan (CCP) dated 7/21/22 documented Resident #315 was incontinent of stool and had a suprapubic catheter. Interventions included to provide incontinent care every 4 hours and as needed, urinary catheter care every shift and to report signs and symptoms of infection. The current Visual/Bedside Kardex Report a guide used by staff to provide care) dated 9/19/22, documented urinary catheter care every shift and incontinent care every 4 hours and as needed. The Hospital Discharge Summary dated 9/12/22 documented positive C. Diff infection, advanced MS with [CONDITION(S)] bladder, and suprapubic catheter with history of pseudomonas (bacteria, [CONDITION(S)]). The 24-Hour Nursing Services Supervisor Report dated 9/12/22 documented Resident #315 was on contact precautions for C-Diff. The Medical Visit Note dated 9/16/22 documented Resident #315 was sent to the hospital on 9/6/22 for loose stools and rectal bleeding. Resident #315's stool was C-Diff positive, therefore seen by Infectious Disease (ID) and started on antibiotics. The note further documented Resident #315 had known history of [CONDITION(S)]. The Order Summary Report dated 9/19/22 documented an active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The order had a start date of 9/12/22 and an end date of 9/20/22. During a continual observation on 9/19/22 at 11:37 AM, Certified Nurse Aide (CNA) #1 completed fecal incontinent care for Resident #315 in the presence of Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1. CNA #1 donned (put on) a gown, completed hand hygiene, gathered linens with water in a wash basin. CNA #1 placed the wash basin on a cluttered (with papers, magazines, cups) over the bed table without cleaning and providing a clean barrier. CNA#1 then positioned Resident #315 on their left side and removed a dry incontinence brief. Without providing a clean barrier under Resident #315, CNA #1 submerged the washcloth into the basin, rung the washcloth, and applied soap from a bottle onto the washcloth. CNA #1 placed the bottle of soap into their uniform pocket and washed the resident's rectum. The washcloth had a medium amount of brown smeared stool. CNA #1 then folded one corner of the washcloth and proceeded to wipe the resident's rectum. The washcloth had a medium amount of brown smeared stool and CNA #1 disposed the washcloth into the precaution bin. Wearing the same gloves CNA #1 submerged a clean washcloth into the basin and removed the bottle of soap from their uniform pocket, opened the cap on the soap, squeezed soap onto the clean washcloth, closed the cap, and placed the bottle of soap back into their uniform pocket. CNA #1 then proceeded to wipe Resident #315 rectum clean and then dried the resident with a towel. Without washing their hands and while wearing the same gloves to complete fecal incontinence care CNA #1 repositioned Resident #315 onto their back; they removed the bottle of soap from their uniform pocket, lathered a clean washcloth, recapped the bottle of soap and put the bottle into their pocket and completed suprapubic catheter care with the same water/wash basin used for fecal incontinent care. Still wearing the same gloves and without completing hand hygiene, CNA #1 placed a urine graduate (container to empty urine) on a barrier on the floor, opened the drainage spout and emptied the urine into the graduate. CNA #1 wiped the spout of the foley drainage bag with a dampened paper towel (with soapy water), then replaced the spout into the spout holder of the drainage bag. Then removed their gloves and completed hand hygiene. During an interview on 9/19/22 at 12:30 PM, CNA #1 stated Resident #315 was on transmission-based precautions for C-Diff. CNA #1 stated soap should be combined with the water in the basin, not kept in their pocket. CNA #1 stated they should have washed the resident from front to back (clean to dirty) to prevent the spread of microorganisms, removed their gloves, washed hands, and replaced the basin with fresh water after doing fecal incontinent care prior to catheter care to avoid contamination and reduced the spread of possible infection. CNA #1 stated a wet soapy paper towel was sufficient to clean the foley drainage spout. There were no alcohol wipes available. During an interview on 9/19/22 at 12:53 PM, RN #1 stated CNA #1 cross contaminated. CNAs were expected to add soap to the basin, cleanse from front to back (genital area to buttocks/rectal), and hand hygiene was expected after soiling which included fecal incontinence care. Alcohol wipes should be used to cleans the spout of the catheter bag to prevented bacteria from entering the foley catheter tube. Paper towels were unacceptable. During an interview on 9/19/22 at 2:51 PM, LPN #1 stated CNAs were expected to provide a clean barrier under residents, wash from clean to dirty, and perform handwashing including changing soiled gloves. When emptying foley catheters the spout should be wiped clean with alcohol wipes. During an interview on 9/21/22 at 11:06 AM, the Assistant Director of Nursing (ADON)/ Infection Preventionist (IP) stated staff were expected to be wash residents front to back during incontinent care. Residents were at risk for UTIs when cleaned inappropriately. Staff were expected to perform hand hygiene between glove changes and between dirty to clean. Cleansing soap should be put on a clean barrier and not kept in their pocket. Alcohol wipes were to be used to clean any openings to foley catheter bags. 415.12 (d)(1)

Based on observation, interview and record review conducted during the Standard survey started 9/15/22 and completed 9/21/22, the facility did not ensure each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #135) of three residents reviewed for falls. Specifically, Resident #135 had a history of falls with injury, was observed without anti-tippers on the front of their wheelchair as planned. The finding is: The facility policy and procedure (P&P) titled Accident/Incident Report Investigation and Prevention dated 4/2015 documented the facility provides an environment that is free from accident hazards and provides supervision and assistive devices to each resident to prevent avoidable accidents. It is the responsibility of licensed nursing professional to implement care plan changes to prevent repeat incidents. 1. Resident #135 had diagnoses including dementia, depression, and fracture of left tibia. The Minimum Data Set (MDS-a resident assessment tool) dated 5/29/22 documented Resident #135 was cognitively impaired and had one fall with major injury. The Kardex (guide used by staff to direct care) dated 8/30/22 documented Resident #135 was to have front anti-tippers on their wheelchair for safety. The comprehensive care plan, with a review date of 8/30/22 and identified as current by the Director of Nursing (DON), documented Resident #135 was at risk for falls and interventions included anti-tippers to the front of their wheelchair. The Accident/Incident Report dated 7/30/22 documented Resident #135 was reaching for their foot and slid forward onto floor and wheelchair pedals. An immediate care plan change was initiated for front anti-tippers to their wheelchair. During observation on 9/19/22 at 2:55 PM, Resident #135 was seated in a wheelchair in the hallway and was self-propelling by using the handrails at the nurse's station. The resident's wheelchair did not have front anti-tippers in place. Additional observation on 9/21/22 at 8:30 AM, Certified Nurse Aide (CNA) #2 placed the resident by the nurse's station and their wheelchair did not have front anti-tippers in place. During an interview on 9/21/22 at 8:54 AM, CNA #2 stated Resident #135 has had falls, they were not aware Resident #135 needed front anti-tippers on their wheelchair and didn't see it listed on the Kardex. During an interview on 9/21/22 at 8:59 AM, Licensed Practical Nurse (LPN) #4 stated the Resident #135 has had falls and safety interventions included not leaving them in their room alone and close supervision. The LPN #4 stated they did not know the resident needed anti-tippers on their wheelchair, and that they would be the one to make sure everything on the care plan was in place. During an interview on 9/21/22 at 11:48 AM, the Assistant Director of Nursing (ADON) stated after a fall the Unit Coordinator (UC) verified the care plan change and should verify that the intervention was in place. If the fall happened on the weekend, a supervisor would be responsible to ensure an intervention was put into place, then the UC should check that the anti-tippers were in place from then on. The ADON stated they had been covering Resident #135's unit the in regular UC's absence and that they would be responsible to check on that stuff. The ADON stated the CNAs and LPNs should be reading the resident's care plans to ensure everything was in place. The ADON stated if the anti-tippers were on the care plan, they should have been in place. During an interview on 9/21/22 at 1:33 PM, the DON stated the CNAs and nurses on the unit should ensure that all safety measures were in place for Resident #135 and that those staff members should be following the care plans. 415.12(h)(2)

Based on observation, interview, and record review completed during the Standard survey started 9/15/22 and completed 9/21/22, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #16) of three residents observed for pressure ulcers. Specifically, pressure ulcer wounds on the resident's bilateral heels were not cleansed with normal saline (NS- mixture of sodium chloride and water used for cleaning wounds) after removal of dressing, moderately soiled with serosanguineous (yellow, pink wound drainage) drainage, prior to application of clean dressing, as ordered by the physician. The finding is: The facility policy and procedure (P&P) titled Dressing- Clean Technique revised 12/07, documented a clean dressing technique is used to provide an appropriate and safe environment conducive to wound healing. The treatment is performed by licensed nurse following a physician order. The procedure documented to remove the soiled dressing and discard. Clean wound with NS solution or as specified by order. The facility P&P titled Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. Resident #16 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated 6/14/22 documented Resident #16 had moderate cognitive impairment. Additionally, it documented the resident had no unhealed pressure ulcers and two venous (caused by problems with blood flow in the veins) and arterial (caused by problems with blood flow in the arteries) ulcers. The comprehensive care plan, last reviewed 6/28/22, documented Resident #16 had impaired skin integrity related impaired bed mobility, recent hospital stay, and [NAME] (vascular ulcer) both heels. Interventions documented to administer treatment per MD (medical doctor) order. Review of the electronic medical record (EMR) physician Orders documented the following: -9/6/22 Collagen powder (forms a protective gel on wounds to aid in healing) daily (day shift). Cleanse with NS, pat dry, apply and cover with dry clean dressing (DCD). -4/7/22 Left (L) heel, every shift check for skin/wound dressing placement. Check for visible redness, swelling, or saturation. Follow up and document accordingly. -2/8/22 Right (R) heel every shift check for skin/wound dressing placement. Check for visible redness, swelling, or saturation. Follow up and document accordingly. Review of Wound Care Specialty Vascular Group notes dated 8/2/22 through 9/6/22, electronically signed by Wound Consultant NP, documented R and L heel pressure ulcers with recommendations to cleanse with wound wash/NS, apply treatment, cover with DCD. Review of Nursing Weekly Skin Status Documentation note dated 9/16/22, electronically signed and/or written by the Assistant Director of Nursing (ADON), documented the following measurements: -R heel ulcer measured 2.5 centimeters (cm) length (L) x 2.0 cm width (W) x 0.2 cm depth (D). -L heel ulcer measured 2.0 cm x 1.5 cm x 0.2 cm. The note documented moderate serosanguineous drainage from bilateral heel ulcers, no change in size or appearance noted and that Resident #16 was seen by Wound Consultant Nurse Practitioner (NP). Type of ulcer, for bilateral heels, was documented as vascular. During an observation on 9/20/22 at 10:32 AM, Resident #16 was sitting their wheelchair in their room. Wound treatment supplies were placed on residents over bed table located next to the resident. Licensed Practical Nurse (LPN) #6, and Registered Nurse (RN) #1 Clinical Instructor washed their hands, and applied clean gloves. LPN #6 removed the dressing from the resident's left (L) heel and discarded in trash. LPN #6 then removed the dressing from the resident's right (R) heel which was slightly adhered to the heel wound with a moderate amount of serosanguineous drainage noted when the dressing was removed. LPN #6 discarded the dressing, removed gloves, washed their hands, and applied new, clean, gloves. Resident #16 was able to keep L foot slightly elevated off the floor while RN #1 Clinical Instructor was assisting with supporting their R leg. LPN #6 opened an abdominal (ABD-large absorbent gauze pad) pad, then the collagen powder packet and sprinkled it on the ABD pad, placed it on the L heel ulcer followed by kerlix gauze wrap. LPN #6 repeated the process for the R heel wound. The bilateral heel ulcers were not cleansed with NS, as ordered by the physician, after removal of the old dressing, prior to application of the new treatment/collagen powder. During an interview on 9/20/22 at 10:43 AM, LPN #6 returned to the medication cart to electronically sign off the treatment. Upon reviewing the order LPN #6 stated I missed the NS, I forgot. I was just thinking about the collagen and forgot the NS. I was a little nervous. I usually take off the old dressing, cleanse with NS, pat it dry, then do the collagen. The wounds should be cleansed in between to remove any old drainage or debris from the old dressing being on. During an interview on 9/20/22 at 10:45 AM, RN #1 Clinical Instructor stated LPN #6 missed the NS, the cleansing of the wound. The expectation was that when taking off the old dressing you cleanse the ulcers with NS to remove any germs or anything harboring on the wound since the last time the treatment was done. During a telephone interview on 9/21/22 at 12:04 PM, Wound Consultant NP was reviewing Resident #16's electronic medical record and stated they had the wound classified as stage 2 pressure ulcers (partial thickness skin loss presenting as a shallow open ulcer). The expectation was that Resident #16's wound should be cleansed, after removal of the old dressing, because drainage will stick and could make the wound go necrotic (dead tissue). Overall, I would expect the wounds to be cleansed. During interview on 9/21/22 at 1:21 PM, the Assistant Director of Nursing/Infection Preventionist (ADON/IP) stated all wounds should be cleansed with NS to cleanse any bacterial or drainage from the wound prior to applying a new treatment. The ADON stated wounds were classified as vascular when there were diagnostic studies, venous or arterial dopplers (ultrasound that evaluates blood as it flows through blood vessels in the body's major arteries and veins), to confirm the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON stated they would review Resident #16 EMR and follow up. During a follow up interview on 9/21/22 at 1:46 PM, the ADON stated there were no doppler studies on resident #16 current admission to confirm the vascular diagnosis. That was my incorrect assumption. During interview on 9/21/22 at 1:59 PM, the Director of Nursing (DON) stated wounds should be cleansed with NS to clean any debris, bacteria or drainage from the wound, better assess the wound bed, and check for odor. The DON stated they would expect the MD order to be followed when administering a wound treatment. 415.12(c)(2)

Based on observation and interview conducted during a Standard survey started on 9/15/22 and completed on 9/21/22, it was determined that the facility did not ensure that they stored, prepared, distributed, and served food in accordance with professional standards for food service safety for one of one facility kitchen observed. Specifically, the hot rack utensil holder was soiled with a white debris layer covering it from the ceiling to where utensils were hung, an area of the kitchen floor was soiled with black, brown, green, and white debris. The findings are: A review of the facility policy and procedure (P&P) titled General Daily Cleaning dated 6/1/2000 documented the entire facility will be kept clean at all times. A review of the facility P&P titled Frequency of Types of Floor Care for Resilient Floors dated 6/1/200 documented that flooring will be in a clean state using the frequency in which specific types of floor care performed, and documented that dust mopping and damp mopping are to be done daily. 1. During an observation of the kitchen on 9/15/22 at 8:45 AM the floor in front of the food cooler, the kitchen entrance door, and the food preparation area was soiled with dried black, brown, green, and white debris. The debris was in an area 10 feet and 12 feet between the cooler and the food preparation area. Additionally, the hot rack utensil holder above a food preparation table had a layer of white debris from the ceiling attachments to the oval, metal ring that held ready for use cooking utensils. During an observation of pureed food prep on 9/20/22 at 10:15 AM the hot rack utensil holder was soiled with white debris on it from the ceiling attachments to the oval, metal ring that held the utensils. The hot rack utensil holder hung four feet above a food preparation table. During this observation, the kitchen floor was noted to have the same debris in the 10-foot area by 12-foot area between the food cooler, the kitchen entrance, and the food preparation area. During an interview on 9/20/22 at 10:28 AM, the Assistant Food Service Director (FSD) stated that maintenance was supposed to clean the hot rack utensil holder and that it needed to be cleaned. During an interview on 9/20/22 at 10:34 AM, the Corporate Project Manager/Interim Environmental Service Worker stated that maintenance was responsible for cleaning the rack. They also stated that housekeeping was responsible for high (areas that are closer to the ceiling) dusting but if a ladder is involved then maintenance does the cleaning. During an observation on 9/20/22 at 11:26 AM during tray line preparation of the lunch meal, a yellow blower (fan) was aimed at the floor which was wet. The floor between the food cooler, the entrance to the kitchen, and the food preparation area had black, brown, green, and white debris. During an in interview at the time of the observation the Food Service Director stated that one of the dietary staff had just mopped this area. During an interview on 9/20/22 at 11:41 AM, the Food Service Director stated that the floors could be cleaner. They also stated that mopping the floor will not bring up things that are stuck to the floor. They stated that the floors needed to be scrubbed to remove the stuck-on debris. 415.14(h) Part 14-1

Based on interview and record review, conducted during the Standard survey started on 9/15/22 and completed on 9/21/22, the facility did not ensure that each resident receives an assessment that accurately reflects their status at the time of the assessment for 4 (Residents #23, 73, 80, and 135) of four residents reviewed for accuracy of the Minimum Data Set, (MDS - a resident assessment tool). Specifically, the MDS assessments were inaccurately coded for anticoagulants (#23, #73), did not include the use of an antibiotic (#135), and did not indicate falls with injury (#80). The findings are, but not limited to the following: The facility policy and procedure (P&P) titled, Minimum Data Set (MDS), dated ,d+[DATE] documented that each resident's physical, functional, psychosocial, and nutritional status is assessed. The policy documented a significant error is defined as the resident's overall clinical status is not accurately represented (mis-coded); and the error has not been corrected via submission of a more recent assessment. 1. Resident #23 was admitted to the facility with high blood pressure ([CONDITION(S)]) and dementia. The MDS dated [DATE], Section N - Medications Received documented Resident #23 received anticoagulants (medication for preventing blood clotting/blood thinning medication) for 7 days. Review of the Active Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/20/22 at 11:42 AM, Registered Nurse (RN) #2 MDS Coordinator stated they coded aspirin as an anticoagulant because it was marked as a prophylaxis in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #135 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #135 was cognitively impaired and had one fall with major injury. Review of the quarterly MDSs dated 5/29/22 and 8/25/22 revealed section N-Medications did not include that the resident received antibiotics. Review of the Order Summary Report dated 8/17/22 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MARs dated 5/1/2022 to 8/30/22 revealed the resident received [MEDICATION(S)] 50 mg by mouth once daily starting on 5/12/22 through 8/31/22. During an interview on 9/21/22 at 1:46 PM, RN #2 MDS Coordinator stated they missed that Resident #135 received an antibiotic during the MDS look back periods. RN #2 MDS Coordinator stated they usually reviewed the orders and MARS when they completed the MDS, but they must not have seen the antibiotic listed. 3. Resident #80 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #80 was understood, sometimes understands and had severe cognitive impairments. The MDS documented Resident #80 had no falls since the prior assessment. The Comprehensive Care Plan (CCP) last reviewed 8/10/22 documented Resident #80 had prior fall in the last 90 days. The A (accident) & I (incident) Report dated 7/9/22 at 9:20 AM documented Resident #80 was found on the floor and sustained two lacerations to the left elbow. Additionally, the A&I Report dated 7/25/22 at 8:45 PM documented Resident #80 was found on floor with laceration to right inner thigh requiring emergency room visit for sutures. The MDS dated [DATE] section J1800 did not document Resident #80 had falls. Additionally, section J1900 did not include coding for falls with injury (except major). During an interview on 9/20/22 at 12:12 PM, RN #3 MDS Coordinator stated they were not aware Resident #80 had falls with injury (7/9 and 7/25). RN #3 MDS Coordinator stated they reviewed the documentation under the evaluation tab in the software program and did not see that the resident had falls. Additionally, RN #3 MDS Coordinator stated they should have captured (coded) the falls for 7/9/22 and 7/25/22. During an interview on 9/20/22 at 12:29 PM, the Administrator stated the MDS coordinators were responsible for completing the MDSs accurately. The Administrator stated that it was their expectation that the coordinators refer to the database and progress notes to determine if criteria was met for the MDS. 415.11 (B)

Based on observation, record review and interview conducted during the Standard survey completed on 10/2/18, the facility did not ensure that residents who require [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. One (Resident #120) of one resident reviewed for [MEDICAL TREATMENT] had an issue with the lack of ongoing communication and collaboration by nursing staff and medical staff of the [MEDICAL TREATMENT] center regarding [MEDICAL TREATMENT] care and services that resulted in a lack of monitoring the resident's shunt (bypass of blood directly from arteries to vein)/ fistula (abnormal connection or passageway) post [MEDICAL TREATMENT]. Specifically, a pressure dressing remained on the resident's shunt/ fistula site for greater than four to six hours in conflict with the resident's person-centered care plan by the [MEDICAL TREATMENT] center. The finding is: 1. Resident #120 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 9/1/18 revealed the resident was cognitively intact, understands and understood. Review of the facility's policy entitled [MEDICAL TREATMENT] Shunt/ Fistula Monitoring last revised on 6/2009 documented the standard is to assure proper functioning of the [MEDICAL TREATMENT] shunt and the shunt will be evaluated and monitored every shift by a licensed nurse. The policy did not address care of the shunt post [MEDICAL TREATMENT] related to the pressure dressings on a shunt. Review of Physician order [REDACTED]. Review of the Comprehensive Care Plan completed on 8/25/18 documented a resident focus of [MEDICAL TREATMENT] related to [MEDICAL CONDITION] with a goal for the shunt to remain patent with planned interventions to monitor the shunt site for post [MEDICAL TREATMENT] hemorrhage and positive bruit and thrill. There was no documented intervention related to the use of pressure dressings on the shunt site. During an observation on 9/26/18 at 9:26 AM, the resident was observed with two pressure dressings on a right wrist shunt/ fistula. The resident stated he returned from [MEDICAL TREATMENT] the previous day just before 4:00 PM and staff would get around to removing them soon. During an observation on 10/01/18 at 7:56 AM, the resident had two pressure dressings on a right wrist shunt/ fistula. The resident stated he returned from [MEDICAL TREATMENT] on Saturday (9/29/18) shortly before 4:00 PM and staff would remove the dressings. During an observation on 10/01/18 at 9:35 AM, the Licensed Practical Nurse (LPN) #7 was in the resident's room and the resident was seated in a chair wearing a short-sleeved shirt. LPN #7 stated, I just removed the pressure dressing because I know to do it if it's not done already. Review of the admission Progress Notes dated 8/3/18 through 10/2/18 revealed no documentation that the resident had any complications, including bleeding, at the shunt/ fistula site. During an interview on 10/2/18 at 10:04 AM, Registered Nurse (RN) #2 Resident Care Coordinator stated the site care is completed at the [MEDICAL TREATMENT] center. RN #2 stated she completed the resident's care plan and had not specified shunt site or any other directions regarding the pressure dressings in the care plan. During an interview on 10/2/18 at 10:08 AM, RN #1 Subacute Rehab Director stated that she called the [MEDICAL TREATMENT] center yesterday (10/1/18) and was informed how long to keep the dressing in place. The Physician's Assistant (PA) wrote an order to keep the dressing on for 24 hours. During an interview on 10/2/18 at 10:19 AM, the [MEDICAL TREATMENT] Center RN Director stated that the resident had the right AV fistula (arteriovenous shunt- a tube or device surgically implanted to create an artificial connection between an artery and a vein) created on 7/19/18 and started receiving [MEDICAL TREATMENT] services on 8/4/18 (this information was not contained in the resident's medical record). The resident has not had any problems with post [MEDICAL TREATMENT] bleeding that she is aware of and the pressure dressing should be removed within four to six hours; generally, four hours after the resident gets back to the nursing home. The problem with keeping a pressure dressing on to long is that it can negatively affect the functioning/ patency of the shunt. During an interview on 10/2/18 at 10:39 AM, the PA stated that she did not speak directly to the [MEDICAL TREATMENT] center; she wrote the order to remove the dressing after 24 hours based on the RN #1's communication with the [MEDICAL TREATMENT] center. During the interview the PA did not provide a clinical rationale for the duration of a pressure dressing on the [MEDICAL TREATMENT] shunt and could not define the potentially negative effect of keeping a pressure dressing on the [MEDICAL TREATMENT] shunt too long. 415.12

Based on observations, interviews, and record review conducted during the Standard survey completed on 10/2/18, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. One (Resident #104) of two residents observed for pressure ulcers had a delay in notification and treatment of [REDACTED]. The finding is: 1. Resident #104 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 8/22/18 revealed the resident understands and is understood. The resident required staff assistance for bed mobility, transfers, dressing, and personal hygiene. The resident was a risk for developing pressure ulcers and had one Stage 2 pressure ulcer present on admission. Review of the Policy and Procedure entitled Documentation of Pressure Ulcer and Chronic Wounds dated 8/2017 revealed pressure ulcers and chronic wounds are monitored closely to monitor treatment and change in risk factors. Review of the undated Comprehensive Care Plan revealed under Skin Integrity related to Stage 3 pressure ulcer on the sacrum (area above the tailbone on right and left buttocks) as a focus area with the planned interventions: Apply moisture barrier following incontinence care and as needed; Reposition every two hours and as needed; Float heels when in bed; Air mattress; Pressure reduction device out of bed; Skin and feet check daily with care; Skin risk tool. Review of the Bedside Kardex Report (used to provide care) dated 8/15/18 revealed to monitor skin for changes daily during care. Review of the Nursing Weekly Skin Status Documentation dated 9/26/18 revealed a pressure ulcer to the sacrum measuring 8.0 cm (centimeters) x 8.0 cm x 3 cm. There were no other documented skin sites. Observation on 9/28/18 at 7:50 AM, Resident #104 was positioned in bed on her right side with wedge cushion and at 11:15 AM the resident was up in the wheel chair watching television in the lounge area. Observation of incontinent care on 9/28/18 at 1:38 PM, the Certified Nurse Aide (CNA) #1 cleansed the resident's rectal area until visibly clear of black debris. An uncovered stage 2 pressure ulcer was located on the left gluteal fold (buttocks). Following morning care Licensed Practical Nurse (LPN) #1 removed a soiled gauze dressing from the stage 3 pressure area on the sacrum; completed a treatment to the sacral ulcer and reapplied the resident's brief. The stage 2 area to the left gluteal fold remained exposed. During an interview on 9/28/18 at 2:18 PM, when asked if Resident #104's treatments were completed, LPN #1 responded, Yes. During an interview on 9/28/18 at 2:19 PM, Registered Nurse (RN) #3 after observing the resident's left gluteal fold stated that it was visibly open. During an interview on 9/28/18 at 2:50 PM, CNA #1 stated she applied A&D (skin barrier) to the area during morning care and typically will inform the Team Leader but had not. During an interview on 9/28/18 at 2:58 PM, LPN #1 stated CNA #1 did not notify him of the new open area and he would expect to be notified, so he could alert the Unit Manager to obtain a treatment order. During an interview on 9/28/18 at 3:10 PM, the RN Director of Subacute Rehab stated the stage 2 measured 1 cm x 1 cm and Allevyn (absorbent dressing) was ordered and applied. In addition, the expectation is that CNA's are to notify their Team Leader, Unit Manager or the RN Supervisor when discovering skin breakdown so they can assess and order the proper treatment. During an interview on 10/2/18 at 11:33 AM, the Director of Nursing stated the expectation is that CNA's notify the Team Leader of skin breakdown who then notify the Unit Manager or RN Supervisor during an off-shift. Measurements are taken and treatment to be addressed by the end of the shift. 415.12(c)(2)

Based on observation, interview and record review conducted during the Standard survey completed on 10/2/18, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Two (Resident #15, 113) of five residents reviewed for wound care had issues. Specifically, Resident #113 had chronic peripheral vascular wounds, and the Licensed Practical Nurse (LPN) Treatment Nurse did not change gloves between treating a wound of the left heel and the left dorsal leg and did not perform the left heel wound treatment in accordance with the physician's orders [REDACTED].>The findings are: Review of the facility's policy entitled documentation of Pressure Ulcer and Chronic Wounds last reviewed on 8/2017 directed that chronic wounds are monitored closely for effectiveness of treatment and chronic wound dressings will be inspected daily. Review of the facility's policy entitled Dressing-Clean Technique last reviewed 12/2007 directed a clean dressing technique is used to provide an appropriate and safe environment conducive to wound healing. The treatment is performed by a LPN following a physician order [REDACTED]. 1. Resident #113 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Date Set (MDS - a resident assessment tool) dated 8/30/18 revealed the resident was cognitively intact, understands and is understood. The resident had four venous and arterial ulcers. Review of the Comprehensive Care Plan completed on 9/4/18 documented initiation of a problem on 5/31/18, that the resident had impaired skin integrity related to a surgical wound, ulcers of the left great toe, right heel and right lower extremity anterior aspect; on 7/25/18 a revision included an ulcer of the left dorsal ankle. Review of the Readmission History and Physical dated 9/13/18 documented the resident was sent to the hospital on [DATE] for a left heel ulcer which was foul smelling with maggots. There was question of erosion on x-ray and a comfort approach was chosen. Review of Physician order [REDACTED]. Review of a microbiology report dated 9/19/18 documented the left heel wound contained [MEDICATION NAME] species (bacteria), proteus mirabilis (bacteria) and pseudomonas aeruginosa (bacteria); there was no wound culture for the LLE anterior aspect wound. Review of the Nursing Weekly Skin Status Documentation dated 9/26/18 revealed the resident had a left heel arterial ulcer that measured 13 centimeters (cm) in length, 7.5 cm width and 0.2 cm. depth with a moist eschar (black or brown dead tissue) cap with thick yellow tightly adhered slough (soft, moist, dead tissue) and a left dorsal foot/ ankle arterial ulcer that measured 9.3 cm length x 6.0 cm. depth x 0.2 cm depth with 30 % red moist base, 70% brown and yellow tightly adhered slough with exposed tendon. Observation on 9/26/18 at 10:55 AM, LPN #5 performed wound treatment(s) for the LLE and left heel. The resident was sitting in the wheelchair with the dressings open but not fully removed from the underside of the extremity. LPN #5 cleansed the (LLE) with NS, the anterior aspect was oozing a moderate amount of serosanguinous (blood and serum) drainage, discarded the 4 x 4 (dressing), dried the wound with a dry 4 x 4 without changing gloves. LPN #5 obtained a 4 x 4 and cleansed and dried the left heel wound and moved to the heel dressing. LPN #5 removed the contaminated gloves and washed his hands and changed gloves. He placed the Acetic Acid gauze on the LLE anterior aspect wound and without changing gloves placed an Acetic Acid gauze on the left ankle; the old dressing was still underneath the left heel and he had to discard the dressing. He changed gloves, and during this the Acetic Acid gauze fell off the left heel on the floor and the left ankle was fully exposed. He began wrapping the ankle with Kerlix and when asked if he was aware that the Acetic Acid gauze was on the floor he replied that the Acetic Acid gauze was just a cleanse and did not need to remain in contact with the wound. He then wrapped the ankle and the LLE anterior aspect wound with Kerlix. During an interview on 9/26/18 at 11:11 AM, LPN #5 stated that he should have changed gloves and applied the treatments of the two wounds separately. During an interview on 9/28/18 at 8:43 AM, the LPN #6 Resident Care Coordinator stated that the resident's wound treatments were recommended by the wound consultant. The Acetic Acid dressings are to remain on the wound and LPN #5 should have performed the two wound treatments separately. 2. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented that the resident has cognitive impairments, sometimes understands others and sometimes understood by others. Review of the Comprehensive Care Plan documented the resident is at risk for skin integrity related to Diabetes Type 2, impaired mobility and impaired skin integrity related to left lateral bunion venous ulcer with interventions including administer treatment per doctor order, float heels when in bed, pressure reduction mattress on bed, reposition every 2 hours and as needed and place pillow under bilateral feet on foot rest while in wheelchair. Review of Physician order [REDACTED]. Review of Nursing Weekly Skin Status Documentation dated 9/28/18 documented that the resident has a vascular ulcer on the left lateral bunion measuring 2.0 cm length by 1.78 cm width by 0.1 depth. Review of the Treatment Administration Record dated 9/1/18 through 9/30/18 documented Santyl ointment apply to left lateral bunion topically every day shift for skin treatment - cleanse with NS, pat dry, apply followed 4 x 4 with kerlix wrap. During an observation with LPN #2 In-service Educator on 9/28/18 at 10:43 AM, the resident was seated in a tilt in space wheelchair with the dressing on his left foot. LPN #4 with gloved hands removed the dressing, disposed of the soiled dressing, removed gloves, washed hands; the wound base presented with 95% pink tissue and 5% yellow tissue adhered in the wound base with white macerated (softened as a result of wetness) edges. LPN #4 re-applied gloves, applied Santyl and followed with a dressing and Kerlix wrap without cleansing the wound with NS as ordered. During an interview on 9/28/18 at 10:58 AM, LPN #4 stated he did not cleanse the wound because he did not see any drainage. He added that it is a standard of care to clean all wounds prior to applying a treatment and he should have cleansed it as ordered with NS, but he was nervous and forgot. During an interview on 9/28/18 at 11:03 AM, LPN #2 In-service Educator stated the wound was not cleansed and should have before the treatment was applied as ordered. During an interview on 10/2/18 at 8:19 AM, LPN #3 Resident Care Coordinator (RCC) of Unit D stated the nurse should have cleansed the wound as ordered with normal saline during the treatment change; a cleanser is important to clean off old medicine and wipe off any organisms as much as possible for wound healing. During an interview on 10/2/18 at 12:13 PM, the Director of Nursing stated cleansing the wound is very important because it will take off the exudate (drainage / organisms) on the wound to promote healing. 415.12

Based on observation, interview, and record review conducted during a Standard survey completed on 5/26/17, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. One (Unit C) of four resident care units had issues. Specifically, resident room floors and bathroom floors were unswept and soiled, soiled walls and toilet seats, and missing ceiling tiles. The findings are: Unit C: Resident Room #1 observations are as follows: - 5/22/17 at 10:39 AM there were two areas with dried brown debris on the floor in the bathroom near the toilet. One was the size of a quarter and the other one was the size of a nickel. The bathroom floor also had debris in the corners and along the walls. The bedroom floor had dust and dirt particles throughout the room; in the corners, under the heater and beds. - 5/23/17 9:12 AM the bathroom floor near the toilet still had the dried brown debris on the floor. The bathroom floor still had debris in the corners and along the walls. Bedroom floor had dust and dirt particles throughout the room; in the corners, under the heater and beds. During an observation on 5/23/17 at 9:26 AM the housekeeper went into room and bathroom. At 9:30 AM the housekeeper came out of the room with a bag of trash and moved onto the next room. It was observed that the housekeeper did not take the broom from his cart or used a mop. At 9:32 AM the Surveyor went back in room, the bathroom floor still had the dried brown debris on the floor near the toilet and still had debris in the corners and along the walls. The bedroom floor had dust and dirt particles throughout the room; in the corners, under the heater and beds. An additional observation on 5/24/17 at 12:40 PM revealed the bathroom floor near the toilet still had the dried brown debris on the floor in the bathroom near the toilet. One was the size of a quarter and the other one was the size of a nickel. The bathroom floor still had debris in the corners and along the walls. The bedroom floor had dust and dirt particles throughout the room. In the corners, under the heater and beds. On 5/25/17 between 9:49 AM and 10:00 AM, the Surveyor and the Housekeeping Supervisor went into the room. The bathroom floor still had same two areas of dried brown debris on the floor near the toilet. The bathroom floor still had debris in the corners and along the walls. The bedroom floor still had dust and dirt particles throughout the room; in the corners, under the heater and beds. Resident Room #2 observations are as follows: - 5/23/17 at 9:21 AM the floor in room and bathroom was dusty and had dirt particles all over, in the corners, behind the doors and under the beds. On the bathroom floor near the toilet there was two areas with smudged dried brown debris. One was approximately three inches in length and the other was approximately the size of a dime. In addition, an eight oz. size plastic drinking cup was laying on the floor under the sink area and in the corner between the toilet and wall was a disposable cloth wipe. During an observation on 5/23/17 at 9:31 AM, the Housekeeper went into room and came out of room at 9:34 AM with a bag of garbage and then moved cleaning cart to the next room and went into the next room. The Surveyor went into Room #2 at 9:37 AM and the bathroom floor near the toilet still had the two areas dried brown debris, the plastic drinking cup was still laying on the floor under the sink area, and in the corner between the toilet and wall a disposable cloth wipe. - 5/24/17 at 1:44 PM the bathroom floor near the toilet was still soiled with the dried brown debris, an eight oz. plastic drinking cup, and the cloth wipe. On 5/25/17 between 9:49 AM and 10:00 AM the Surveyor and the Housekeeping Supervisor went into the room and the bathroom. The bathroom floor near the toilet still had the two areas with smudged dried brown debris, an eight oz. plastic drinking cup was still lying on the floor under the sink area and in the corner between the toilet and wall still had a disposable cloth wipe. Resident Room #4 observations are as follows: - 5/23/17 at 09:23 AM the floors in room and bathroom were soiled. There was paper and dirt particles on the floor under beds, in the corners and under the heater unit. Additionally, there was a liquid brown substance running down the wall under toilet paper holder and onto the floor. On 5/23/17 at 9:35 AM the Housekeeper was observed going into the room and at 5/23/17 at 9:39 AM exited the room and moved cleaning cart down to the next room. On 5/23/17 at 9:41 AM the Surveyor entered room. The floors in both the room and bathroom were still not swept. The floor had paper and dust debris under beds, in the corners and along the walls. The bathroom was still had the brown liquid substance on the wall under the toilet paper holder and onto the floor. - 5/24/17 at 12:37 PM the the bathroom wall and floor under the toilet paper hold was still soiled with the brown dried liquid substance. The floor in room and bathroom were still dirty and not swept. There were dust particles, dirt particles, and a plastic cap on the floor in the corner of the bathroom. On 5/25/17 between 9:49 AM and 10:00 AM the Surveyor and the Housekeeping Supervisor went into the room. The dried brown liquid substance remained on the wall and floor under the toilet paper holder, the plastic cap from a bottle was still in the corner on the floor of the bathroom. The floors in the bedroom and bathroom remained soiled with dust particles and debris throughout the room and bathroom. Resident Room #6 observations are as follows: - 5/23/17 at 9:25 AM the bedroom floor was soiled with dust and dirt particles under the beds, heater, behind the doors and in the corners. Food particles on the floor appeared to be fried food. On 5/23/17 at 9:40 AM the Housekeeper went into the room and came out of room at 9:44 AM. At 9:45 AM the Surveyor re-entered the room and floors remained soiled with dust and debris. -5/24/17 at 1:48 PM the floor remained soiled was not swept and had fried food particles on the floor. On 5/25/17 between 9:49 AM and 10:00 AM the Surveyor and the Housekeeping Supervisor went into the room and floor still remained unswept and there was fried food, and dust/ dirt debris throughout the room. Resident Room #10 observations are as follows: - 5/23/17 at 9:28 AM the room floor had potato chip crumbs and little pieces of toilet paper all over the floor between the two beds and under the beds. The floor was soiled and not swept with dust and debris under the beds, in the corners, behind the doors, and under the heater. - 5/25/17 9:11 AM the room floor still had dust, toilet paper and food particles on the floor throughout the room. The base of the floor and wall was grimy with a brownish color. On 5/25/17 between 9:49 AM and 10:00 AM the Surveyor and the Housekeeping Supervisor went into the room. The floor in the room still had dust, toilet paper and food particles on the floor throughout the room. The base of the floor and wall was grimy with a brownish color. Resident Room #18 observations are as follows: - 5/22/17 at 11:07 AM the floor was soiled and not swept. In the corners and under heating system there was dust and dirt debris. - 5/23/17 at 8:03 AM the floors in the bedroom remained soiled with dust and dirt debris, in the corners and under the heating system. - 5/25/17 at 9:15 AM the floor under heating unit and corners continued to have dirt and dust particles. The base of the wall and floor was grimy with a blackish color. On 5/25/17 between 9:49 AM and 10:00 AM the Surveyor and the Housekeeping Supervisor went into the room and the floor in the room remained soiled and not swept. Resident Room #20 observations as as follows: - 5/22/17 at 11:10 AM the floor in the room had dirt debris, food crumbs, plastic bottle cap and dust debris throughout the room. - 5/23/17 at 9:05 AM the floor remained with dust, plastic bottle cap, food crumbs and debris on the floor throughout the room, under the beds and in the corners. Additionally, there was smeared dried brown debris on the toilet seat. - 5/25/17 9:16 AM the floor remained with debris; dirt, dust, plastic bottle cap and food particles on the floor. The toilet seat continued to have smeared dried brown substance on the toilet seat. On 5/25/17 between 9:49 AM and 10:00 AM the Surveyor and the Housekeeping Supervisor went into the room. The floor in the room and the toilet seat remained soiled. Resident Room #23 observations are as follows: - 5/22/17 at 11:03 AM the floor throughout the room was soiled with food crumbs, candy wrappers, tissues, used gloves and dust. The toilet seat had dried brown debris on the seat. - 5/23/17 at 9:07 AM the floor room remained with dust, debris and food crumbs. There was also crumpled tissues on floor between the beds, under the beds and by the night stand. The toilet seat remained soiled with a dried brown substance. - 5/25/17 at 9:20 AM the floor remained unswept, there was still dust, dirt and tissues on the floor. This was in both the room and bathroom. On 5/25/17 between 9:49 AM and 10:00 AM the Surveyor and the Housekeeping Supervisor went into the room. The floor in the room remained unswept with tissues on the floor. The Housekeeping Supervisor stated that the resident in this room always throws tissues on the floor. Resident Room #26 observations are as follows: - 5/22/17 at 11:05 AM a ceiling tile was missing in the bathroom (across from the toilet were the sprinkler head hangs) exposing the pipes in the ceiling. The floor in the room and bathroom were dirty with dust and dirt debris and food crumbs throughout the room, under the bed, under the heating unit and behind the doors and in the corners. - 5/23/17 at 9:09 AM the floors remained soiled with dust, dirt and crumbs. The ceiling tile in the bathroom was still missing. - 5/25/17 at 9:22 AM the floors remained with dust, dirt and crumbs. On 5/25/17 between 9:49 AM and 10:00 AM the Surveyor and the Housekeeping Supervisor went into the room and the floor in the room remained dirty with dust, and crumbs. Resident Room #124 observations are as follows: - 5/22/17 at 11:16 AM in the bathroom was soiled with a brown smeared substance on the tile wall to the right of the door. - 5/23/17 at 8:06 AM the bathroom wall to the right of the door still had a brown smeared substance on it. During an observation on 5/23/17 at 10:55 AM the Housekeeper was observed going into the room. After housekeeper left, the surveyor went in the bathroom and the brown smeared substance remained on the wall to the right of the door. Resident Room #125 observations are as follows: - 5/22/17 at 10:54 AM the bathroom toilet seat was soiled with a dried smeared brown substance on it. The floor in front of the toilet had a brown/ reddish stain approximately 6 inches by 6 inches. - 5/25/17 at 9:13 AM the bathroom floor in front of the toilet still had a brown/ reddish stain approximately 6 inches by 6 inches. During an interview on 5/23/17 at approximately 2:27 PM the Environmental Services Manager (EMS) stated the Housekeeping Aides sweep and mop the floors every day in the residents' rooms. The deep cleaning for each room is done monthly where all the furniture is moved out of the room and then cleaned. The floors are stripped and waxed by an outside company and is done by request. During an interview on 5/25/17 at approximately 9:33 AM the Housekeeping Aide stated her daily cleaning for the residents' room is to makes sure the gloves, tissues, toilet paper, paper towels and soap dispensers are all full and takes out the trash. When asked about the floors, the Housekeeping Aide stated she will sweep and mop the floors when they need it done, but she does not do this daily, only when it is needed. During an interview on 5/25/17 between 9:49 AM and 10:00 AM the Housekeeping Supervisor stated that housekeeping is to sweep and mop the floors every day in each of the residents' rooms. The Housekeeping Supervisor stated that these rooms are unacceptable with the way they were and would take care of them. Review of the Housekeeping Aide Job description, under job performance/ knowledge/ responsibilities revealed that rooms are mopped daily as directed by EMS Director and once weekly with an approved disinfectant. Review of policy and procedures entitled General Daily Cleaning and Room Cleaning Procedures both policy's dated 6/1/2000 revealed the facility provides an environment that fosters a positive self-image for the resident and preserves his or her human dignity. Sinks and toilets are cleaned with a disinfectant cleaner inside and out. Flooring is dust mopped and then wet mopped with the specific floor cleaner. Bathing room tiles are wiped down and floors damp mopped with a disinfectant cleaner. 415.5(h)(2)

Based on observation and interview conducted during the Standard survey completed on 5/5/16, the facility did not store, prepare, distribute, and serve food under sanitary conditions. One (kitchen) of one kitchen observed had soiled food and non-food contact surfaces, pots and pans that were not air dried after being sanitized, and dirty floors. Two (B-Unit and D-Unit) of four unit serveries had issues with cups and bowls that were not air dried after being sanitized. In addition, B-Unit had an issue with unsanitary procedure used for opening a beverage container. The findings are: 1. Observation in the kitchen on 4/29/16 at 8:46 AM revealed the following: - The slicer was covered with a plastic bag. The plastic bag was removed from the slicer and the counter top under the slicer was soiled with food debris and crumbs. Interview with the Food Service Director (FSD) at the time of the observation revealed the slicer was clean and ready for use and that it had been used the night before. Observation in the kitchen on 4/29/16 at 8:46 AM revealed the following: - An approximate 4 foot (') tall mixer was covered with a plastic bag. The plastic bag was removed from the mixer and the splash shield, the area around the splash shield, and the cage were covered with a white colored substance. Interview with the FSD at the time of the observation revealed the mixer was clean and ready for use. The FSD revealed the kitchen staff had made ambrosia the previous night and that the white substance on the splash shield and guard was probably whip cream. Observation in the kitchen on 4/29/16 at 8:51 AM revealed the following: - Two long handled sauce pans and three approximate three gallon pots that were stored on the clean pot and pan rack were wet and greasy to the touch. - Six pans stored on the clean pot and pan rack were stacked together wet and water was observed dripping from them when they were turned over. Interview with the FSD at the time of the observation revealed the pots and pans were ready for use. Observation in the kitchen on 4/29/16 at 8:56 AM revealed the following: - An approximate 4' long x 2' wide area of the floor under the rack that contained boxes of juice for the juice machine was heavily soiled with food debris, crumbs, and pieces of packing tape. Interview with the FSD at the time of the observation revealed the kitchen floor was cleaned every night. Observation in the kitchen on 4/29/16 at approximately 9:10 AM revealed the following: - An approximate 4' long x 2' wide area of the floor near the small dishwashing machine was heavily soiled with food debris and crumbs. - An approximate 3' long x 1' wide area of the floor between the deck oven and the range top was covered with an approximate one quarter inch thick layer of a greasy, black, brown, and tan colored substance. - The top of the deck oven was heavily soiled with chunks of black debris and dust. 2. Observation in the D Unit servery on 4/29/16 at 9:27 AM revealed the following: - Approximately 24, wet eight ounce cups were stacked together and stored on the counter. - Approximately 36, wet four ounce cups were stacked together and stored on the counter. Interview with the FSD at the time of the observation revealed the cups were ready for use. 3. Observation in the B Unit servery on 4/29/16 at 9:33 AM revealed the following: - Two wet coffee cups were stored on the counter. - 2 wet bowls were stored in a cupboard. Interview with the FSD at the time of the observation revealed the cups and bowls were ready for use. 4. Observation in the B Unit dining area on 4/29/16 at approximately 12:15 PM a certified nurse aide (CNA) #1 was stabbing the plastic cover on a 4 ounce glass of orange juice with a knife. She grabbed the knife by the cutting part with her bare hands and placed it back in the clean knife container with the other knives. CNA #1 then took a pen from her pocket and stabbed the plastic cover several times and pierced a hole in the cover. CNA #1 then placed a straw through the hole and served the drink to a resident. Interview on 5/5/16 at 10:18 AM CNA #1 stated, I was using the knife because some of the covers do not have a hole in it for the straws. They only had those lids for a while because they were ordered wrong. The lids they have now have holes. They must still had a few left. I don't think it was a good idea to put the knife back or stab the lid with a pen. During an interview on 5/5/16 at approximately 8:32 AM the Registered Nurse (RN) Assistant Director of Nursing (ADON) stated, Using a pen to make a hole is not the correct process. We don't stab things around here. 415.14(h) New York State Sanitary Code Subpart 14-1 14-1.110(a) 14-1.110(b) 14-1.110(d) 14-1.110(e) 14-1.116 14-1.80(b)

Based on observations, interview, and record review conducted during the Standard Survey completed on 5/5/16, the facility did not promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Five (Residents #43, 112, 153, 218, 356) of five residents observed had to wait approximately 15 to 25 minutes for their meal trays after other residents at the table were served. This involved B-Unit and D-Unit dining serveries. The findings are: 1. Resident #356 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/14/16 revealed that the resident is cognitively intact, is understood and understands. During a dining observation on the B-Unit on 5/3/16 at approximately 12:05 PM, three residents at a table received their meals and Resident #356 did not. Resident #356 had her liquids, but did not receive her food until approximately 12:30 PM. The resident was served everything on her ticket except for rice that was listed. During an interview on 5/3/16 at approximately 12:30 PM, Resident #356 stated I didn't get my food right away because they had to make the rice that I ordered. They know I can't have potatoes because I'm on a potassium restrict. During an interview 5/3/16 at approximately 12:57 PM, the Food Service Director stated If something is added like rice to the ticket, they would have to call down and we would have to make it. The rice takes about 20 minutes to make. During an interview on 5/3/16 at approximately 1:30 PM, the Diet Technician stated Every resident should be served at one table first before moving to the next table. Residents should not have to wait that long. During an interview on 5/5/16 at approximately 9:00 AM, Resident #356 stated I'm a patient person, but it was upsetting to have to wait that long for my food, especially when everyone else at the table had theirs. But, you just have to go with the flow when you're in a facility like this I guess! 2. Resident #112 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment and receives a mechanically altered diet. During a dining observation on the D-Unit on 4/29/16 at 12:40 PM, Resident #112 was sitting at a table in the TV lounge with Resident #43 who was eating her lunch meal. At 12:52 PM, Resident #112 was observed eating coleslaw that her table mate gave to her. The resident had two bites of coleslaw. Resident #43 then was observed giving Resident #112 her bowl of coleslaw and Resident #112 took two bites. Continued observation revealed a certified nurse aide (CNA #2) was observed to go to the table and move the bowl away from the resident to the center of the table and told Resident #43 not to give her food to Resident #112. CNA #2 walked away and Resident #112 was observed to take another bite of coleslaw after her table mate gave the bowl back to her. At 12:56 PM, CNA #2 brought Resident #112 her lunch and the resident began eating her meal. During an interview on 4/29/16 at 1:10 PM, Resident #43 stated she needed it when asked why she shared her food with Resident #112. During an interview on 4/29/16 at 2:03 PM, CNA #2 when asked if she observed Resident #43 to share her food with Resident #112 stated Yes, I did see that the resident was sharing her food with the other resident; it was the coleslaw. I moved the food away from the resident and went to get her lunch. 3. Resident #153 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment. During a dining observation on the D-Unit on 4/29/16 at 12:15 PM, Resident #153 was sitting at a table with several other residents. At 12:19 PM, two other residents at the table were served their lunch. At 12:34 PM, Resident #153 still did not receive her tray. The staff member sitting at the table, assisting another resident, stated to Resident #153 Sorry you've had to wait for your lunch. At 12:37 PM, the resident was served her lunch. 4. Resident #218 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment. During a dining observation on the D-Unit on 5/3/16 at 12:17 PM, Resident #218 was sitting at a table with five other residents and two of the residents had their meal trays. Resident #218 was the last resident to receive her tray at the table at 12:36 PM. The resident stated, I thought you forgot about me and the CNA stated No, never. During an interview on 5/3/16 at 1:35 PM, the Diet Technician stated, Everybody at the same table should be served at the same time, that's what they expect nursing to be doing. They should try to do that before they move to the next table. 415.5(a)